Chapter X: Deformities of the Extremities (3)

The first phalanx is dorsiflexed, and the second is plantar-flexed, while the third varies in its attitude, sometimes being in line with the second (Fig. 160), sometimes even more plantar-flexed, and sometimes dorsiflexed. When the second toe alone is affected, as is commonly the case, it is partly buried by those on either side of it, only the knuckle of the first inter-phalangeal joint projecting above the level of the other toes (Fig. 160). The skin over the head of the first phalanx being pressed upon by the boot usually presents a corn, under which a bursa forms (Fig. 161). Both the corn and the bursa are subject to attacks of inflammation, which cause suffering and disability in walking. The soft parts at the distal extremity of the toe are flattened out by contact with the sole of the boot--hence the supposed resemblance to the head of a hammer.

On dissection, it is found that the contracture is maintained by shortening of the plantar portions of the collateral ligaments of the first inter-phalangeal joint and of the glenoid ligament upon which the head of the first phalanx rests.

Hammer-toe is usually ascribed to the use of tight socks and of ill-fitting boots, especially those which are median-pointed and are too short for the feet, but in some persons there appears to be an inherited predisposition to the deformity.

_a_, Corn.
_b_, Bursa over first inter-phalangeal joint.]

While corrective manipulations, strapping, and the use of splints may be of service in slight cases, it is usually necessary to perform an operation in order to extend the toe permanently. Before operating, any infective condition, such as a suppurating corn or bursa, must be corrected. The collateral and glenoid ligaments are divided subcutaneously--Spitzy also divides the flexor tendons and capsule--and if the toe can then be straightened, the foot is secured to a metal splint moulded to the sole and provided with longitudinal slots opposite the intervals on either side of the toe affected. The toe is drawn down to the splint by passing a loop of cotton or elastic bandage round the toe and through the slots. In many cases the contraction of all the tissues on the plantar aspect, including the skin, prevents the toe being straightened even after division of the ligaments, and it is then necessary to remove the head and neck of the first phalanx through a lateral incision. This is more satisfactory than amputation of the affected toe at the metatarso-phalangeal joint, as after this the adjacent toes tend to fall together and favour hallux valgus. If amputation is performed, a pad of cotton wool or rubber prop should be worn to fill up the vacant space.

The term _Gampsodactyly_ has been applied to a deformity in which all the toes assume the position of hammer-toe, usually from a spastic condition of the muscles controlling the toes.

#Hypertrophy of the Toes.#--One or more of the toes may be the seat of hypertrophy or local giantism. This is usually present at birth or appears in early childhood, and may form part of an overgrowth involving the entire lower extremity (Fig. 162). The overgrowth may involve all the tissues equally, or the subcutaneous fat may be specially affected. The medial toes are those most commonly hypertrophied. In addition to being enlarged, the toe may be displaced from its normal axis. The hypertrophy may affect two or more toes which are fused together or webbed (Fig. 162). The treatment consists in amputating as much of the toe as will allow of an ordinary boot being worn.

#Supernumerary Toes# (_Polydactylism_).--These vary from mere appendages of skin to fully developed toes (Fig. 163); if they interfere with the wearing of boots they should be removed.

#Webbing of the Toes# (_Syndactylism_).--This may affect two or more toes, which may be united merely by a web of skin, or so completely fused that the individual digits are only indicated by the nails; the degree of fusion is shown by means of skiagrams. Unless associated with congenital hypertrophy, no treatment is called for.

(Photograph lent by Sir George T. Beatson.)]

THE UPPER EXTREMITY

#Congenital Absence of the Clavicle.#--Both clavicles may be absent, and it is possible for the patient voluntarily to bring his shoulders into contact with one another in front of the chest; there is little or no impairment of function.

#Displacements of the Scapula.#--_Congenital Elevation of the Scapula_ (Sprengel's shoulder, 1891).--This abnormality is rare, and is not usually recognised till several years after birth. In one variety there is a bridge of bone or fibrous tissue connecting the superior angle of the scapula with the spinous process of one of the cervical vertebrae, and there may be a false joint at one end of the bridge permitting a certain amount of movement of the scapula. Associated abnormalities in the vertebrae and in the ribs are shown in skiagrams. In the more common type, the scapula seems to be held in its elevated position by shortening of the muscles attached to its body, and it is often rotated so that its lower angle is close to the spine and its axillary border nearly horizontal, or the axillary border may lie in close to the ribs, and the vertebral border project from the chest wall. The shoulder is generally higher and farther forward on the affected side, and there is a moderate degree of scoliosis. There is a want of purchase in the movements of the shoulder and upper arm.

