Amelanotic subungual malignant melanoma with multiple nodular local skin metastases

We present a 72-year-old man with a subungual amelanotic malignant melanoma (MM) on the right first toe with numerous local nodular metastases after trauma and without regional lymph node involvement. Most of the lesions were angiomatous (reddish blue), and some had a hyperkeratotic surface, clinically resembling Kaposi sarcoma. Results of biopsies performed on skin taken from the toe and from a metastatic lesion of the tibia revealed a classic case of amelanotic MM. This case has 2 interesting points: the clinical presentation of the metastatic lesions and the topical spreading of the lesions, which was initiated after traumatic injury of the prime lesion.

Effect of synergistic motion on flexor digitorum profundus tendon excursion

Clinical and experimental studies have shown that postoperative rehabilitation is an important factor that improves digital function after flexor tendon repair. In the current study, the effect of synergistic wrist and finger motion therapy and fixed flexed wrist motion therapy on the in vivo gliding excursion was evaluated after repair of partial laceration of the canine flexor digitorum profundus tendon. The gliding excursion of the repaired tendons treated with synergistic wrist and finger motion therapy was significantly greater than that of tendons rehabilitated with the wrist fixation therapy, suggesting that wrist extension generates force that can pull the repair site through the pulley, thereby increasing passive excursion of the tendon. As a result of increased tendon excursion, synergistic therapy may improve the clinical outcome after repair of partial tendon lacerations.

Acute digital ischemia in infants: the hair-thread tourniquet syndrome--a report of two cases

Infants are susceptible to digital ischemia if a toe is encircled by a strand of hair on some other similar material. Infants under 6 months are particularly at risk. There is often a delay of 3-4 days before the condition is recognized. Prompt removal is necessary in order to prevent loss of the part. This syndrome is referred to as the hair-thread tourniquet syndrome. Two cases illustrating the presenting clinical findings and the operative treatment are presented.

Digital foot trauma: emergency diagnosis and treatment

Trauma to the foot is commonly seen in the emergency setting. An accurate diagnosis and step-wise management is appropriate. Although most injuries respond to aggressive non-surgical treatment, surgical intervention may be required for an unstable or a displaced fracture, particularly of the first metatarsophalangeal joint.

A center's callosities

We present a case report of a 14-year-old white male who developed hyperkeratotic plaques on the distal aspects of 2 toes. He was referred by his primary care physician for the treatment of onychomycosis. With questioning, the patient stated that he played center for his high school basketball team. After physical examination, he was diagnosed with callosities caused by his basketball activities. Proper nail hygiene and wearing of larger footwear resulted in improvement of his callosities. Sports-related cutaneous injuries should be included in the differential diagnosis of nail and toe abnormalities.

The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx

Stubbing injuries to the great toe can be a cause of occult open fractures and osteomyelitis. Five such patients were identified after conducting a retrospective review of injuries to the hallux between January 1998 and December 1998. The study was conducted to draw attention to the association between this trivial trauma and its possible complications. All five children had open fractures of the distal phalanx of the great toe. Osteomyelitis did not develop in the children whose injuries were recognized early and who were treated with antibiotics. However, three children with delayed diagnoses and treatment developed osteomyelitis. At a mean follow-up of 10 months (range, 9-11) after injury, all five fractures had healed with no active signs of infection. Two of these children experienced a partial growth arrest and two experienced a full growth arrest of the distal phalanx of the great toe, the significance of which is yet unknown. Clinical signs such as bleeding from the eponychium and a laceration proximal to the nail bed should alert physicians to the presence of a possible open fracture. Early detection and treatment of these injuries may reduce or eliminate hospital stays and prolonged intravenous antibiotic treatment for osteomyelitis.

Injuries to the toes and metatarsals

Traumatic injuries to the toes and metatarsals are common injuries affecting nearly every individual. Injuries may be precipitated by industrial accidents or simple bumps in the night. They can produce a wide spectrum of consequences ranging from permanent disability to asymptomatic deformities. With appropriate treatment, most individuals should have the capacity to return to their preinjury functional status.

Homodigital reverse pedicle island flap for reconstruction of the great toe

A new homodigital reverse pedicle island flap is described for the reconstruction of the distal part of the great toe. It involves only a single stage procedure with minimal donor site morbidity and provides a good cosmetic result. Its use in two successful reconstructions is described.

