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Modern Technique in Treatment.
1312
THE TREATMENT OF HAMMER-TOE.
Modern Technique Series A
in Treatment.
of Special Articles, contributed by invitation, on the Treatment of Medical and
Surgical Conditions.
CXXVII.—THE TREATMENT OF
HAMMER-TOE.I
PART II.—OPERATIVE MEASURES. ONE difficulty in these small operations is that of The operation must be done delicately, and a access. dressing applied which maintains complete correction without being cumbersome. To fix the deformed toe, and to hold the toes on either side out of the way, a stout fishing gut suture is passed through the pulpy end of each of the three toes. The ends of each suture are gathered up in three separate artery forceps, and the toes held rigidly and firmly out of the way of each other by the assistant. At the end of the operation, when the dressing has been applied-the toe-tip being left uncovered ,in order to watch the circulation subsequently-the retention sutures are removed. To assist precision and delicacy a rubber bandage should be used as a tourniquet, applied immediately above the ankle after the foot has been exsanguinated by a similar bandage, and is not removed until the dressing is dry and set. The best dressing is sterile ribbon gauze of the same width as the length of the toe, applied directly to the wound (which is sewn up with two or three fine interrupted fishing-gut sutures), and wound around the toe moderately firmly and closely (but without risk of strangulation), with thick collodion applied as the layers are increased. About a dozen or so layers are requisite, and the retention sutures hold the toes corrected for a few minutes while the collodion dries. The " splint " is rigid, and the circulation is noted to be satisfactory in the uncovered toe-tip before the patient leaves the
theatre. The dressing does not shrink subsequently. It is maintained for two weeks, and then cut off with strong scissors, and the skin sutures removed. A similar dressing is applied, and renewed again in another fortnight, taking six weeks in all. The patient can walk a week or two after the operation in this dressing, which is so rigid and small that the walking is harmless and comfortable. Another advantage of the sealed dressing is the avoidance of the thickening of the joint which is liable to persist for many weeks if an ordinary gauze dressing be used. Excision of Head of Proximal Phalanx, with Removal of Cartilaginous Base of Middle
Phalanx.
Of the several operations that have been advised from time to time for acquired hammer-toe excision of the head of the proximal phalanx, combined with the removal of the cartilaginous base of the middle phalanx, is to be preferred. No flexor tenotomy or division of the flexor capsule is done, and only just as much of the head of the proximal phalanx is removed as will enable the toe to be made quite straight on strong passivestretching into extension. There should be no tension tending to reproduce flexion when the operation is finished. An ankylosis (arthrodesis) of the proximal joint is desired. If the base of the middle phalanx is left untouched, fibrous rather than bony ankylosis is likely to result, with some risk of recurrence of the flexion deformity. The dorsal incision is elliptical, of about three-fifths the width of the toe, and the redundant skin with the dorsal corn is removed. There is no need to damage the lateral digital arteries. If the deformity be severe, the dorsal expansion of the extensor tendon should be removed with the elliptical piece of skin ; if not, it may be preferable merely to incise the tendon longitudinally, to give access to the head of the bone. But the excision is more difficult to do delicately in this case. The head of the bone is best removed by fine-pointed bone-cutting forceps, and the neck of the bone need not be fragmented. :1 fine chisel or stout, small knife
is used to denude the base of the second phalanx of its cartilage. The skin suturing helps to maintain subsequent correction. In operating on the congenital type, the proximal or terminal joints are similarly corrected, according to the site of greater flexion. It is never necessary to correct both joints. To correct the adduction and rotation of the terminal (one or two) phalanges, the elliptical excision of the skin will be placed somewhat to the outer side of the joint, at the site of the maximum bend. The dorsal expansion of the tendon is removed. In these tiny toes the joint excision is best done with a small, stout scalpel. The skin wound can be sutured in such a way as to assist in correcting flexion, adduction, and rotation. Two or three toes can be operated upon at the same time.
