Bone Health

Introduction Relevant Anatomy And Contraindications Workup Treatment Outcome And Prognosis Pictures Bibliography Introduction Giant cell tumors of the tendon sheath are the second most common tumors of the hand, with simple ganglion cysts being the most common. Chassaignac first described these benign soft-tissue masses in 1852, and he overstated their biologic potential in referring to them as cancers of the tendon sheath. Giant cell tumors of the soft tissue are classified into the common localized type and the rare diffuse type. The rare diffuse form is considered the soft tissue counterpart of diffuse pigmented villonodular synovitis (PVNS). The diffuse form typically affects the lower extremities. Its anatomic distribution parallels that of PVNS, with lesions most commonly found around the knee, followed by the ankle and foot. However, the diffuse form occasionally affects the hand. Typically, these lesions, like those of PVNS, occur in young patients; the condition is diagnosed in one half of the patients before they are aged 40 years. The diffuse form is often locally aggressive, and multiple recurrences after their excision are common. Because of the similarity in patients' ages, tumoral locations, clinical presentations, and symptoms in PVNS and the diffuse form of giant cell tumors of the tendon sheath, the diffuse form probably represents an extra-articular extension of a primary intra-articular PVNS process. Findings from flow cytometric DNA analysis suggest that PVNS and giant cell tumors of the tendon sheath are histopathologically similar but clinically distinct lesions. When the origin of these poorly confined soft-tissue masses is uncertain, Enzinger and Weiss classify these tumors as the diffuse type of giant cell tumors of the tendon sheath, whether or not they involve the adjacent joint. This article focuses on the common localized form of giant cell tumors, that is, the giant cell tumors of the tendon sheath that often are found in the hands and feet. Author: James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic & Neurosurgical Center of the Cascades Coauthor(s): Timothy A Damron, MD, David G Murray Professor, Department of Orthopedic Surgery, Upstate Medical University; Professor, Orthopedic Oncology and Adult Reconstruction, Department of Orthopedics, State University of New York at Syracuse eMedicine 2002

Wheeless' Textbook of Orthopaedics
this procedure allows long toe flexors to behave like intrinsic muscles producing active plantar flexion at MP joints & extension at IP joint; - indicated for flexible hammer toes and claw toes;

Wheeless' Textbook of Orthopaedics
hallux rigidus results from degenerative changes at the first MTP joint; - this may be more disabling than hallux valgus, because pt is unable to achieve relief even when not wearing shoes; - it is a frequent complaint of runners; - there is limitation of motion and pain at the MTP joint of the great toe secondary to repetitive trauma and DJD; - because the great toe has limited dorsiflexion, puff of during ambulation can be painful; - loss of motion is due to new growth of bone around dorsal articular surface of first metatarsal head

Wheeless' Textbook of Orthopaedics
Overview of options for the investigation and management of hallus valgus

The term hallux varus refers to medial deviation of the great toe. Hallux varus has variable degrees of severity, symptomatology, and etiology. Causes range from the most common iatrogenic postoperative variety to idiopathic, rheumatic, and posttraumatic (tear of the hallux lateral collateral ligament) forms. Flexible hallux varus is a common finding in newborn children and usually corrects to valgus in early childhood when walking begins.
Synonyms and related keywords: medial deviation of the great toe, flexible hallux varus, hallux valgus, congenital hallux varus, primary dynamic infantile hallux varus, traumatic hallux varus, idiopathic hallux varus, first metatarsophalangeal joint arthrodesis, MTP arthrodesis, intermetatarsal angle, IM angle
Amy Ptaszek 2004

Wheeless' Textbook of Orthopaedics
term describes abnormal flexion posture of PIP joint of one of lesser 4 toes;
- the hammer toe deformity is similar to the curly toe deformity but is not malrotated;
- flexion deformity of PIP may be fixed or supple;
- w/ severe hammer toe deformity, MP joint may go into hyperextension (distal joint usually stays supple);

Wheeless' Textbook of Orthopaedics
procedure combines soft tissue release and removal of the medial eminence with resection of the proximal end of the proximal phalanx;
- complications include transfer metatarsalgia (helped with MP bar), recurrence (reduced w/ medullary pin and splinting), hallux varus, and hallux extensus (minmized with use of IM pin);

Wheeless' Textbook of Orthopaedics
Discussion: - self limiting avasulcar necrosis of the navicular; - usually unilateral and affects children, most often boys; - onset is at age 4 in boys and age 5 in girls; - navicular is subjected to repetitive compressive forces during wt bearing which may be a risk factor for AVN; - navicular is last bone in foot to ossify & delayed ossification appears to make the navicular more vulnerable to compressive damage; - compressive forces can occlude the vessels of the soft ossification center redering it avascular;

Wheeless' Textbook of Orthopaedics
Lapidus procedure is indicated for w/ severe hallux valgus deformity + a hypermobile 1st ray;
- procedure involves: arthrodesis of metatarsalcuneiform joint
- note that shortening of metatarsal will occur if large biplanar wedge is resected from the joint;
- therefore, minimal cartilage resection is optimal technique;
- incidence of pseudoarthrosis is approximately 15%;

Wheeless' Textbook of Orthopaedics
disorder of unknown etiology characterised by local proliferation of abnormal fibrous tissue in the plantar fascia
- this tissue is locally aggressive and progressively replaces the normal plantar aponeurosis
- this leads to often painful thickened fascia with nodules from 0,5-3 cm in diameter
- may also infiltrate the dermis or very rarely the flexor tendon sheath (flexion contracture of 2nd toe)
- age range from childhood until 6th decade, more common in men than in women
- 25 % of patients have bilateral involvement
- in older people sometimes associated to other fibromatoses like Dupuytren's in the hand or La Peyronie's disease, a fibrous infiltration of the corpora cavernosa
- increased incidence in patients with:
- diabetes mellitus
- seizure disorders

Wheeless' Textbook of Orthopaedics
refers to flexion posture of DIP;
- may occur as isolated disorder or along w/ hammer toe deformity;
- this deformity occurs most often in 2nd toe, which is frequently the longest & which is impinged in a tight fitting shoe, causing DIP flexion;
- mallet toe is common in diabetics with peripheral neuropathy, and end corns in this population may become infected

Wheeless' Textbook of Orthopaedics
Modified McBride Procedure for Hallux Valgus
modified procedure includes release of adductor hallucis, transverse metatarsal ligament, and lateral capsule combined w/ excision of medial eminence and plication of the capsule medially;
- this procedure was modified to retain the lateral sesamoid, which helps to prevent hallux varus (which as common w/ original Mcbride bunionectomy);

Wheeless' Textbook of Orthopaedics
in the normal foot, metatarsal heads bear one half of a person's body wt, when the foot is plantigrade;
- the first metatarsal normally bears half the wt of the forefoot;
- long 2nd metatarsal can contribute to pressure under metatarsal head;
- limitation of dorsiflexion (from heel cord contracture or ankle impingement can contribute to diffuse metatarsalgia

Wheeless' Textbook of Orthopaedics
a condition in which the there is medial displacement of the metatarsals on the cuneiform;
- forefoot is adducted at the tarsal metarsal joint;
- usually seen in the first year;
- is bilateral in 50% of patients may be associated with hip displasia (10-15%);
- most common congenital foot deformity is metatarsus adductus;
- is caused by intrauterine position, is flexible & resolves spontaneously in more than 90 % of children.

Full text and illustrations of 1991 textbook