(Mr. D. M. Greig's case.)]

When the deformity is bilateral, which is rare, the neck is short and thick, the chin lies close to the sternum, and the arms can scarcely be raised to the horizontal.

Gymnastic exercises and the wearing of a brace to hold the shoulders back and down may be followed by some improvement, but, as a rule, it is necessary to mobilise the scapula by operation. An X-ray photograph should first be taken, because, when the scapula is connected with the spine by a bridge of bone, this must be resected. The muscles attached to the vertebral border and spine of the scapula are divided, the bone is drawn down to its proper position, and the parts are fixed by plaster bandages.

_Winged Scapula._--This condition consists in a marked displacement backwards of the lower angle and vertebral border of the scapula, when the patient attempts to raise the arm from the side (Fig. 165). Under normal conditions, in making this movement the serratus and rhomboid muscles pull forward the vertebral border and inferior angle of the scapula, and so fix the bone firmly against the chest wall. When these muscles are paralysed, as a result of anterior poliomyelitis, neuritis, or injury of the long thoracic nerve of Bell, or of the fifth and sixth cervical nerve-roots through which they receive their supply, the patient is unable to abduct the arm, and the deltoid having lost its _point d'appui_, its contraction merely results in tilting the angle of the scapula backward (Fig. 165).

_Treatment._--In the majority of recent cases the condition yields to the administration of strychnin and other muscle and nerve tonics, and the use of massage and the faradic current. The application of a carefully adjusted padded belt is sometimes useful. The method of treatment by stitching the latissimus dorsi over the lower angle of the scapula is based on the erroneous assumption that the displacement is due to the slipping of that muscle off the bone; at the same time, it must be admitted that the operation sometimes diminishes the deformity and adds to the patient's comfort.

A more efficient method consists in detaching the clavicular portion of the pectoralis major from its insertion, and stitching it to the serratus anterior so as to make it take on the function of this muscle, or stitching it to the axillary border of the scapula. Success has also followed suture of the vertebral border of the scapula to the subjacent ribs (Eiselsberg).

_Displacement of the scapula upwards and laterally_ has been observed as a result of partial paralysis of the trapezius when the nerves supplying it have been divided in removing tuberculous glands from the neck. In these acquired displacements, treatment is directed towards the nerve lesion and towards the improvement of the muscles by electricity, massage, and exercises; when the paralysis of the trapezius is permanent, the disability is gradually overcome by the compensatory hypertrophy of the levator muscle.

#Congenital Dislocation of the Shoulder.#--This rare condition is usually bilateral, and is associated with other congenital defects. The glenoid cavity is deformed or absent, and the dislocation may be sub-coracoid, sub-acromial, or sub-spinous. The movements of the arm are restricted, and the development of the extremity as a whole is imperfect. It is sometimes possible to reduce the dislocation by manipulation, or, if this fails, by operation. Unilateral dislocation is sometimes mistaken for dislocation that has occurred during delivery and _vice versa_.

#Habitual Dislocation# is described on p. 65.

#Paralytic Deformities--Paralytic Dislocation of the Shoulder.#--The muscles in the region of the shoulder may have their innervation interfered with as a result of various conditions, of which poliomyelitis and injuries of the brachial plexus at birth are the most important. The capsular ligament of the shoulder-joint, being no longer kept tense by the scapular muscles--especially the deltoid and lateral rotators--becomes relaxed, and is gradually stretched by the weight of the arm. The appearances are characteristic; the muscles of the shoulder are wasted, the acromion is prominent, and between it and the upper end of the humerus there is a marked hollow into which one or more fingers may be inserted. The arm hangs flaccid by the side, rotated medially and pronated, and moves in a flail-like fashion in all directions, the patient having little control over it. The best results are obtained by the transplantation of muscles, the trapezius being detached from the clavicle and stitched to the surface of the deltoid, and the upper arm fixed in the position of horizontal abduction with the arm rotated laterally and supinated. Bradford inserts a portion of the trapezius into the humeral insertion of the deltoid. When these methods are impracticable, the upper arm may be fixed to the trunk by some form of apparatus, or arthrodesis is performed so that the movements of the scapula are communicated to the upper arm; the best attitude for ankylosis is one of abduction with medial rotation, so that the hand can be brought to the mouth.