Alternative Operations. The alternative operations may be mentioned. Amputation of the whole second toe in the acquired variety is not usually desirable unless its terminal nail portion is grossly deformed, or the toes on either side so rigid in their position that there will be no longer room for the corrected toe in its proper place, or unless, as in neglected cases, lateral corns exist. The objection to total amputation is that the frequently associated hallux valgus is liable to increase subsequently, from pressure of the stocking and want of the preventive effect of the second toe. Amputation of the terminal phalanx alone would in most cases leave an awkwardly dorsiflexed proximal stump. In some cases, however, where the hammer deformity is not giving trouble from pressure on a dorsal corn, but where the nail is thick and distorted, with painful terminal corn, the terminal phalanx can be amputated at the end joint, with removal of the bone and nail bed, by the palmar flap method. Total removal of the proximal phalanx has been advocated, leaving a short, stumpy toe which would serve to prevent the hallux valgus from increasing, but with no other function. The writer has no experience of this method, nor does it appeal to him. In milder cases of acquired deformity, subcutaneous division of the flexor tendons and capsule may be done, followed by passive correction and splintage as after the open operation, but there is some risk of relapse. Flexor tendons do not unite after tenotomy, and thus the only important function of the toes, flexion, is permanently lost, which is not the case after excision by the dorsal method. In any operative method extension contracture of the metatarso-phalangeal joint must also be overcome by subcutaneous division of the extensor tendons, otherwise relapse into flexion at the distally corrected joint is fostered. After the tenotomy the toe is forced into flexion at the metatarso-phalangeal joint, and retained thus in the dressing while the joints of the toe are kept fully extended.
Correction of " Clawed Toes. In the correction of " clawed toes-i.e., those associated with pes cavus and boot-caused deformities -attention is directed chiefly to the extension of the metatarso-phalangeal joints rather than to the flexion of the distal joints. In pes cavus the toes are dealt with after the arch has been flattened sufficiently by the Steindler operation. The various procedures for correcting the toes are : (1) Division of dorsal extensor tendons and
capsules, and tethering the toes down to a sole-plate for four to six weeks, by night and day, followed by active and passive
slotted and looped
exercises and electrical stimulation of the intrinsic muscles. This is the older method, and is liable to result in relapse after some months. (2) Transplanting the dorsal extensor tendons into the necks of one or more metatarsals or into the dorsum of the foot. There are several modifications of this method. (3) Transplantation of the long flexor tendons from the terminal to the proximal phalanges, a method first advocated by the writer. The hyper-extension at the
metatarso-phalangeal joints is corrected by one or other of these methods, while the flexion of the toe-
DR. W. G. SAVAGE : IMPROVEMENT OF THE MILK-SUPPLY.
1313
is overcome by passive stretchings and active Agriculture and Fisheries. These powers are, thereexercises, perhaps assisted by tenotomy of the flexor fore, very much in the nature of a dark horse of tendons. In deformed toes associated with hallux possibilities but hardly a certainty, perhaps not a valgus the excision and tenotomy methods as starter. The need for a new Milk and Dairies Order to
joints
described for real hammer-toe may be carried out
control method in milk production has been amply demonstrated in my last article, and under Section I. of the 1915 Act an effective Order is possible. The Draft Milk and Dairies Order, 1915, proposed to be made under the Act was very valuable, and it is to be hoped that any Order issued will be along the lines of this Order, with additions dealing with methods of
on
those toes which are causing painful disability. In retentive splintage after correction, when the toes need to be held flexed in the metatarso-phalangeal and extended in the more distal joints, the sealed dressing and looped sole-plate methods described above are more practicable than the use of plaster-of-Paris in which it is difficult to obtain precise correction without risk of producing pressure sores. W. H. TRETHOWAN, F.R.C.S. Eng., Orthopædic Surgeon to Guy’s Hospital.
