Prolonged Union in Conservative Treatment of Symphalangeal Toe Fractures: Case Series

Background

Toe symphalangism is characterized by a fusion of the interphalangeal joint between the middle and distal phalanges. While typical lesser toe fractures heal well with conservative treatment, in our clinical experience, we encountered patients with symphalangeal toe fractures who experienced long-lasting pain and delayed radiographic union. Therefore, this study aimed to report radiographic outcomes following conservative treatment of symphalangeal fractures of the lesser toes.

Methods

We retrospectively reviewed 14 patients with symphalangeal lesser toe fractures who were treated conservatively. We investigated the mechanism of injury and measured the time from the initial injury date to the complete radiographic union. The fracture gap distance was measured on an initial lateral radiograph.

Results

Symphalangeal fractures involved the fourth toe in 4 patients (28.5%) and the fifth toe in 10 patients (71.4%). Regarding the mechanism of injury, 6 patients (42.9%) were injured by stubbing or bumping into the door, 5 patients (35.7%) were injured by tripping, 2 patients (14.3%) were injured by heavy objects falling directly on their toes, and 1 patient (2.3%) complained of pain after wearing pointed shoes for half a day. The mean time to complete union was 9.1 months, and the median period was 5.5 months (range, 0.8-29 months). The initial gap of the fracture was 0.60 mm (range, 0.30-1.04 mm).

Conclusions

The results of our case series may help counsel patients in the outpatient clinic that prolonged healing time may be required for the union of symphalangeal toe fractures.

[Severe and complex traumatic hand]

SEVERE AND COMPLEX TRAUMATIC HAND . Serious and complex traumatic injuries of the hand are multiple tissue injuries (skin, vascular, bone and nerves), requiring urgent surgical management. They are responsible for significant functional and aesthetic sequelae. Their incidence is clearly decreasing thanks to information, prevention and security measures. The absolute emergencies are injections under pressure, amputations-devascularizations, and serious mutilations. The objective of the management is to make a functional and aesthetic hand: restoration of the opposition of the thumb with a key-pinch, a sufficient length thumb, and restoration of the sensitivity of the reconstructed hand. This calls for numerous surgical and microsurgical techniques and must be undertaken by trained teams in specialized centers.

[Effectiveness of finger reconstruction using nail flap anastomosing nerve branch of the first toe nail bed]

Objective

To investigate the effectiveness of finger reconstruction using nail flap anastomosing the nerve branch of the first toe nail bed.

Methods

Between January 2016 and December 2022, 18 patients (18 fingers) with thumb or finger nail bed defects were admitted. There were 12 males and 6 females, with an average age of 32 years (range, 19-42 years). Four cases were finger tip tissue damage caused by machine compression, and 4 cases were distal tissue necrosis after finger replantation. There were 9 cases of thumb injury, 3 cases of index finger injury, 5 cases of middle finger injury, and 1 case of ring finger injury. There were 11 cases of distal nail damage and 7 cases of distal nail root (including nail root) damage. The time from injury to admission was 1-5 hours, with an average of 2 hours. After debridement and anti-infection treatment for 5-7 days, the wounds in size of 1 cm×1 cm to 4 cm×3 cm were reconstructed by using nail flaps anastomosing the nerve branches of the first toe nail bed. The size of the nail flaps ranged from 1.5 cm×1.5 cm to 4.5 cm×3.5 cm. The donor sites were repaired with the flaps in 16 cases and skin graft in 2 cases.

Results

All nail flaps, flaps, and skin grafts survived after operation and the wounds healed by first intention. All patients were followed up 6-12 months (mean, 10 months). The nails of 18 cases were all grown, in which 16 cases had smooth nails with satisfactory appearances, 1 case had uneven nails, and 1 case had obvious scar hyperplasia around the suture opening. At 6 months after operation, the two-point discrimination of the skin flap was 4-8 mm (mean, 6 mm). Meanwhile, the skin grafts and flaps at the donor sites regained protective sensation, good abrasion resistance, and had no negative effect upon walking and wearing shoes.

Conclusion

The application of a nail flap that anastomoses the nerve branch of the first toe nail bed for finger reconstruction has minimal damage and can achieve good nail bed repair results.

The Women's Soccer Health Study: From Head to Toe

OBJECTIVES

Women are under-represented in the sports literature despite increasing rates of sports participation. Our objective was to investigate the risks and benefits of an elite women's soccer career in five health domains: general, musculoskeletal, reproductive endocrinology, post-concussion, and mental.