In cases of poliomyelitis, when all the muscles governing the elbow are paralysed while the muscles of the hand have escaped, it may be of great service to fix this joint permanently at rather less than a right angle. This may be effected by arthrodesis, or by removing an extensive diamond-shaped portion of skin from the flexor aspect of the joint and bringing the raw surfaces together, commencing the stitching at the lateral apices of the gap.

#Congenital Dislocations at the Elbow.#--_The head of the radius_ may be dislocated forwards, backwards, or laterally--usually in association with imperfect development of the radius and of the lateral condyle of the humerus. When the displaced head of the bone interferes with supination, or with extension, it should be removed. Congenital dislocation of both bones of the forearm is extremely rare.

#Cubitus Valgus# and #Cubitus Varus#.--When the normal arm hangs by the side with the palm of the hand directed forward, the forearm and upper arm form an angle which is open outwards--known as the "carrying angle"; it is usually more marked in women in association with the greater breadth of the pelvis and the relative narrowness of the shoulders. When this angle is increased, the attitude is described as one of _cubitus valgus_. This deformity may be acquired as a result of rickets, but more commonly it is due to fracture of the lateral condyle of the humerus, in which the separated fragment has been displaced upwards.

_Cubitus varus_ is the reverse of cubitus valgus. It is more common, is always pathological, and is nearly always a result of fracture of the lower end of the humerus or separation of the lower humeral epiphysis and subsequent interference with growth. These deformities may be corrected by supra-condylar osteotomy of the humerus.

#Synostosis of the superior radio-ulnar joint# is a rare congenital condition, in which the hinge movements at the elbow are free, but supination is impossible; an attempt may be made by operation to form a new joint.

#Volkmann's ischaemic contracture# of the muscles of the forearm, resulting in the production of claw-hand, is described in Volume I., p. 415.

#Deformities of the Forearm and Hand.#--The _radius_ may be absent completely or in part, frequently in combination with other malformations. The most evident result is a deviation of the hand to the radial side--one variety of _club-hand_. The forearm is shortened, the ulna thickened and often bent, and the thumb and its metacarpal bone are often absent, so that the usefulness of the hand and arm is greatly impaired (Fig. 171). For this condition Bardenheuer devised an operation which consists in splitting the lower end of the ulna longitudinally and inserting the proximal bones of the carpus into the cleft.

Congenital deficiency of the _ulna_ is extremely rare.

#Intra-uterine amputation# by constriction of amniotic bands sometimes occurs (Figs. 168, 169).

#Drop Wrist from Anterior Poliomyelitis.#--In this condition the capacity of extending the fingers is deficient or absent. Recovery can be confidently predicted if, on still further flexing the fingers, they can be voluntarily extended towards the point from which they are flexed (Tubby and Jones). Considerable improvement may result from fixing the hand by means of a splint in the attitude of dorsal flexion. The splint is removed at frequent intervals to allow of massage and other treatment being carried out, and it has usually to be worn for a period of one to two years. In some cases recourse should be had to arthrodesis.

(Mr. D. M. Greig's case.)]

In _spastic paralysis_ the most pronounced deformity is flexion of the forearm and pronation and flexion of the hand (Fig. 166). Gradual extension at the wrist may be brought about by the use of a malleable splint, in which the angle is gradually increased, over a period of at least twelve months. Failing success by this method, operation may be had recourse to, and this consists in lengthening of tendons, and tendon transplantation. Tubby has devised an operation for converting the pronator radii teres into a supinator, and Robert Jones another in which the flexors of the carpus are made to take the place of the extensors. "These operations, combined if necessary with elongation of the flexors of the fingers, pave the way for diminution of the angle of flexion at the elbow, lessening of the pronator spasm, increase of the supinating power, reduction of the carpal flexion, and addition to the extensor power at the wrist" (Tubby and Jones).