clean milk production. While education is more important than legislation connexion with an improved milk-supply, more definite legal requirements as regards milk production and handling are in themselves of great educative influence when tactfully carried out. No experienced milk-reformer wants drastic enactments, and the essentials are very simple things. Too zealous workers have done much harm, and led agricultural interests to take fright at what are to them, and indeed in reality, impossible requirements. If, however, it is THE MILK-SUPPLY AND ITS right to require cows’ udders to be clean and milkers to have clean hands and to milk in cleanly fashion, IMPROVEMENT. and for churns to be sent locked, why not say so BY WILLIAM G. SAVAGE, B.Sc., M.D. LOND., legally and have done with it ? There is no dispute as to the essentials. COUNTY MEDICAL OFFICER OF HEALTH, SOMERSET. In my opinion it is for the medical profession to press for better control, either by the passing of a 111. *-remedies TO IMPROVE THE MILK-SUPPLY. suitable Milk Act or, failing that, by no further postTHE final report, issued in 1919, of the Committee ponement of the operation of the 1915 Act. It is on the Production and Distribution of Milk, emphasised impracticable to discuss all the sections of this Act, what all authorities on the subject are agreed upon, but as regards tuberculosis they demand a little more that the present milk-supply is highly unsatisfactory. consideration. Since that date the only Act passed affecting milk has The Prevention of Human Tuberculosis from Milk. been the Milk and Dairies (Amendment) Act, 1922, which in most essentials leaves the problem alone. Everyone who has made a study of the problem of In addition to questions of chemical purity, which the eradication of bovine tuberculosis is aware of its cannot be dealt with from limits of space, there are extreme complexity and difficulty, in part due to its three different bacteriological problems-i.e., freedom magnitude, in part to the large financial interests from tubercle bacilli, general bacterial cleanliness, and involved, in part to the fact that it concerns two removal of the liability to spread acute infectious Government departments looking at the problem disease. With so many problems it will be obvious from different angles. Fortunately it is equally that there can be no simple short cut to a satisfactory obvious that it is a solvable problem, while it is agreed supply, but that it is a problem which must be surveyed that progress can be achieved along several lines. from many angles. It is an agricultural even more than a public health question, and while the two are not identical they are More Effective Legal Control. It is impracticable to discuss these interdependent. The need for additional legal powers has been lines of progress and remedies in detail here, and, There is, demonstrated in the previous article. indeed, they would involve a very large number of however, another Act upon the Statute-book, the purely technical considerations. Fortunately there Milk and Dairies (Consolidation) Act, 1915. This is are many valuable papers available on the subject. a unique measure, since (with some modifications) it Just as with human tuberculosis, it is obvious that is a repetition of and substitution for the Milk and drastic measures are impracticable and would defeat Dairies Act, 1914, which, although passed, never their object, and that progress can only result by came into force, and, like it, the 1915 Act has been advancing along definite and approved lines. The postponed and has never come into operation. two most approved lines have been (a) the thorough The 1922 Act further extended its date of coming separation of healthy from tuberculous animals and into force to Sept. 1st, 1925. This Act has been the rearing of a healthy non-infected herd ; (b) the kept in cold storage for ten years, and there is nothing elimination of cases of " open " tuberculosis in to prevent a further Act from still further extending bovines as the cases which most spread the disease the period of hibernation. and mainly infect the milk-supply. From the point of view of the milk-reformer this Experience has shown that much can be effected Act cannot be accepted as likely to solve all the existing these lines. Judging from past legislation the along milk deficiencies. On the other hand, it contains a most lines of administrative action will be probable The a re-enactment of the 1914 Tuberculosis number of valuable and important sections. Order,. mother Bill was in the end an " agreed " measure. with the tuberculosis clauses of the 1915 Act. together " An agreed " Bill in the sphere of public health usually These clauses in the 1915 Act, if they become effective, means that to get it passed many of the best clauses will a good deal of power, but they seem comgive have either to be withdrawn or accepted handicapped in working and, while they may prevent with " safeguards " which make them unworkable or plicated some infection from tuberculous milk, will do little so slow in operation that they fail to do much good. to reduce the amount of bovine tuberculosis. Their It is cumbersome in working, since it gives both the hope in this direction is in the power they smaller local authorities and county councils powers ! greatest for the appointment of whole-time veterinary give which are in part concurrent. Its chief value is in and for bacteriological examinations. The Section I. which gives the Ministry of Health power inspectors Tuberculosis Order of 1914 is an Order of the Board of to make Orders which, if fully made use of, would go which was suspended at the onset of the Agriculture a long way legally to ensure clean milk. These powers war and has not been re-enacted. In the words of the are coupled with the " safeguard " that they have the Order " aims at securing the circular, covering to be made with the concurrence of the Board of destruction of every cow found to be suffering from * Parts I. and II. appeared in THE LANCET of May 23rd and tuberculosis of the udder, or to be giving tuberculous 30th and June 6th respectively. milk. as well as of bovine animals which are suffering .
in
Special Articles.
