(b) Deformities of the Toes The wearing of shoes whose manufacture is dictated by common sense (the so-called "American cut") prevents to a certainty all deformi ties of the foot and toes which are caused by too short or too narrow and pointed footwear. Although, as a rule, deformities only reach full development in adults, children must suffer in later years for the mis takes parents make at an earlier period.
The sometimes observe in children a peculiar posi tion of the toes, especially of the first phalanx, which resembles very much the condition in claw-hand. The arch is raised and the heads of the metatarsal _bones project towards the sole and the third phalanges of the toes turn in like claws. This attitude is caused partly by too short shoes and partly by an affection of the interosscous muscles (mani fest in nervous degeneration—see Paralysis of the ulnar nerve). Opera tions such as tenotomy of the plantar fascia or lengthening of the short ened tendons of the extensors are in my opinion of less benefit than a well-fitting brace to readjust the depressed row of metatarsal bones. The foot must be freed of shoes by the frequent use of sandals.
HaMix valgus is an outward deviation of the great toe, generally the result of wearing too pointed shoes. The big toe, which in children is turned inward, is pressed outward by the deflecting inner border of the shoe and separated more and more from the head of the metatarsal bone. The tendons of the flexor and extensor muscles are likewise deflected. In severe cases the deformity forces the great toe entirely outward and often above or beneath the other toes. The head of the
metatarsal bone projects inward and calloused skin is formed over tha as a result of pressure from the shoe. Chilblains appear as a result of deficient blood supply. The periosteum becomes thickened and produces exostosia, and a condition termed bunion results.
Prophylaxis is all that is necessary in children; good, well-fitting shoes with a straight inner border ("American cut") will certainly prevent deformities or correct them without the necessity of performing operations or wearing sonic kind of redressing apparatus.
Pressing the toes over one another in very pointed shoes produces often a flexion and contraction which is termed The second toe being the longest is the one usually affected. The end phalanx faces downward. The second phalanx is deviated and presents a large corn on its dorsal surface. The deformity may be acquired by wearing short and narrow shoes, but it also may he a congenital condition. (Per sonal observation of a fami'-y, all the members of which, including even the smallest children, presented the same deformity of the second toe.) In mild cases elevation of the downward bent distal end of the toe is sufficient by placing it on a bridge made of adhesive plaster which runs from one neighboring toe to the other. If a correction is not perfected after two months a subcutaneous division of the flexor tendons is per formed in the first interphalangeal joint, and if further necessary, the shortened capsule transversely divided. The affected toe is firmly bandaged with a steel splint covered with felt, and thus kept in fixation for fourteen days.