METHODS

An online survey was distributed to retired US college, semi-professional, professional, and national team soccer players using personal networks, email, and social media. Short validated questionnaires were used to evaluate the health domains, including the Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numerical Evaluation (SANE), Post-Concussion Symptom Scale (PCSS), and Patient Health Questionnaire (PHQ).

RESULTS

A total of 560 eligible players responded to the survey over a 1-year period. The highest competitive levels were 73% college, 16% semi-professional, 8% professional, and 4% national team. The mean number of years since retirement was 12 (SD = 9), and 17.0% retired for involuntary reasons. The mean SANE scores (0-100 scale as percentage of normal) were knee = 75% (SD = 23), hip = 83% (SD = 23), and shoulder = 87% (SD = 21). The majority (63%) reported that their current activity level included participation in impact sports. A substantial proportion of players reported menstrual irregularities during their careers: 40% had fewer periods with increasing exercise and 22% had no periods for ≥ 3 months. The players (n = 44) who felt that post-concussion symptoms were due to soccer reported more time-loss concussions (F[2] = 6.80, p = 0.002) and symptom severity (F[2] = 30.26, p < 0.0001). Players who recently retired (0-5 years) reported the highest anxiety/depression scores and lowest satisfaction rates compared with those who retired 19+ years ago.

CONCLUSION

Health concerns include musculoskeletal injuries, post-concussion symptoms, and lower mental health in the early years following retirement. This comprehensive survey provides initial results that will lay the foundation for further analyses and prioritize research studies that can help all female athletes.

[Traumatic Turf-Toe: challenging diagnosis and controversial treatment]

INTRODUCTION

Turf-Toe includes a wide variety of traumatic injuries of the metatarsophalangeal joint of the first toe (MTF1). It is a potentially severe injury and there is no consensus for surgical management. The objective of this case report was to describe a patient with traumatic Turf-Toe injury grade III with a sesamoid fracture treated surgically.

CLINICAL CASE

24-year-old male with motorcycle fall with hyperflexion of the MTF1 joint, presented pain, edema and functional limitation; the radiographs showed soft tissue edema, lateral displacement of lateral sesamoid with fracture. Traumatic Turf-Toe was established. The ultrasound of the MTF1 joint showed breakage of the plantar plate and collateral ligaments. Patient was surgically managed with sesamoid reduction and plantar plate repair; postoperative evolution was satisfactory. At 8 weeks the patient was assessed with the AOFAS forefoot scale, obtaining 82 points, SF-12 with 87% and VAS of two and returned to his daily activities.

CONCLUSION

We describe a patient with traumatic Turf Toe grade III injury, not related to sports practice; first report in the literature of the use of ultrasound in the evaluation of patients with lesion of the metatarso-phalangic joint of the first toe.

Quality of Life in Individuals With Peripheral Arterial Disease Who Underwent Toe Amputations: A Descriptive, Cross-sectional Study

Studies have shown above- or below-the-knee amputation has a profound impact on physical, mental, and emotional health; the impact of having a toe(s) amputated is unknown.

PURPOSE

This descriptive research study measured health-related quality of life (HRQoL) using the Vascular Quality-of-Life Questionnaire-6 (VascuQol-6) among persons with peripheral arterial disease (PAD) who had undergone toe amputations.

METHODS

A list of 127 patients discharged from the hospital in 2016 with a diagnosis of PAD and toe amputation was provided to the investigator. The independent variables of age (subsequently divided into groups of persons <65 and ≥65 years of age), gender, race, diabetes mellitus, and time of PAD diagnosis (within the year or 2 to 7 years before 2016) were abstracted from the patient charts. A letter was mailed to potential participants that explained the study and the VascuQol-6 tool, along with a prepaid envelope to return the completed tool. The VascuQol-6 tool is a valid and reliable instrument for assessing HRQoL that covered the different aspects of quality of life (QoL) affected by PAD. The tool contains six 4-point Likert scale questions about activity, symptoms, pain, emotional status, and social life, resulting in a total score between 6 and 24. Higher values indicate better perceived quality of life. Variables were analyzed using frequencies, percentages, means, and standard deviations, and a standard t test was used to compare interval scale items. Statistical significance was noted when P <.05.