I
THE TREATMENT OF HAMMER-TOE.
Modern Technique Series A
in Treatment.
of Special Articles, contributed by invitation, on the Treatment of Medical and
Surgical Conditions.
CXXVII.—THE TREATMENT OF
HAMMER-TOE.I
PART II.—OPERATIVE MEASURES. ONE difficulty in these small operations is that of The operation must be done delicately, and a access. dressing applied which maintains complete correction without being cumbersome. To fix the deformed toe, and to hold the toes on either side out of the way, a stout fishing gut suture is passed through the pulpy end of each of the three toes. The ends of each suture are gathered up in three separate artery forceps, and the toes held rigidly and firmly out of the way of each other by the assistant. At the end of the operation, when the dressing has been applied-the toe-tip being left uncovered ,in order to watch the circulation subsequently-the retention sutures are removed. To assist precision and delicacy a rubber bandage should be used as a tourniquet, applied immediately above the ankle after the foot has been exsanguinated by a similar bandage, and is not removed until the dressing is dry and set. The best dressing is sterile ribbon gauze of the same width as the length of the toe, applied directly to the wound (which is sewn up with two or three fine interrupted fishing-gut sutures), and wound around the toe moderately firmly and closely (but without risk of strangulation), with thick collodion applied as the layers are increased. About a dozen or so layers are requisite, and the retention sutures hold the toes corrected for a few minutes while the collodion dries. The " splint " is rigid, and the circulation is noted to be satisfactory in the uncovered toe-tip before the patient leaves the
theatre. The dressing does not shrink subsequently. It is maintained for two weeks, and then cut off with strong scissors, and the skin sutures removed. A similar dressing is applied, and renewed again in another fortnight, taking six weeks in all. The patient can walk a week or two after the operation in this dressing, which is so rigid and small that the walking is harmless and comfortable. Another advantage of the sealed dressing is the avoidance of the thickening of the joint which is liable to persist for many weeks if an ordinary gauze dressing be used. Excision of Head of Proximal Phalanx, with Removal of Cartilaginous Base of Middle
Phalanx.
Of the several operations that have been advised from time to time for acquired hammer-toe excision of the head of the proximal phalanx, combined with the removal of the cartilaginous base of the middle phalanx, is to be preferred. No flexor tenotomy or division of the flexor capsule is done, and only just as much of the head of the proximal phalanx is removed as will enable the toe to be made quite straight on strong passivestretching into extension. There should be no tension tending to reproduce flexion when the operation is finished. An ankylosis (arthrodesis) of the proximal joint is desired. If the base of the middle phalanx is left untouched, fibrous rather than bony ankylosis is likely to result, with some risk of recurrence of the flexion deformity. The dorsal incision is elliptical, of about three-fifths the width of the toe, and the redundant skin with the dorsal corn is removed. There is no need to damage the lateral digital arteries. If the deformity be severe, the dorsal expansion of the extensor tendon should be removed with the elliptical piece of skin ; if not, it may be preferable merely to incise the tendon longitudinally, to give access to the head of the bone. But the excision is more difficult to do delicately in this case. The head of the bone is best removed by fine-pointed bone-cutting forceps, and the neck of the bone need not be fragmented. :1 fine chisel or stout, small knife
is used to denude the base of the second phalanx of its cartilage. The skin suturing helps to maintain subsequent correction. In operating on the congenital type, the proximal or terminal joints are similarly corrected, according to the site of greater flexion. It is never necessary to correct both joints. To correct the adduction and rotation of the terminal (one or two) phalanges, the elliptical excision of the skin will be placed somewhat to the outer side of the joint, at the site of the maximum bend. The dorsal expansion of the tendon is removed. In these tiny toes the joint excision is best done with a small, stout scalpel. The skin wound can be sutured in such a way as to assist in correcting flexion, adduction, and rotation. Two or three toes can be operated upon at the same time.
