|
#1
05.06.2007, 11:52
|
||||
|
||||
Механизм развития клювовидных пальцев
Уважаемые Коллеги,
Клювовидные (молоткообразные) пальцы - актуальная проблема для наших пациентов с сахарным диабетом (это деформация, приводящая к диабетическим язвам). Раньше считалось, что это - следствие атрофии межкостных мышц вследствие моторной диабетической полинейропатии. Потом исследования с МРТ показали, что атрофия мышц есть, но никак не коррелирует с клювовидностью пальцев. Поэтому получается, что причина клювовидности как бы неизвестна. Возможно, коллеги-ортопеды имеют информацию на эту тему? (тем более, что эта проблема нередко встречается у пожилых людей, не только при диабете)... SY, Удовиченко Олег, эндокринолог, Врач кабинета "Диабетическая стопа". 
|
|
#2
05.06.2007, 16:12
|
||||
|
||||
|
Hammer Toe and Claw Toe
The term hammer toe is used most often to describe an abnormal flexion posture of the proximal interphalangeal joint of one of the lesser four toes (Fig. 80-5). The flexion deformity may be fixed, that is, not passively correctable to the neutral position, or flexible, that is, passively correctable. If the flexion contracture at this middle joint of the digit is severe and of long duration, the metatarsophalangeal joint usually will be deformed in the opposite direction, that is, extension. The distal joint usually stays supple, but it also may develop a flexion or an extension deformity. The terms claw toe and hammer toe are differentiated from one another by the following: claw toes frequently are caused by neuromuscular diseases, and often a similar deformity is present in all toes, whereas in hammer toe deformity only one or two toes are involved; claw toes always have extension deformity at the metatarsophalangeal joint, but in hammer toe deformity extension of metatarsophalangeal joint may or may not be present; claw toes often have a flexion deformity at the distal interphalangeal joint, but this usually does not occur in hammer toes (Fig. 80-6). ETIOLOGY Claw toes can be caused by neuromuscular diseases. The intrinsic muscles of the foot, specifically the interossei, pass plantar to the axis of rotation of the metatarsophalangeal joint, causing flexion of this joint. Loss of intrinsic function of the foot leads to an imbalance, allowing the extensor digitorum longus to extend the metatarsophalangeal joint and the flexor digitorum longus to flex the interphalangeal joints. Although the long extensors of the toes may extend the interphalangeal joints with the metatarsophalangeal joint in neutral, once an extension posture of the metatarsophalangeal joint develops, the long extensor loses its excursion and will no longer extend the interphalangeal joints. The powerful flexors of the toe, specifically the long flexor, which attaches to the base of the distal phalanx, accentuates the deformity, causing flexion of the interphalangeal joints. Although the causes of claw toe deformity can be easily understood, the majority of hammer toes have no underlying intrinsic imbalance. Mann and Inman, using electrodes to evaluate the phasic activity of the intrinsic muscles of the foot, found no activity of the intrinsic muscles during the first 35% of the gait cycle. With quiet standing, intrinsic muscle activity was absent. Hammering of the toes usually is accentuated by standing, and the lack of activity of the intrinsics during quiet standing implies that loss of intrinsic function is not the cause of the deformity. Factors commonly thought to contribute to hammer toe deformity include the long-term use of poorly fitting shoes. Crowding of the toes within an excessively tight toe-box causes some deformation of the metatarsophalangeal and interphalangeal joints that over time can lead to flexible and eventually fixed deformities at these joints. Anatomical factors that can cause lesser toe deformities include a "two-bone toe" and a long second ray, which may result in buckling of the toe and hallux valgus, causing pressure against the second toe. Other factors include connective tissue disorders and trauma. CLINICAL FINDINGS Three areas may be painful in hammer toe deformity. The most common area is the dorsum of the proximal interphalangeal joint, where a hard corn caused by pressure from the toe-box or vamp of the shoe develops. When a flexion posture or end-bearing posture of the distal interphalangeal joint is present, a painful callus will develop just plantar to the nail end. This is called an end corn. Finally, a painful callus may develop beneath the metatarsal head if the proximal phalanx subluxates dorsally. In a patient with decreased sensibility, such as occurs in diabetes mellitus or myelomeningocele, ulceration and deep infection can develop at one or more of these areas of pressure, complicating the treatment plan and endangering the toe or foot. Sometimes the dorsofibular side of the second metatarsophalangeal joint is tender (Fig. 80-7, A). TREATMENT Conservative treatment of hammer toe usually is disappointing. Various pads and strappings are commercially available to reduce the deformity and relieve pressure over painful points (Milgram). If the deformity is not of long duration and an extension deformity at the metatarsophalangeal joint also is not present, daily manipulations and taping the toe so that the metatarsophalangeal joint is not extended occasionally can correct the flexion deformity at the proximal interphalangeal joint. This is because the extensor digitorum longus can forcefully extend the middle phalanx only if the metatarsophalangeal joint is in neutral or some degree of flexion. However, recurrence is likely once the passive stretching and taping ceases, and most patients with symptomatic hammer toe eventually require surgery. The following are not all of the operations available for treating hammer toes; rather, they are the most commonly recommended procedures that have follow-up data to support the recommendations. оперативное лечение не влезло, если надо- пишите.
|
|
#3
05.06.2007, 19:32
|
||||
|
||||
|
Большое спасибо
 Видимо, в исследованиях с применением МРТ видели только межкостные мышцы, а влияние обуви и действия длинных сгибателей/разгибателей не изучалось...
|
|
#5
13.02.2011, 21:13
|
||||
|
||||
|
Цитата:
|
Линейный вид
