Diabetic gangrene in multiple fingers and toes after a dog bite in an elderly patient with type 2 diabetes

A 78-year-old diabetic woman experienced multiple sites of gangrene not only in fingers that were directly bitten by a dog but also in fingers and toes that had not beenbitten. Her glycemic control was fair and microvascular complications were mild. There were no clinical findings related to angitis, collagenosis or severe infection. The fingers and toes with gangrene were amputated. The pathological diagnosis was diabetic gangrene. This report presents a case of multiple sites of gangrene of the fingers and toes after a dog bite in an elderly patient with type 2 diabetes.

The translating Weil osteotomy in the treatment of an overriding second toe: a report of 25 cases

We present a retrospective study of 25 feet operated for an overriding second toe deformity, whether or not associated with hallux valgus deformity and metatarsalgia. The surgical technique of a medial sliding and decompressive Weil osteotomy is described. All patients, operated between January 2002 and December 2007 for this condition in our institution, were reviewed clinically and radiologically. The mean AOFAS score improved with 47.6 points from 45.9 to 93.5. The theoretical advantages of such a translation Weil osteotomy are discussed trying to clarify the previously described pathologic anatomy of this condition.

Diagnosis, management, and complications of glomus tumours of the digits in neurofibromatosis type 1

BACKGROUND

Glomus tumours are benign painful tumours of the glomus body, a thermoregulatory shunt in the digits. Glomus tumours of the fingers and toes are associated with the monogenic disorder neurofibromatosis type 1 (NF1) and are recently recognised as part of the NF1 phenotype.

METHODS AND RESULTS

A multi-institutional experience with 15 individuals with NF1 and glomus tumours of the fingers or toes is reported. The majority of individuals presented with at least two of the symptoms in the classic triad of localised tenderness, severe paroxysmal pain, and sensitivity to cold. Appearance of the nail and finger or toe is often normal. Women are affected more often than men. Multifocal tumours are common. There is often a delay in diagnosis of many years and clinical suspicion is key to diagnosis, although magnetic resonance imaging may be useful in some scenarios. Surgical extirpation can be curative; however, local tumour recurrence and metachronous tumours are common. Three of our patients developed signs and symptoms of the complex regional pain syndrome.

CONCLUSIONS

Glomus tumours in NF1 are more common than previously recognised and NF1 patients should be specifically queried about fingertip or toe pain.

Dactylitis, a term for different digit diseases

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.

One case of big-toe re-plantation: a 13-year follow-up and a literature review

In this case of a 3-year-old patient who had a left big-toe amputation through the proximal phalange, re-plantation was performed successfully. Big-toe amputations are not frequent entities, but it should always be re-planted to avoid unsatisfactory aesthetic and functional outcomes. There are just a few reports in literature and their follow-up is very brief compared with our report.

Rectal carcinoma metastasizing to a toe

We report on a 63-year-old patient with rectal carcinoma that metastasized to a toe. Although bone metastases from malignant tumors are common, metastatic lesions of the small bones of extremities are very rare. We have found in the literature only 29 cases of carcinoma which have metastasized to the small bones of the feet. Twenty of these cases are verified histologically. The differential diagnosis includes osteomyelitis, gout, and Reiter's disease. The roentgenographic features and the possible pathogenetic mechanisms of peripheral metastases are discussed.

Prenatal diagnosis of isolated macrodactyly

Congenital enlargement of one or several digits of the hands or feet, known as macrodactyly, is a rare malformation. True macrodactyly, characterized by overgrowth of all mesenchymal elements, must be differentiated from that due to tumorous enlargement of a single element, as in hemangioma, lymphangioma or enchondroma. Furthermore, macrodactyly may be isolated, but it can also be associated with several syndromes. Here we present a case of prenatally diagnosed isolated true macrodactyly of the second toe of the left foot at 24 weeks of gestation, and discuss the key points in its differential diagnosis and management.

Enhancing limb salvage by non-mobilized peripheral blood angiogenic cell precursors therapy in patients with critical limb ischemia

BACKGROUND

Stem cell therapy has been proposed to enhance the salvage of critically ischemic limbs.