Denervation retards but does not prevent toetip regeneration

Toetips of mammals regrow after amputation by a process similar, but not identical, to that which occurs during regeneration of a newt limb. Nerve is needed as a mitotic stimulant for newt limb regeneration but the requirement for nerve during rodent digit-tip regeneration is not known. Nerve dependence in rats was tested by severing the sciatic nerve in one hindlimb, amputating digit-tips from the central digits of both hind feet, and comparing the amount of regrowth in innervated and denervated digits. Denervation delayed soft-tissue wound healing. However, denervation did not significantly affect bone regrowth when animals were examined at one month. Because we suspected delayed bone regrowth, we used a new method that we developed to follow bone growth at several time points in each animal. Termed visible bone fluorescence through nail, this technique used serial injections of fluorescent calcium-deposition markers and observation through the toenails to observe bone growth in living animals. Using this method it was possible to detect retarded bone regrowth in denervated digits. Thus, although denervation of rodent tips delayed both soft tissue healing and bone regrowth, it did not prevent ultimate restitution of the amputated part. This suggests that neurotrophic stimulation in the mammalian digit-tip is not identical to that documented during newt limb regeneration, and that growth stimulation may be provided by tissues other than nerve.

Chondrosarcoma of the distal phalanx of a toe. A case report

Secondary malignant transformation of a solitary enchondroma into a chondrosarcoma is extremely rare. We report a case of such transformation in anenchondroma of the distal phalanx of a toe.

[Reconstructing the limb end defects with a free mini-flap, a report of 18 cases]

OBJECTIVE

Some operative procedures were introduced for repairing hand or foot defects using the free mini-flap from the finger or toe.

METHODS

Eighteen cases of finger tip or foot wound were treated with the free mini-flap and vessel anastomosis. The size of the flap was 2 cm x 1 cm to 6 cm x 4 cm and the length of the pedicle was 2 to 4 cm.

RESULTS

All the eighteen free mini-flaps survived and the results were satisfactory.

CONCLUSION

The method of the mini-flap is a good option for covering of thumb, finger or foot defects when a local or an island flap is not available.

Foot and ankle injuries in dance

Acute traumatic injuries are common in ballet dancers. A careful history, thorough examination, and appropriate imaging should allow for the diagnosis of most problems. The clinician must have a high index of suspicion for occult bony injuries, especially if the patient fails to recover as expected. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries. Kinetic chain dysfunctions are common in ballet dancers with overuse injuries and commonly follow ankle sprains. They may represent a secondary phenomenon that developed in response to the compensatory movement changes caused by the initial injury. It is important to remember, however, that these dysfunctions may have been long standing and a causative factor in the injury. Regardless of the time of onset of the dysfunction, residual kinetic chain dysfunction associated with incomplete rehabilitation of an injury may predispose the dancer to further injuries. Untreated dysfunctions at one site in the kinetic chain may predispose to compensatory dysfunction at other sites in the chain. Accordingly, it is essential to thoroughly examine the entire chain for functional movements when dealing with an injury, because identification and treatment of the kinetic chain dysfunction is important in the rehabilitation of the dancing athlete. Kinetic chain dysfunctions are common in injured ballet dancers and may be a cause of repeated injury. Why then are these dysfunctions left untreated? Medical personnel caring for dancers are sometimes guilty of tunnel vision, and focus solely on the injured site without considering what is happening at other sites in the kinetic chain. This oversight is compounded when the physicians or therapists are satisfied with discovering simply what injury has occurred rather than asking why the injury has occurred. The significance of kinetic chain dysfunctions is only just beginning to be recognized, and many examiners are not aware of the relationship between abnormal motion and injury. Generally, people see only what they look for, and they look only for what they know. Kinetic chain dysfunctions can easily be detected with simple tests of functional movement if the examiners include these tests in their assessment of the injured dancer. As long as clinicians are either unaware of or unwilling to perform these tests, these dysfunctions will remain untreated and may put the dancer at risk of failed rehabilitation or predispose them to further injury.