#Congenital Club-hand.#--This rare deformity corresponds to congenital club-foot, and probably arises in the same way. The hand and fingers are rigidly flexed to the ulnar or radial side, so that the patient is incapable of moving them. Treatment is carried out on the same lines as for club-foot.

A deformity resembling this, _acquired club-hand_, is brought about when the growth of either of the bones of the forearm has been arrested as a result of disease or of traumatic separation of its lower epiphysis. The hand deviates to the side on which the growth has been arrested--_manus valga_ or _vara_. The treatment consists in resecting a portion of the longer bone.

(Photograph lent by Sir George T. Beatson.)]

#Madelung's Deformity of the Wrist.#--In 1878, Madelung called attention to a deformity also called sub-luxation of the hand, in which the lower articular surface of the radius is rotated so that it looks towards the palm; there is palmar displacement of the carpus, and the lower end of the ulna projects on the dorsum. The cause of the condition is obscure, but it is met with chiefly in young women with slack ligaments, whose laborious occupation or athletic pursuits subject the hand and wrist to long-continued or repeated strain. It is as frequently unilateral as bilateral and may recur in successive generations. There is a good deal of pain, the grasping power of the hand is impaired, and dorsiflexion is considerably restricted. The deformity disappears on forcible traction, but at once reappears when the traction is removed. A wristlet of poroplastic or leather extending from the mid-forearm to the knuckles is moulded to the limb in the corrected position, and is taken off at intervals for massage and exercises.

When _operative treatment_ is called for, it takes the form of osteotomy of the radius and ulna about an inch or more above their articular surfaces.

#Congenital dislocation of the wrist# is rare.

#Deformities of the Fingers.#--Various forms of _congenital dislocation_ of the fingers are met with, but they are of little clinical importance, as they interfere but slightly with the usefulness of the digit affected.

_Congenital lateral deviation of the phalanges_ is more unsightly than disabling; it is met with chiefly in the thumb, in which the terminal phalanx deviates to the radial or to the ulnar side in extension; the deviation disappears on flexion.

_Congenital contraction of the fingers_ is comparatively common. It is an inherited deformity, and is often met with in several members of the same family. It most frequently affects the little or the ring and little fingers (Fig. 172), and is usually bilateral. The second and third phalanges are flexed towards the palm; the first phalanx is dorsiflexed, this being the reverse of what is observed in Dupuytren's contraction. Duncan Fitzwilliams suggests that it should be called "hook-finger," and that it is probably due to imperfect development of the anterior ligament of the first inter-phalangeal joint. He has observed it in association with laxity of the ligaments of the other joints of the body.

The affection is usually disregarded in infancy and childhood as being of no importance. In young children, the deformity is corrected by wearing a light splint fixed with strips of plaster, or a piece of whalebone or steel inside the finger of a glove. In older children, the finger may be straightened by subcutaneous division of the ligament over the palmar aspect of the base of the middle phalanx, or failing this by lengthening the flexor tendons and resecting a wedge from the dorsal aspect of the first phalanx close to the inter-phalangeal joint.

#Dupuytren's Contraction.#--This is an acquired deformity resulting from contraction of the palmar fascia and its digital prolongations (Fig. 173). It is rare in childhood and youth, but is common after middle life, especially in men. It is often hereditary, and is said to occur in those who are liable to gout and to arthritis deformans. While it is met with in the working-classes and attributed to the pressure of some hard object on the palm of the hand--such as a hammer or shovel or whip--its greater frequency in those who do no manual work, and the fact that it is very often bilateral, indicate that the constitutional factor is the more important in its causation.

In the initial stage there is a localised induration in the palm opposite the metacarpo-phalangeal joint, and the skin over it is puckered and closely adherent to the underlying fascia. After a variable interval, the finger is gradually and progressively flexed at the metacarpo-phalangeal joint. The ring finger is usually the first to be affected, less often the fifth, although both are commonly involved. It is rarest of all in the index. The flexion may be confined to the metacarpo-phalangeal joint, or the middle and distal phalanges may also be flexed; and as the deformity becomes more pronounced, the nail of the affected finger may come into contact with the skin of the palm. Dissections show that the flexion of the finger is the result of a chronic interstitial overgrowth or fibrositis and subsequent contraction of the palmar fascia and of its prolongations on to the sides of the fingers. The digital processes of the fascia are thickened and shortened, and come to stand out like the string of a bow. The adipose tissue in the skin of the palm disappears, and the skin and fascia thus brought into contact become fused. The tendons and their sheaths are not implicated; they are found lying deeply in the concavity of the curve of the flexed digit. There is no pain, but the grasp of the hand is interfered with, the patient is unable to wear an ordinary glove, and he may be incapacitated from following his occupation.