OBJECTIVE

Assess the efficacy and safety of the implantation of non-mobilized peripheral blood angiogenic cell precursors (NMPB-ACPs) in patients with critical limb ischemia (CLI) who were poor candidates for standard revascularization treatment options.

MATERIAL AND METHOD

Six patients with CLI due to the infrapopliteal artery occlusive disease were included in the present study. Intramuscular injections of NMPB-ACPs were administered in the ischemic limbs. The efficacy was evaluated by clinical outcomes, ankle brachial index, toe brachial index, and computerized tomographic angiography.

RESULTS

There was no evidence of local or systemic complication related to the procedure. Five patients (83.3%) had clinically significant improvement of adequate circulation at the distal limb for the complete healing. Four of them had complete healing of ischemic ulcers and stumps of toe amputation. However one patient with adequate granulation tissue at the stump of the left first toe amputation subsequently suffered from severe foot infection originating from the other toes and eventually underwent below knee amputation. There was no improvement of circulation at the distal limb after the administration of NMPB-ACPs in one patient (16.7%) who eventually underwent major amputation.

CONCLUSION

The preliminary result of NMPB-ACPs therapy may be safe and provide benefits in the improvement of circulation in patients with CLI. A larger controlled trial is required to ascertain these preliminary results.

[Fibular dimelia]

It is presented an extremely rare condition characterised by total absence of tibia and fibular dimelia. Only few patients were presented till now. Our patient was observed and treated for 19 years. He was born with normal forearms (radiologically ulna and radius were present), syndactyly of hands, mirror feet and extremely equinus. The knees were normal in flexion and dislocated in extension. Radiologically there was total absent of tibia and duplication of fibula; moreover there was duplication of toes (right foot--9, left foot--10 toes), metatarsal bones, cuneiform, cuboid and calcaneal bone. Although the unstable knees and equinus feet deformities he was able to walk indenpendently.

Brachydactyly

Brachydactyly ("short digits") is a general term that refers to disproportionately short fingers and toes, and forms part of the group of limb malformations characterized by bone dysostosis. The various types of isolated brachydactyly are rare, except for types A3 and D. Brachydactyly can occur either as an isolated malformation or as a part of a complex malformation syndrome. To date, many different forms of brachydactyly have been identified. Some forms also result in short stature. In isolated brachydactyly, subtle changes elsewhere may be present. Brachydactyly may also be accompanied by other hand malformations, such as syndactyly, polydactyly, reduction defects, or symphalangism. For the majority of isolated brachydactylies and some syndromic forms of brachydactyly, the causative gene defect has been identified. In isolated brachydactyly, the inheritance is mostly autosomal dominant with variable expressivity and penetrtance. Diagnosis is clinical, anthropometric and radiological. Prenatal diagnosis is usually not indicated for isolated forms of brachydactyly, but may be appropriate in syndromic forms. Molecular studies of chorionic villus samples at 11 weeks of gestation and by amniocentesis after the 14th week of gestation can provide antenatal diagnosis if the causative mutation in the family is known. The nature of genetic counseling depends both on the pattern of inheritance of the type of brachydactyly present in the family and on the presence or absence of accompanying symptoms. There is no specific management or treatment that is applicable to all forms of brachydactyly. Plastic surgery is only indicated if the brachydactyly affects hand function or for cosmetic reasons, but is typically not needed. Physical therapy and ergotherapy may ameliorate hand function. Prognosis for the brachydactylies is strongly dependent on the nature of the brachydactyly, and may vary from excellent to severely influencing hand function. If brachydactyly forms part of a syndromic entity, prognosis often depends on the nature of the associated anomalies.