Correction of scar contracture deformities of the big toe with a multiplanar distraction device

A multiplanar distraction device was used in a 65-year-old woman for correction of multiplanar deformities of her right big toe. These deformities were caused by long-standing scar contracture after a crushing injury to the right foot. Without the necessity of other complicated procedures, the dorsal contracture and lateral deviation were corrected from 43 deg to 0 deg and from 22 deg to 0 deg respectively 3 weeks postoperatively. Kirschner wires were inserted temporarily for prevention of recurrence after removal of the frame, and were removed 6 weeks later. In follow-up after 8 months, the position of the big toe was stable and without recurrence of contracture. Application of the multiplanar distraction device simplified the surgical procedure to achieve this correction.

A biomechanical comparison of double-plate and Y-plate fixation for comminuted equine second phalangeal fractures

OBJECTIVES

To compare the biomechanical properties, in full limb preparations, of intact second phalanx and a simulated comminuted second phalangeal fracture stabilized with either two bone plates or a custom Y-plate.

STUDY DESIGN

In vitro biomechanical assessment of intact limbs and of paired limbs with a simulated second phalangeal fracture stabilized by one of two fixation methods. Animal Population-Thirteen pairs of equine cadaveric forelimbs.

METHODS

A comminuted second phalangeal fracture was created in six paired cadaveric limbs. For each limb pair, the fracture was stabilized with two plates in one limb, and with a Y-plate in the contralateral limb. These limbs and seven pairs of intact limbs were subjected to axial compression in a single cycle until failure. Mechanical properties were compared with a mixed-model ANOVA and post hoc contrasts. Joint contact pressure, screw insertion torque, and final screw torque remaining after mechanical testing were also evaluated for constructs.

RESULTS

No significant differences in mechanical testing variables were detected between construct types. However, the Y-Plate construct had significantly greater yield load, yield displacement and yield energy, and failure load and stiffness values than those for intact specimens, whereas the double-plate construct only had greater stiffness than intact specimens. There were no significant differences in joint contact pressures for both constructs. The final screw torque for proximal phalangeal screws was significantly greater for the Y-plate constructs than for double-plate constructs.

CONCLUSIONS

The Y-plate was as effective as the double-plate technique for stabilization of simulated comminuted second phalangeal fractures in monotonically tested equine cadaveric forelimbs.

CLINICAL RELEVANCE

This investigation supports evaluation of the Y-plate for repair of comminuted second phalangeal fractures in equine patients. Its specific design may facilitate repair of second phalangeal fractures, and may provide increased stability by allowing the proximal fragments of the second phalanx to be fixed with three screws placed through the plate.

A new model for experimental tendon adhesions in the chicken

A minimally invasive model using a manual abrader to induce adhesions in the chicken's central digit is described. The flexor synovial sheath and the profundus tendon were abraded with access through small flaps at the level of the proximal and distal phalanges of the avian long toes. The birds were divided into two groups according to the severity of the induced trauma. Group I birds received an abrasion injury and were euthanized to allow biomechanical testing 5 weeks postoperatively. Group II birds had a more severe abrasion and were euthanized similarly and tested 5 weeks after surgery. Results were compared with nonsurgical controls. Long toe function was evaluated weekly by measuring (1) the range of active flexion of each interphalangeal joint, resolved to total angular range; (2) the grasping ability on graded-diameter perches; and (3) the flexion deficit of the long toe. Postmortem biomechanical properties of the adhesions were measured. There was a significant difference between the unoperated controls and abraded digits of both groups in all parameters (p < 0.001). There was, in addition, a marked change in most of the measured parameters between groups I and II. In group I digits the functional and biomechanical deficit was less than group II. In summary, this animal model of long-segment abrasive injury to the tendon and sheath is a simple and reproducible method to generate adhesions and can be used for the evaluation of treatment modalities for adhesion prevention.

War wounds to the foot

Thirty-nine patients with foot injuries were admitted to the Clinic for Orthopedic Surgery in Lovran during the war against Croatia. All of them were soldiers wounded by antipersonnel mines. All of the patients were treated using the same protocol. Primary wound care included debridement, necrectomy, and three-dimensional external fixation with or without Kirschner wires. External fixation facilitated postoperative wound care, prevented vicious contracture position, and made fracture healing possible with early weight bearing.