Alternative Operations. The alternative operations may be mentioned. Amputation of the whole second toe in the acquired variety is not usually desirable unless its terminal nail portion is grossly deformed, or the toes on either side so rigid in their position that there will be no longer room for the corrected toe in its proper place, or unless, as in neglected cases, lateral corns exist. The objection to total amputation is that the frequently associated hallux valgus is liable to increase subsequently, from pressure of the stocking and want of the preventive effect of the second toe. Amputation of the terminal phalanx alone would in most cases leave an awkwardly dorsiflexed proximal stump. In some cases, however, where the hammer deformity is not giving trouble from pressure on a dorsal corn, but where the nail is thick and distorted, with painful terminal corn, the terminal phalanx can be amputated at the end joint, with removal of the bone and nail bed, by the palmar flap method. Total removal of the proximal phalanx has been advocated, leaving a short, stumpy toe which would serve to prevent the hallux valgus from increasing, but with no other function. The writer has no experience of this method, nor does it appeal to him. In milder cases of acquired deformity, subcutaneous division of the flexor tendons and capsule may be done, followed by passive correction and splintage as after the open operation, but there is some risk of relapse. Flexor tendons do not unite after tenotomy, and thus the only important function of the toes, flexion, is permanently lost, which is not the case after excision by the dorsal method. In any operative method extension contracture of the metatarso-phalangeal joint must also be overcome by subcutaneous division of the extensor tendons, otherwise relapse into flexion at the distally corrected joint is fostered. After the tenotomy the toe is forced into flexion at the metatarso-phalangeal joint, and retained thus in the dressing while the joints of the toe are kept fully extended.
Correction of " Clawed Toes. In the correction of " clawed toes-i.e., those associated with pes cavus and boot-caused deformities -attention is directed chiefly to the extension of the metatarso-phalangeal joints rather than to the flexion of the distal joints. In pes cavus the toes are dealt with after the arch has been flattened sufficiently by the Steindler operation. The various procedures for correcting the toes are : (1) Division of dorsal extensor tendons and
capsules, and tethering the toes down to a sole-plate for four to six weeks, by night and day, followed by active and passive
slotted and looped
exercises and electrical stimulation of the intrinsic muscles. This is the older method, and is liable to result in relapse after some months. (2) Transplanting the dorsal extensor tendons into the necks of one or more metatarsals or into the dorsum of the foot. There are several modifications of this method. (3) Transplantation of the long flexor tendons from the terminal to the proximal phalanges, a method first advocated by the writer. The hyper-extension at the
metatarso-phalangeal joints is corrected by one or other of these methods, while the flexion of the toe-
DR. W. G. SAVAGE : IMPROVEMENT OF THE MILK-SUPPLY.
1313
is overcome by passive stretchings and active Agriculture and Fisheries. These powers are, thereexercises, perhaps assisted by tenotomy of the flexor fore, very much in the nature of a dark horse of tendons. In deformed toes associated with hallux possibilities but hardly a certainty, perhaps not a valgus the excision and tenotomy methods as starter. The need for a new Milk and Dairies Order to
joints
described for real hammer-toe may be carried out
control method in milk production has been amply demonstrated in my last article, and under Section I. of the 1915 Act an effective Order is possible. The Draft Milk and Dairies Order, 1915, proposed to be made under the Act was very valuable, and it is to be hoped that any Order issued will be along the lines of this Order, with additions dealing with methods of
on
those toes which are causing painful disability. In retentive splintage after correction, when the toes need to be held flexed in the metatarso-phalangeal and extended in the more distal joints, the sealed dressing and looped sole-plate methods described above are more practicable than the use of plaster-of-Paris in which it is difficult to obtain precise correction without risk of producing pressure sores. W. H. TRETHOWAN, F.R.C.S. Eng., Orthopædic Surgeon to Guy’s Hospital.
