Hundreds of patients have been referred to the Physical Therapy Department by the orthopedists of Stark General Hospital during the past eighteen months. They were sent, for the most part, for rehabilitation of muscles and joints of the lower extremities following severe injuries and infections that were, of necessity, immobilized over long periods of time. In the restoration of function and mobility to these injured extremities, 8 cases of clawing of the great toe, not present at the time of injury, were observed by one of us (A. M. P.). In this group of 8 cases the deformity appeared in the presence of chronic infection, prolonged healing following surgery of the foot, and with osteomyelitis resulting from gunshot wounds or compound Fig. 1.-Clawing of the great toe, medial aspect. fractures, where prolonged immobilization is imperative. The only author to have recognized a similar entity is James Mennell in Sir Robert Jones's book "Orthopedic Surgery of Injuries," 1 who mentions a hallux rigidus deformity of the great toe in connection with gunshot wounds of the lower extrem¬ ity.Mercer,2 quoting Todd, describes clawing of the toes as "a dropping of the metatarsal heads below the nor¬ mal level, alteration of their line of action which leads to pulling up of the proximal interphalangeal joint of the toes, with a secondary important effect of shortening the course of weakened extensor muscles so that they then adaptively contract (and may, in this way, mask their original weakness)." This condition is seen in children following poliomyelitis, infections of the sole of the foot, peroneal muscle atrophy, as part of the little understood picture of Friedreich's ataxia, and in other similar nervous system degenerations or failures of development.The accepted technic for the immobilization of the leg and foot in a plaster cast made with a "reverse or reinforcement," applied to the posterior aspect of the leg, is to carry the edge of the cast beyond the toes on the sole of the foot (in order to protect them from the weight of the bedclothes) and to the base of the toes on the dorsum of the foot. The longitudinal arch is routinely molded, and the metatarsophalangeal joint of the great toe is usually immobilized in extension. In the application of this standard type of cast, force is exerted to maintain the foot at right angles to the leg, i. e. in a neutral position. By incorrectly placing trac¬ tion on the projecting end of the "reverse" to dorsiflex the foot, the projecting plantar toe piece is rounded off in such a manner as to produce further extension of the metatarsophalangeal joint and a depression of the metatarsal head. A bed in the soft plaster is often unintentionally molded, in which the great toe is held with the interphalangeal joint in flexion, and, since the extremity is kept immobile while the cast dries, a well defined ridge under the interphalangeal joint is formed -thus the clawing of the great toe. The fixed exten¬ sion of the metatarsophalangeal joint in itself may cause the clawing, since the in...
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