A case of symptomatic tumoral calcinosis on the great toe and review of the literature

A 67-year-old woman with no specific medical history showed a hard mass on her great toe for several years. The lesion was elastic, round, and had good mobility. An X-ray showed the lesion to be a calcified "chicken wire" lesion; CT and MRI findings indicated it as a benign subcutaneous calcified tumor. Therefore, a resection biopsy was performed. The mass was a 20 x 20 mm calcified tumor diagnosed as tumoral calcinosis. Pathological findings showed that the calcified lesion lay in fibrous connective tissue and characteristic cells were seen around the calcification site. In this case, the lesion was mature and surgical resection was successful. The patient showed no symptoms or recurrence 3 years after the surgery.

Isolated dextrocardia with bilateral undescended testis and bilateral polydactyl of the hands and feet: a case report

The incidence of dextrocardia with or without situs inversus is rare though the true incidence in Nigeria is not known. Plain films are the preliminary investigations of choice in diagnosis of situs anomalies. The aim of this case report is to emphasise the importance of recognition of the spectrum of situs anomalies, because the altered anatomy associated with these anomalies may result in confusing imaging findings, misdiagnosis and difficulties with treatment when seen in conjunction with acquired abnormalities of the chest and abdomen. This study also aim to emphasise the need for accurate placement of radiographic markers by the radiographers before exposure of the films as the key for identification of situs anomalies. The case of dextrocardia without situs inversus diagnosed in a 4-month old baby boy who also had bilateral undescended testis and bilateral polydactyl of hands and feet is presented. The imaging modalities for assessment of situs anomalies are discussed.

Chondrolipoma of the toe

Chondrolipoma is a rare benign mesenchymoma composed of mature cartilage and adipose tissue. We present a 71-year-old man with a chondrolipoma of the great toe. On histological examination, the tumor contained both mature fat cells and chondrocytes. To our knowledge, this is the first report of a chondrolipoma on the toe. This case contributes to better awareness of an extremely rare lesion of the distal lower limb.

Craniodigital syndrome of Scott: clinical and neuroradiological features of a new case

We report on a girl presenting with mental retardation, craniofacial dysmorphisms, and syndactyly. The child's mother and maternal grandfather presented bilateral syndactyly of toes 2 and 3. These manifestations, falling within the ambit of what has been termed the craniodigital syndromes, were first reported by Scott et al (1971) in 3 brothers.

Real-time 3D computed tomographic reconstruction using commodity graphics hardware

The recent emergence of various types of flat-panel x-ray detectors and C-arm gantries now enables the construction of novel imaging platforms for a wide variety of clinical applications. Many of these applications require interactive 3D image generation, which cannot be satisfied with inexpensive PC-based solutions using the CPU. We present a solution based on commodity graphics hardware (GPUs) to provide these capabilities. While GPUs have been employed for CT reconstruction before, our approach provides significant speedups by exploiting the various built-in hardwired graphics pipeline components for the most expensive CT reconstruction task, backprojection. We show that the timings so achieved are superior to those obtained when using the GPU merely as a multi-processor, without a drop in reconstruction quality. In addition, we also show how the data flow across the graphics pipeline can be optimized, by balancing the load among the pipeline components. The result is a novel streaming CT framework that conceptualizes the reconstruction process as a steady flow of data across a computing pipeline, updating the reconstruction result immediately after the projections have been acquired. Using a single PC equipped with a single high-end commodity graphics board (the Nvidia 8800 GTX), our system is able to process clinically-sized projection data at speeds meeting and exceeding the typical flat-panel detector data production rates, enabling throughput rates of 40-50 projections s(-1) for the reconstruction of 512(3) volumes.

Polydactyly of the foot

Fifty-six patients with 72 duplicated toes were analysed. Postaxial duplication accounted for 79%, and the most common anatomical pattern was duplication of the proximal phalanx with a wide metatarsal head. Forty-two patients with 55 duplications were clinically and radiographically evaluated at long-term follow-up (mean 22.5 years). Results were satisfactory in 91% of the patients. Poor results were often associated with preaxial polydactyly because of persistent hallux varus. Surgical treatment is usually straightforward but must be individualized, and some anatomical and surgical details should be considered to obtain a better result.