RESULTS

Thirty-eight (38) completed surveys were returned (30% completion rate). The mean total score was 15.5 ± 3.93 (range 7-24), and the mean overall score of the 6 items was 2.66 ± 0.90 (range 1-4). In addition to a low overall QoL score, the data showed QoL was negatively affected in every area assessed, but some participants were strongly affected whereas others were not affected at all. No significant differences in QoL scores were noted concerning age groups, gender, race, the presence of diabetes mellitus, or time since PAD diagnosis.

CONCLUSION

In this study, patients with PAD and toe amputations had low QoL scores related to their disease. Additional research is needed to better understand HRQoL related to PAD to facilitate education of patients considering toe amputation.

Micro-arteriovenous malformation causing spontaneous metacarpal pad hemorrhage in a dog

A 5-year-old neutered male Labrador retriever dog with a 3-year history of intermittent hemorrhage from the right metacarpal pad was evaluated. A small region of hyperattenuation of the metacarpal pad was evident on computed tomographic angiography. Excisional biopsy of the location of the purported hemorrhage revealed a micro-arteriovenous malformation on histologic examination.

Assessing Readiness for En Pointe in Young Ballet Dancers

Children begin ballet lessons as young as age 2 years. The graceful movements of classical ballet require a combination of artistry, flexibility, and strength to perform. During the training and development of a young ballerina, the transition to dancing en pointe ("on the toes") represents a significant milestone and traditionally begins around age 11 or 12 years, assuming the proper training background and dance aspirations. However, current dance medicine literature describes factors such as maturity, proper technique, strength, and postural control as the more significant factors in determining pointe readiness. An in-office evaluation of these factors can be performed by the clinician to assist dancers, their family, and their dance instructor(s) determine pointe readiness.

Hair tourniquet syndrome: revisited

Hair tourniquet syndrome is a rare condition. It is an important emergency condition where urgent attention is needed. In this condition, body appendages are strangulated by hair that acts like a tourniquet. A strand or strands of hair act like a circumferential constriction band and subsequently strangulate the body appendages. Commonly affected sites include fingers, toes or even genitals. Failure to identify and release the acute constriction may result in amputation of affected body part. We report two cases of hair tourniquet syndrome of the thumb and toe that were successfully released without complications.

High-Pressure Injection to the Great Toe with River Water

CASE

A 53-year-old male sustained a high-pressure water injection injury to his foot while working in a river. He was taken to the operating room for emergent irrigation and debridement of copious riverbed sediment. Cultures taken from the operating room were positive for multiple anaerobes, fungus and mold and he was treated with appropriate antibiotics. To date, his only residual deficit is a 1 cm area of numbness at the entrance wound.

CONCLUSION

High-pressure water injections to the foot are uncommon injuries. These are serious injuries that require emergent antibiotics, tetanus and surgical debridement.

Adrenaline with lidocaine for digital nerve blocks

BACKGROUND

Surgery on fingers is a common procedure in emergency and day care surgery. Adrenaline combined with lidocaine can prolong digital nerve block and provide a bloodless operating field. Extended postoperative pain relief can reduce the need for analgesics and can facilitate hand rehabilitation. Conventionally, adrenaline is avoided at anatomical sites with end arteries such as digits, penis and pinna because of concerns about arterial spasm, ischaemia and gangrene distal to the site of drug infiltration.

OBJECTIVES

To assess the safety and efficacy of use of adrenaline (any dilution) combined with lidocaine (any dilution) for digital nerve blocks (fingers and toes).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2014), MEDLINE via Ovid SP (1966 to 18 November 2014) and EMBASE via Ovid SP (1980 to 18 November 2014). We also searched specific websites, such as www.indmed.nic.in; www.cochrane-sadcct.org; and www.Clinicaltrials.gov.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared the use of adrenaline with lidocaine and plain lidocaine in patients undergoing surgery on digits (fingers and toes). Our primary outcomes were duration of anaesthesia, adverse outcomes such as ischaemia distal to the injection site and cost analysis. Our secondary outcomes were duration of postoperative pain relief and reduced bleeding during surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. We performed all analyses on an intention-to-treat basis. We used a fixed-effect model when no evidence of significant heterogeneity between studies was found and a random-effects model when heterogeneity was likely.