The condition is easily diagnosed from congenital contraction by the fact that in the latter the proximal phalanx is dorsiflexed.

_Treatment._--When seen in the initial stage, contraction may be prevented by passive movements of the finger and by massage of the indurated fascia; we have observed cases in which these measures have held the malady in check for many years, but when flexion has already occurred, they are useless, and according to the social position, habits, or occupation of the patient, the condition is left alone or the deformity is corrected by operation.

Adam's operation consists in multiple subcutaneous division of the contracted fascia in the palm and of its prolongations on to the finger; in addition to dividing the fascia, the tenotomy knife should be used also to separate the skin from the fascia. The finger is then forcibly extended, and a well-padded splint secured to the hand and forearm. The skin on the palmar aspect opposite the first inter-phalangeal joint may give way when the finger is extended; should this occur, the resulting gap may be covered by a skin graft.

After healing has occurred, massage and movements must be persevered with, and a splint (Fig. 174) worn at night, as there is an inveterate tendency to recurrence of the contraction. In view of this tendency there is much to be said in favour of the radical operation which consists in removal of the fascia by open dissection. Owing to the long time required for healing and the sensitiveness of the scar, the results of excision of the fascia are sometimes disappointing. Greig has obtained good results by resecting the head of the metacarpal bone. When the little finger is completely flexed towards the palm it may be amputated, as it is always in the way.

#Supernumerary Fingers (Polydactylism).#--These may coexist with supernumerary toes, and the condition is often met with in several members of the same family. Sometimes the extra finger is represented by a mere skin appendage, the nature of which may only be indicated by the presence of a rudimentary nail; sometimes it contains bone representing one or more phalanges, or it may be fully formed (Fig. 175). In the majority of cases the superfluous finger should be removed.

(Photograph lent by Sir George T. Beatson.)]

#Congenital Deficiencies in the Number of Fingers.#--One or more fingers may be absent, such deficiency being often associated with imperfect development of the radius or ulna; or they may be represented by short rounded stumps, which are ascribed to the strangulation of the digits by amniotic bands _in utero_--the so-called intra-uterine amputation.

#Webbing of Fingers (Syndactylism).#--Congenital webbing or fusion of the fingers may be associated with polydactylism or with congenital hypertrophy, and, like other digital deformities, may affect several members of the same family. The degree of fusion ranges from a web of skin joining the fingers to a fusion of the bones, the latter being well seen in skiagrams. If an operation is decided upon, it should not be performed until the age of five or six years. In the simplest cases it is only necessary to divide the web and to unite the cut edges of skin along each finger by sutures, a skin graft being inserted into the angle between the fingers. An operation in which the skin is dissected up in the form of flaps may be required, but it should not be lightly entered upon, as in young children it has been known to be followed by gangrene of one or more of the digits.

#Congenital Hypertrophy of the Fingers.#--This is a form of local giantism affecting one or more digits, and involving all the tissues. The finger is usually of abnormal size at birth, and continues to grow more rapidly than the others, and it may also come to deviate from its normal axis. Such a finger should be trimmed down or removed, to permit of the use of the other digits.

#Trigger Finger# (Fig. 176).--This is an acquired condition in which movement of a finger or thumb, either in flexion or extension, is arrested, and is only completed with the assistance of the other hand. The obstacle to movement is usually overcome with a jerk or snap suggesting a resemblance to the trigger of a gun or the blade of a clasp-knife. The commonest cause is a disproportion between the size of the tendon and its sheath, such as may result from a localised thickening of the tendon. Recovery usually takes place under massage and passive movements. Failing this, the thickened portion of the tendon is pared down to its normal size; if it is the sheath of the tendon that is narrow, it is laid freely open.

(Photograph lent by Sir George T. Beatson.)]

#Drop# or #mallet finger# is described on p. 121.