DISLOCATIONS OF THE TOES.
DR. GWILYM G. DAVIS reported the following case: Miss A., aged thirty-six years, rather stout, while jumping from a car riage to the ground felt a pain in the forward portion of her right foot. She thought she had sprained it, and kept off her foot for a few days, and then began walking about, though it still pained her. Her physician examined the foot, but could discover nothing but a sprain. Walking continued painful, and eleven weeks after the reception of the injury she consulted Dr. Davis. On a casual examination there appeared to be little except a tenderness to pressure on the metatarsophalangeal joint of the middle toe of the right foot. On more careful examination it was seen that when the foot was placed on the ground the affected toe was separated from the adjacent ones by a slightly greater space than appeared natural or when it was off the ground. On feeling for the head of the metatarsal bone in the sole of the foot it felt a trifle, but only a trifle, more prominent than the others. On following down the metatarsal bone on the dorsum of the foot the region of the phalangeal joint did not appear so clearly outlined as did those on each side ; there seemed deeper sulcus at this point than there ought to have been. Pain on pressure was most marked over the head of the metatarsal bone in the sole of the foot. There was no apparent shortening of the toe. These signs and symptoms were such as to cause him to form the opinion that a dislocation was the cause of the trouble, and this diagnosis was confirmed by the X-ray.
The character of the injury having been ascertained, attempts at reduction were made, but proved so painful that cocaine was injected, and by forced manipulation the toe was brought into place. It was found impossible, however, to keep the toe in place, so ether was administered, and the extensor tendon, that seemed to be the main agent in causing the dislocation to recur, was divided and the phalanx again replaced.
A plantar splint was applied with a pad extending as far forward as the heads of the metatarsal bones. The affected toe was then flexed firmly over this pad and bound down with adhe sive plaster to the splint beneath. The toe was kept in this posi tion for about a week and then the splint was removed, and the patient began walking. In about ten days she stated that the toe was again out of place. She resumed her occupation as nurse, and while she at times had some pain, still, it was not sufficient to cause her to lay up, and she soon afterwards left the country.
Dr. Davis added that he felt sure that both an ordinary fracture and sprain at the end of eleven weeks would be practi cally recovered from, and that the persistent disability was due to a displacement of some sort which was still present, for in cases of sprains, and of small joint dislocations which have been prop erly reduced, almost or quite perfect function is restored in a com paratively short time if use is made of the injured member. This is seen in the injuries to the finger-joints so common in ball players. In fractures, also, union in fair position is usually fol lowed by quick restoration of function.
As to treatment, the case shows that old dislocations of the toes are just as unsatisfactory to treat as old dislocations of the larger joints ; also that in some cases, at least, it is almost impos sible to prevent the dislocation from recurring, and that simple division of the extensor tendon and replacement are not suffi cient.
The question of treatment still remains to be solved. Should another case of as long standing as the present one present itself for treatment, he would be inclined to adopt the following course: Etherize the patient, lay open the joint from above, divide the capsule freely, and also one or both tendons, so as to replace the luxated phalanx into position, and leave it there resting loosely in place without any muscular or ligamentous attachments which might tend to displace it. That this would produce a stiff joint is not likely, if suppuration was avoided and use of the part early resorted to. If it was desired at all hazards to surely relieve the patient at once of his disability, he would amputate the toe and not attempt a resection. Resection of these joints, done usually on the fourth toe for metatarsalgia, has not been altogether satisfactory ; control over the toe is lost, and sometimes it over rides its neighbors and gets rubbed by the shoe; while at others it gets caught beneath them and becomes very painful ; in either case it becomes a nuisance which may demand removal. This is the experience of Dr. Thomas G. Morton, who has said that he now prefers amputation to resection for cases of metatarsalgia.