Hallux valgus

“ Forcible rectification under an anæsthetic is satisfactory for slighter cases. It may be aided if necessary by subcutaneous section of the opposing tendinous and ligamentous structures on the tibular side, and the toe is fixed for two or three weeks in plaster of Paris. The rectification should be preserved by the use of properly constructed shoes with a septum between the first and second toes, when the patient begins to walk.
3. Resection of the joint is undoubtedly the [120] best operation in the more severe operations of hallux valgus. ”

“ Like hammer toe, the deformity occurs at the age most prone to nutritive disturbance; but hallux flexus tends to undergo cure without the help of the surgeon, because the weight of the body serves as an extending force, which sooner or later proves stronger than the resistance opposed; while in hammer toe the lesser digit is not essential to locomotion, and its retraction at the metatarso-phalangeal joint frees the inter-phalangeal joint from all necessity for action, and favours the permanency of the vicious position. ”

“ The third and fourth varieties are so rare that they are of no practical interest, and need not be further alluded to. It is possible to confound true talipes valgus with flat-foot, a deformity which is the result of undue stretching, from weakness, of the fascial and ligamentous structures which maintain the arched form of the foot. In flat-foot the arch is lost, the patient is splay or flat-footed, and as a secondary deformity the foot is turned outwards, resembling and often confounded with true talipes valgus. ”

“ Musculus flexor hallucis brevis (Fig. 4) .—This minute muscle has a fleshy origin from the medial surface of the hypotarsus. The short belly terminates in a weak, slender tendon which passes down the posteromedial surface of the tarsometatarsus and into the space between the first metatarsal and the trochlea for digit II. In this region the tendon envelops the tendon of the m. flexor hallucis longus and inserts on the distal end of the first metatarsal and on the proximal end of the first phalanx of the first digit.
Action.—Flexes hallux; action must be slight. ”

“ In paralytic valgus the medial border of the foot is depressed and convex towards the sole, and although the foot can readily be restored to the normal position by manipulation, it at once resumes the valgus attitude. The leg is wasted, the skin is cold and livid, and the ankle is flail-like. The treatment consists in reinforcing the paralysed tibial muscles by attaching the peronei, or a strip of the tendo Achillis, to the scaphoid, or in bringing about an ankylosis of the joints above and in front of the talus. ”

“ The heel is drawn upwards and somewhat outwards, the internal malleolus is uncommonly prominent, the instep is flatter than natural, and the muscles of the calf, together with the adductors of the foot, are permanently contracted. When the disease has attained its highest point, the patient has an unsteady, vacillating gait, from the difficulty which he experiences in preserving his centre of gravity. Valgus is comparatively rare; and, like the first variety of the distortion, it may affect one or both limbs. ”

“ The hind extremities are sometimes described as though parallel with the long axis of the body, with the big toe on the inner side. As the hallux is analogous with the pollex, this nomenclature places them on the opposite sides and should not be used for any vertebrates. ”

“ The distal extremity of the tibio-tarsus is not inflected. A hallux is present in some species. The tibio-tarsus and tarso-metatarsus are long and slender, the length of the latter equalling and more often exceeding the length of the femur, and also exceeding half the length of the tibio-tarsus. ”

“ The second phalanx may in some persons be super-extended 30° beyond the axial line of the proximal bone, while in other instances the movement is arrested by tension of the plantar fibres of the lateral ligaments before this line has been attained; [11] and in the distal joint even greater variation may be found. There is, in fact, a physiological tendency to hammer toe in large numbers of people who never actually suffer any inconvenience from it, and it is in the exaggeration of this physiological irregularity that we have to seek the pathology of the surgical hammer toe. ”

“ The arms are very long, and when the animal is in the erect posture they reach as far as the ankle. The hallux is very short and usually destitute of a nail. It is a curious fact that the head of the thigh bone is unattached by a ligament to the socket of the pelvis in which it articulates, a state of affairs which may give the limb greater freedom in movement, but does not add to its strength; indeed, the Orang has been described as moving with laborious caution. ”

“ The fibula and tibia did not coalesce, the latter exceeding the metatarsus in length; the toes were four {25}in number, with two, three, four, and five phalanges respectively, ending in claws, the hallux being directed backwards. The manus had three free digits, and apparently three free metacarpals; the pollex consisted of two joints, the index of three and the third finger of four, while each had a strong hooked claw at the tip. ”

“ 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.” ”

“ The patient can spontaneously flex the foot, none of the flexor muscles being affected, and this flexion may be carried even beyond what is natural, because the divided tendon forms no obstacle to it behind. Spontaneous extension is also practicable, in as much as the peroneus longus, tibialis posticus, &c. which remain uninjured, are capable of producing that motion. Some have alleged that the calf of the leg must be increased in size by the swelling of the gastrocnemii and soleus muscles, in consequence of their state of contraction ”

“ The one direction in which it can yield rather readily is outward toward the other toes because this shortens the distance between the end of the toe and the heel. The pressure put upon the flexor longus hallucis will have a tendency to cause this, for it is over-stretched by the yielding of the arch and keeps constantly pulling on the big toe until that member has a distinct flexion outwards. ”

“ The use of a strong knee-cap may prevent falling, but as a rule an operation is required, and there is quite a number to choose from, the principle of them all being to prevent displacement of the bone without unduly restricting flexion of the joint. That devised by Goldthwait consists in exposing, by means of a vertical incision, the whole length of the patellar ligament, splitting it longitudinally, separating the lateral half from the tibia, passing it under the medial portion and suturing it to the periosteum; this gives the quadriceps a straight line of pull. ”

“ Treatment of Deformities resulting from Antecedent Diseases of the Knee.—Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal space. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. ”

“ It is characterised by persistent flexion of one or more digits, without any articular abnormality, and unassociated with spasm or paralysis, but the contraction is of a different kind from that found in hammer finger and hammer toe. The degree of flexion varies with the position of the hand, and when the wrist [58] is strongly bent forwards the fingers may be extended, perhaps completely, but extension of the wrist is accompanied by a return of the contraction, the degree of which increases progressively as the wrist extension is carried nearer to its limit. ”

“ Morbid anatomy and pathology.—The earlier opinions upon the pathology of hammer toe were very conflicting. Gosselin, who dissected a specimen, was unable to find any lesion. Fano, in 1855, mentions as the chief defect a cartilaginous nucleus in the extensor tendon. Blum described a luxation of the first phalangeal joint, with a thickening of the whole capsule, and maintained that the contraction of the toe was due to a peri-arthritis set up by the inflammation resulting from corns—a curious example of “hysteron proteron.” ”

“ In the backward variety, the plantar flexion is first increased and the foot is then strongly flexed in the opposite direction. In the forward type, forced dorsal flexion will effect reduction. The foot should be placed upon a posterior molded splint for three weeks, after which passive motions are begun. If the reduction is impossible, an arthrotomy with excision of the astragalus may be necessary.
Total Dislocation of the Astragalus. This form of dislocation is much more frequent than those of the ankle joint proper, or of the articulation between the astragalus, calcaneus, and scaphoid. ”