MAIN RESULTS

We included four RCTs with 167 participants. Risk of bias of the included studies was high, as none of them reported method of randomization, allocation concealment or blinding. Only one trial mentioned our primary outcome of duration of anaesthesia. The mean difference in duration of anaesthesia with use of adrenaline with lidocaine was 3.20 hours (95% confidence interval (CI) 2.48 to 3.92 hours; one RCT, 20 participants; low-quality evidence). No trial reported adverse events such as ischaemia distal to the injection site, and no trial reported cost analysis. One trial mentioned the secondary outcome of duration of postoperative pain relief, but available data were insufficient for analysis of the findings. Two trials reported the secondary outcome of reduced bleeding during surgery.Bleeding during surgery was observed in nine out of 52 participants as compared with 25 out of 51 participants in the adrenaline with lidocaine and plain lidocaine groups, respectively. The risk ratio for bleeding in the adrenaline with lidocaine group was 0.35 (95% CI 0.19 to 0.65; two RCTs, 103 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

From the limited data available, evidence is insufficient to recommend use or avoidance of adrenaline in digital nerve blocks. The evidence provided in this review indicates that addition of adrenaline to lidocaine may prolong the duration of anaesthesia and reduce the risk of bleeding during surgery, although the quality of the evidence is low. We have identified the need for researchers to conduct large trials that focus on other important outcomes such as adverse events, cost analysis and duration of postoperative pain relief.

Diagnosis using the proximal and lateral nail folds

This article includes the etiology and pathophysiological data of each entity, classifying them as dermatologic, systemic, infectious, neoplastic, traumatic, and other classifications. The entities inherent to the periungual folds are also included, such as acute paronychia, chronic paronychia, retronychia, hangnails, hematomas of the proximal fold caused by oximeter, onychocryptosis, hypertrophy of the lateral folds, and infections caused by Candida albicans, Pseudomonas, and Staphylococcus aureus. Additionally, pathologies caused by diabetes mellitus, sepsis, endocarditis, drug reactions, and finally less frequent diseases that also affect the nail folds are discussed.

Frostbite of both first digits of the foot treated with delayed hyperbaric oxygen:a case report and review of literature

BACKGROUND

Frostbite is an uncommon event that can occur from exposure to temperatures below -4 degrees C and can lead to potential serious tissue damage and necrosis. This in turn can result in debilitating amputations in otherwise healthy people. The pathophysiological mechanisms of frostbite have marked similarities to those seen in thermal burns, ischemia/reperfusion injuries and crush injuries--i.e., non-healing wounds and inflammatory processes. These injuries are commonly treated with hyperbaric oxygen therapy.

OBJECTIVES

Evidence for treating frostbite with hyperbaric oxygen (HBO2) is scarce, and to date HBO2 is not a standard addition in the multidisciplinary care of freezing injuries. We aim to contribute to the available evidence with a case report and review the literature to reassess the multidisciplinary treatment of frostbite injuries.

CASE REPORT AND REVIEW OF LITERATURE

We present a case report of a woman with deep frostbite of the toes treated with hyperbaric oxygen therapy, after a delay of 21 days, with good results. No surgical intervention was needed. A literature search revealed 17 human case reports on frostbite and four animal studies in which hyperbaric oxygen was applied. All case reports showed positive effects, and in none of the cases was amputation necessary. In the animal studies, two showed significant positive results regarding tissue loss and reduction of inflammatory markers, whereas two did not.

CONCLUSIONS

Based on our case report as well as the literature and the mechanisms of hyperbaric oxygen, we make the recommendation that this therapy be considered as an addition to the multidisciplinary treatment of frostbite, even after significant delay of treatment.

Crying infant with painful toes

Our patient's sleepless parents sought care for their infant's mysteriously injured toes.

Snakebites of fingers or toes by viperidae family members: an orthopaedic approach

The purpose of this study was to review current principles of therapy for affected patients and determine whether an emergent surgical approach or expectant management should be selected in cases of snakebites of fingers or toes by Viperidae family members. Over the past five years (January 2004 to December 2009), 12 patients bitten by Vipera ammodytes were admitted in our department. We retrospectively reviewed their demographic and epidemiological characteristics as well as their symptoms, laboratory findings, and complications. All snake bites occurred at the extremities (fingers and toes). The main complications were oedema, disseminated intravascular coagulation, and decrease in haematocrit. None of the patients developed compartment syndrome or required surgical debridement. The majority of the patients with snakebites of fingers or toes by Vipera ammodytes can be treated conservatively. Surgery is indicated only in case of compartment syndrome, where fasciotomies should be performed without delay after diagnosis.