William Anderson

“ It is unnecessary here to say anything as to the nature and course of the general disease. As a rule the case falls into the hands of the physician, and the surgeon is rarely asked to intervene. It must be pointed out, however, that the contractions may cause severe inconvenience, and that despite the intractable nature of the complaint the reaction of the patient to surgical operation is favourable, recovery being nearly as speedy as in true hammer toe. ”

“ The contraction is slow, progressive, and painless, and becomes arrested spontaneously at any degree of flexion, but seldom goes beyond an angle of 90°. The joint cannot be extended by any ordinary force except in the earliest stage, and even then the bent position is immediately resumed after the cessation of the effort. Flexion, on the other hand, is complete and of fair power. No alteration is produced in the deformity by flexion of the wrist, a fact which proves that the main obstacle to extension does not lie in the tendons. ”

“ Blandin attributed the affection to a shortening of the plantar fascia; Boyer to a retraction of the extensor tendons; Roche and Sanson to a contraction of the flexor tendons, and other surgeons to a paralysis of the interossei, but no attempt was made to separate true hammer toe from the arthritic and traumatic deformities which simulate it. It is now beyond doubt that the essential seat of the contraction is in the joint itself. ”

“ During the last two years I have applied the principle of the operation recommended for hammer toe. Excision of the head of the metatarsal bone is performed through a longitudinal incision over the inner side of the joint, the toe is then replaced and fixed for three weeks in a slightly extended position by means of plaster of Paris. The success of these measures is far more complete than could have been anticipated on theoretical grounds. The distal joint appears to replace almost perfectly that which is lost, and the locomotion is easy and unfatiguing. ”

“ Irregularities of development are most likely to occur in those joints which, for one or other reason, have the least functional activity. In the hand the little finger is much less powerful than its fellows; and in association with this it may often be noticed that the fourth tendon of the flexor sublimis is reduced to a mere thread; in the foot the same thing is observed in the corresponding digit, but in a more marked degree, and it is the degenerate little toe which is most liable to the “hammer deformity.” ”

“ Any attempt to overcome the flexion by violence is met by powerful resistance, and great pain is induced. If the patient be anæsthetised, the contraction remains unaltered, but the resistance is felt to be of a peculiar elastic character, and yields to a slight extent during the application of passive force. The defect leads to great interference with the functions of the hand. The pain caused by anything that tends to stretch the shortened muscles induces a voluntary exaggeration of the flexion, and after a time the control over the extensors is apt to become impaired. ”

“ As secondary results of the contraction of the proximal inter-phalangeal joint the patient is subject to certain inconveniences which may give rise to much suffering, and are usually the immediate cause of his appeal to the surgeon. The chief of these are a bursal formation, which is very liable to inflammation, over the angle of flexion, and two associated callosities, one above the head of the retracted phalanx, the other beneath the head of the metatarsal bone, both consequent upon the pressure exercised by the boot. ”

“ The treatment must, of course, be based on general principles; but it is necessary to recollect that an ankylosed finger-joint nearly always renders the digit worse than useless, especially if the articulation be fixed in the position of extension.
It is only necessary to mention that contractions without joint lesion may occur in the fingers as a result of disease or injury of the bone. Simple fracture in the neighbourhood of an articulation may produce a deformity closely resembling that of dislocation. ”

“ In some persons a hammer toe of a marked kind will cause so little trouble that no medical advice is sought—this is especially the case when the contraction is limited to the little toe; in others the suffering is so great that the patient begs the surgeon to remove the offending member with the knife, and remains absolutely crippled until an operation is practised [95] for his relief. When the deformity affects more than a single digit, an interval varying from a few months to five or six years may elapse before the second attack appears. ”

“ In gouty contractions of the toes the history of the sudden and painful inflammatory attacks preceding the deformity, the almost constant implication of the first metatarso-phalangeal joint, and the presence of other indications of gout leave no question as to the nature of the disease. In this affection the surgeon can rarely be called upon to interfere. The distortions of the great toe are generally associated with eversion—a valgus—and complete ankylosis may supervene. Contractions in association with acute rheumatism or acute rheumatoid arthritis are comparatively rare. ”

“ Treatment.—If the injury be seen in the early stage and there is no loss of substance at the point of lesion, it may be treated satisfactorily by fixing the finger, hand, and wrist in full extension, to allow the passive approximation of the divided extremities of the tendon; but should the case not come under notice until a later period it will be necessary to cut down and suture the tendon. If there is loss of substance and the two ends of the tendon cannot be brought together, the treatment must vary with the position of the injury. ”

“ It has long been a popular as well as a medical opinion that the deformity is handed down by inheritance. Even Laforest, who contests the belief, says, “Je m’entends souvent dire que l’on est né avec un doigt ainsi; que c’est un doigt de famille.” Boyer asserted that it was frequently inherited, and Blum and others have adduced examples in [90] support of this view. In a paper read before the Clinical Society in 1887, I referred to a history in four cases out of twenty-two which had the same bearing; and other striking examples have since been brought forward by Mr. Adams. ”

“ Plastic operations may be conducted under the same principles as those which guide the surgeon in the treatment of cicatricial contractions from burns or other causes. In cases of contraction at the metacarpo-phalangeal joint, where the skin is greatly involved, I have made a transverse incision through the integument and fibrous cord at the root of the finger and filled up the wide gap left on extending the joint by the transplantation of a flap from the side of the digit. ”