Korrektur des rheumatischen Vorfußes

INTRODUCTION

Resection of the metatarsal heads is an established procedure for the therapy of rheumatic forefoot deformations. However, a recurrence of lateral deviation of the lesser toes and painful plantar keratosis remain a challenging problem for the treatment of these patients. The aim of this study was to evaluate our results in cases of rheumatoid forefoot deformities. We performed a resection of the metatarsal heads 2-5 in combination with an arthrodesis of the first toe and resection of keratosis by the plantar approach.

MATERIAL AND METHODS

Fifteen patients (20 feet) were followed-up clinically and radiologically using the American Orthopedic Foot and Ankle Society (AOFAS), Miehlke-, and Larsen scores.

RESULTS

Average follow-up time was 3.5 years (range: 1.5-7.5 years). An average AOFAS score of 81/90 was found for the hallux and 90/100 for the lesser toes. A total of 18 feet were rated as pain free, while two feet showed some residual pain. Every case showed an harmonic cascade of the resection. All patients stated that the operation had improved their quality of life and that they would consent to undergoing it again.

CONCLUSION

Our results after arthrodesis of MP-1 and resection of the metatarsal heads 2-5 using the plantar approach were good compared to the data published in the literature.

Computer based methods for measurement of joint space width: update of an ongoing OMERACT project

Computer-based methods of measuring joint space width (JSW) could potentially have advantages over scoring joint space narrowing, with regard to increased standardization, sensitivity, and reproducibility. In an early exercise, 4 different methods showed good agreement on measured change in JSW over time in the small joints of the hands and feet. Despite differences in measurement values between methods, measurement of within-joint change over time showed no systematic differences. The within-method variation was small, with intra-operator variation being smaller than inter-operator variation. Although this initial study was limited in terms of the number of patients and timepoints (total 10), the number of joints was relatively high (340 joints), so the results were considered strong evidence supporting the validity of computer-based JSW measurements to continue the study of the potential value of JSW by comparison of measurements to manual scoring of joint space narrowing using the COBRA trial images.

Multiple calcified subungual epidermoid inclusions

Subungual epidermoid inclusions (also known as subungual onycholemmal cysts) are an uncommon and distinctive nail abnormality occurring in the dermis of the nail bed. Clinically the nail plate may exhibit onychodystrophy, clubbing, ridging, thickening, pigmentation, or appear normal. We report the case of a patient with onychodystrophy of the right halux of 7 years' duration. This case is presented with serial pictures demonstrating the gradual development of nail plate thickening, yellow discoloration, and nail bed hyperkeratosis indicative of the disease. She had negative fungal cultures, poor response to topical and oral antifungal agents, and an initial nondiagnostic superficial biopsy. Repeat full-thickness nail bed biopsy results revealed multiple calcified subungual epidermoid inclusions epidermoid inclusions. Histologic features included characteristic elongation of the rete ridges with cyst formation and pinching off of the connection to the nail bed epithelium, forming free-lying cysts within the dermis of the nail bed. The cysts contained compact onycholemmal keratin and calcification. A granular layer was not present. This case reinforces the need to clinically reassess, possibly x-ray, and perform a sufficient biopsy for persistent undiagnosed nail unit disorders. Subungual calcified inclusions may be an underrecognized and more common entity than currently recognized.

A novel patient with Cooks syndrome supports splitting from “classic” brachydactyly type B

We report on a 2-year-old girl affected by an isolated form of brachydactyly type B (BDB)-like malformation of the limbs consistent with Cooks syndrome (CS). A literature review was carried out in an attempt to delineate the CS clinical spectrum and separate it from BDB. The two conditions can be differentiated on clinical, radiological, and genetic grounds. In particular, CS shows a characteristic pattern of ungueal and phalangeal anomalies. In the hands, all rays are involved to a similar extent with bulbous tips. The feet are generally more severely affected than the hands. Involvement of the nails appears to be a primary feature and not secondary to phalangeal hypo/aplasia. Also, radial and ulnar rays are similarly affected. The CS clinical spectrum is expanded to include ungueal tumor-like lesions, observed in the present patient.