clean milk production. While education is more important than legislation connexion with an improved milk-supply, more definite legal requirements as regards milk production and handling are in themselves of great educative influence when tactfully carried out. No experienced milk-reformer wants drastic enactments, and the essentials are very simple things. Too zealous workers have done much harm, and led agricultural interests to take fright at what are to them, and indeed in reality, impossible requirements. If, however, it is THE MILK-SUPPLY AND ITS right to require cows’ udders to be clean and milkers to have clean hands and to milk in cleanly fashion, IMPROVEMENT. and for churns to be sent locked, why not say so BY WILLIAM G. SAVAGE, B.Sc., M.D. LOND., legally and have done with it ? There is no dispute as to the essentials. COUNTY MEDICAL OFFICER OF HEALTH, SOMERSET. In my opinion it is for the medical profession to press for better control, either by the passing of a 111. *-remedies TO IMPROVE THE MILK-SUPPLY. suitable Milk Act or, failing that, by no further postTHE final report, issued in 1919, of the Committee ponement of the operation of the 1915 Act. It is on the Production and Distribution of Milk, emphasised impracticable to discuss all the sections of this Act, what all authorities on the subject are agreed upon, but as regards tuberculosis they demand a little more that the present milk-supply is highly unsatisfactory. consideration. Since that date the only Act passed affecting milk has The Prevention of Human Tuberculosis from Milk. been the Milk and Dairies (Amendment) Act, 1922, which in most essentials leaves the problem alone. Everyone who has made a study of the problem of In addition to questions of chemical purity, which the eradication of bovine tuberculosis is aware of its cannot be dealt with from limits of space, there are extreme complexity and difficulty, in part due to its three different bacteriological problems-i.e., freedom magnitude, in part to the large financial interests from tubercle bacilli, general bacterial cleanliness, and involved, in part to the fact that it concerns two removal of the liability to spread acute infectious Government departments looking at the problem disease. With so many problems it will be obvious from different angles. Fortunately it is equally that there can be no simple short cut to a satisfactory obvious that it is a solvable problem, while it is agreed supply, but that it is a problem which must be surveyed that progress can be achieved along several lines. from many angles. It is an agricultural even more than a public health question, and while the two are not identical they are More Effective Legal Control. It is impracticable to discuss these interdependent. The need for additional legal powers has been lines of progress and remedies in detail here, and, There is, demonstrated in the previous article. indeed, they would involve a very large number of however, another Act upon the Statute-book, the purely technical considerations. Fortunately there Milk and Dairies (Consolidation) Act, 1915. This is are many valuable papers available on the subject. a unique measure, since (with some modifications) it Just as with human tuberculosis, it is obvious that is a repetition of and substitution for the Milk and drastic measures are impracticable and would defeat Dairies Act, 1914, which, although passed, never their object, and that progress can only result by came into force, and, like it, the 1915 Act has been advancing along definite and approved lines. The postponed and has never come into operation. two most approved lines have been (a) the thorough The 1922 Act further extended its date of coming separation of healthy from tuberculous animals and into force to Sept. 1st, 1925. This Act has been the rearing of a healthy non-infected herd ; (b) the kept in cold storage for ten years, and there is nothing elimination of cases of " open " tuberculosis in to prevent a further Act from still further extending bovines as the cases which most spread the disease the period of hibernation. and mainly infect the milk-supply. From the point of view of the milk-reformer this Experience has shown that much can be effected Act cannot be accepted as likely to solve all the existing these lines. Judging from past legislation the along milk deficiencies. On the other hand, it contains a most lines of administrative action will be probable The a re-enactment of the 1914 Tuberculosis number of valuable and important sections. Order,. mother Bill was in the end an " agreed " measure. with the tuberculosis clauses of the 1915 Act. together " An agreed " Bill in the sphere of public health usually These clauses in the 1915 Act, if they become effective, means that to get it passed many of the best clauses will a good deal of power, but they seem comgive have either to be withdrawn or accepted handicapped in working and, while they may prevent with " safeguards " which make them unworkable or plicated some infection from tuberculous milk, will do little so slow in operation that they fail to do much good. to reduce the amount of bovine tuberculosis. Their It is cumbersome in working, since it gives both the hope in this direction is in the power they smaller local authorities and county councils powers ! greatest for the appointment of whole-time veterinary give which are in part concurrent. Its chief value is in and for bacteriological examinations. The Section I. which gives the Ministry of Health power inspectors Tuberculosis Order of 1914 is an Order of the Board of to make Orders which, if fully made use of, would go which was suspended at the onset of the Agriculture a long way legally to ensure clean milk. These powers war and has not been re-enacted. In the words of the are coupled with the " safeguard " that they have the Order " aims at securing the circular, covering to be made with the concurrence of the Board of destruction of every cow found to be suffering from * Parts I. and II. appeared in THE LANCET of May 23rd and tuberculosis of the udder, or to be giving tuberculous 30th and June 6th respectively. milk. as well as of bovine animals which are suffering .
in
Special Articles.
I