“ The ideal constitution of a joint depends upon the existence of a certain ratio between the growth of bone and that of ligament. Should the ligaments grow in excess, their redundant length will permit great super-extension, and may even cease to check the movement; but if the bone grow relatively faster than the ligaments, the anterior portion of the latter will the sooner become tense during extension, and where this disproportion is exceptionally great the motion may be checked before it attains physiological completeness, the result being a [54] “hammer finger.” ”

“ Over-use in walking induces much suffering, and any attempt at passive extension is extremely painful, while flexion still remains unimpaired. The head of the metatarsal bone thrown into prominence by the unwonted position of the proximal phalanx looks abnormally large. In some cases a reflex hyperæmia of the tissues surrounding the joint may be induced by forced exercise; but there is rarely, if ever, any effusion within the capsule. The patient finds walking more and more difficult, and to avoid pressure upon the contracted articulation limps on the outer edge of the foot ”

“ There are no contracted fascial bands, and, as a rule, the skin is normal, but occasionally a small longitudinal fold may be present in the angle of flexion. In rare instances the resistance to extension is capable of yielding suddenly with a spring-like action, and [46] a similar movement recurs as the joint is replaced in the position of flexion. These cases are usually classed with the condition known as “trigger finger.” The contraction also occurs in the metacarpo-phalangeal joint, but very rarely attains a degree marked enough to attract the attention of patient or surgeon. ”

“ Wounds implicating the flexors may occasionally lead to permanent contraction—either as a result of actual loss of substance, or in young subjects from interference with the development of the muscle (as in the case already mentioned) . Under these circumstances the operation of tendon lengthening may be required if the endeavours to secure gradual extension are unsuccessful. König describes a case of flexion of the hand and fingers in a newly-born child, caused by a tearing of the flexors at the moment of disengagement of the arm in the course of delivery. ”

“ During my own residence of six years in Japan I never met with an example, and my friend Surgeon-General Takaki writes to me that his observations, covering a period of fifteen years, are equally negative; but it must be noted that it is [99] the rising and boot-wearing generation that has been especially brought under our notice, and the conclusions to be drawn from our experience tend as much to contradict the view that boots are an immediate cause of hammer toe, as to support the belief that the Japanese are exempt from the defect. ”

“ It is indeed rather a pathological curiosity than an important item in surgical disease, and many surgeons of long experience have never met with a single example. Of the mechanism of its causation we know almost nothing, of its ultimate tendencies we know little more, and its morbid anatomy is almost entirely speculative. ”

“ When the most prominent parts of the contracted cords are exposed for excision they bear much resemblance to tendon in contour and striation, but they are less bluish and lustrous in aspect. On dissecting them away from the radiating fascia the transverse fibres interlocking the digital segments of the latter may often be seen unchanged, and in one case in which the disease had attacked the sole the new fibrous tissue could easily be detached from the fascial fibres, which retained all their lustre. ”

“ There are certain affections of the fingers which have hitherto attracted little notice, but are interesting on account of their relationship to deformities of much greater frequency in the lower extremity. These are conditions of abnormal flexion and of lateral deviation of the phalanges at the inter-phalangeal articulations, the first of which corresponds exactly to the well-known deformity of the foot called “hammer toe.” ”

“ On the other hand, in a permanent contraction of a finger-joint occurring during the period of active growth the flexors are never stretched to their full extent, and consequently do not undergo their normal longitudinal development; but should such a contraction originate in an adult the case is different, as muscle and tendon show very little disposition to undergo active involution in the direction of their length after their complete development is attained ”

“ The articular structures [7] show no trace of disease, the tendons are normal, the finger retains all its strength within the progressively narrowing range of motion left to it by the disease, and the utility of the hand may for a long while be little impaired. Sooner or later other fingers may become involved, and the affection may appear in the opposite hand, to follow a like course. The process of contraction is slow in progress, perhaps extending over ten or twenty years; it is painless, and is uncomplicated by any signs of active inflammation. ”

“ There is, in addition, a partial loss of power of flexion and abduction of the thumb, with wasting of the thenar eminence and some interference with the delicacy of the movements of the index and middle [76] fingers, owing to the paralysis of the first and second lumbricales. If the nerve be divided above the elbow, the pronators and all the flexors of the wrist, thumb, and fingers, except those supplied by the ulnar nerve (flexor carpi ulnaris, and ulnar half of the flexor digitorum profundus) , are paralysed, and consequently the hand is, for all practical purposes, quite useless. ”

“ Adams are very convenient, but in the early periods plaster of Paris is equally satisfactory, and renders the intervention of the instrument-maker unnecessary. Whatever form be adopted it should be worn day and night for two or three weeks, and then be replaced by a well-moulded front splint of sheet iron, to be applied at night only, and kept in use for several months. The hand once set free during the day the patient is to be urged to practise friction, with passive extension and active movements of the joint, at every possible opportunity ”

“ The contraction progresses rapidly to a certain point, and then ceases to get worse. It rarely becomes so strongly marked as in the worst cases of the true Dupuytren’s disease. The contracted band, starting from the point of injury (which is indicated by an ordinary scar) has seldom the tendon-like form of the well-marked “Dupuytren,” the characteristic puckers in the skin are represented only by ordinary cicatricial adhesions, and the digital extensions are usually in the form of one or two lateral bands following the bifurcation of the digital process of the radiating fascia. ”