Exostosis of the finger is a rare and not serious disease, but it can significantly reduce the quality of life of patients. Neoplasms of this kind are rarely found on the hands; more often they form in the feet, especially on the big toe. By exostosis we mean an osteochondral growth on the surface of the phalanx bone in the form of a linear, spherical or comb-shaped formation. It can form on any part of the bone, including under the nail plate. In the latter case, they speak of the presence of subungual exostosis.
Reasons for development
Exostoses of the fingers and toes may represent an osteochondroma, i.e., a benign tumor, or be a consequence of injury, chronic inflammation, or even prolonged wearing of tight shoes. The latter factors more often provoke the formation of exostoses in adults.
Osteochondromas are mainly typical for children and adolescents under 20 years of age. They can be single or solitary, as well as multiple. Solitary osteochondromas of the fingers and toes are a rare occurrence. More often, in the presence of exostoses with such localization, similar lesions of other skeletal bones are found, in particular the femur, tibia, humerus, spine, clavicle, etc.
The reasons for the formation of osteochondromas have not yet been fully established. It is believed that isolated neoplasms of this kind are a consequence of displacement of the epiphyseal plate. This may be due to disorders of embryonic development, radiation therapy at an early age, or exposure to other types of ionizing radiation. Epiphyseal plates are areas of bone growth that are made up of cartilage and are located directly under the “head” of the bone. Due to the fact that its cells are in the process of constant mitotic division, the child’s bones lengthen as they grow older. Subsequently, the cartilage cells located furthest from the epiphyseal plate ossify and form bone tissue.
If, due to the action of one factor or another, a fragment of the epiphyseal plate moves to the side, it continues to synthesize new cells, which also gradually ossify. This is how exostosis forms in children. Initially, it is represented only by cartilaginous tissue, but over the years it becomes dense and hard, but the cartilaginous cap remains. It usually grows in proportion to the rate of bone growth, and therefore is usually detected during puberty, when a sharp growth spurt occurs.
Multiple exostosis disease is considered to be a hereditary disease. Massive skeletal damage by exostoses is usually detected in early childhood and requires dynamic monitoring, since with it the likelihood of malignancy of neoplasms increases. Single exostoses become malignant in less than 1% of cases.
Toe bones
The bones of the toes are bones that are characterized as tubular short monoepiphyseal bones. The distal part of the lower extremities, in this case, are the bones of the toes, which are connected together with the anterior ends of the metatarsals. The toes, just like the fingers, consist of phalanges. The toe bones have fourteen phalanges. Each finger, with the exception of the thumb, has three phalanges.
The thumb consists of only two phalanges. The phalanges of the fingers, similar to the metatarsal bones, consist of a distant head and a base close to the metatarsus. This base corresponds to the middle of the body. The big toe has two large and powerful phalanges. One of them is called the proximal phalanx, and the second is called the distal phalanx. The remaining fingers include the proximal phalanx, middle phalanx and distal phalanx. In their shape, the bodies of the proximal and middle phalanx differ in convexity towards the back. A flattened fossa, which is necessary to form a joint with the head of a certain metatarsal bone, is located at the base of each proximal phalanx.
Two flat-shaped pits, separated by a comb, are located at the base of the distal and middle phalanges. Their task is to articulate with the head, which is located slightly proximally. At the end of each distal phalanx there is a tubercle. A person's toes are not as mobile as the fingers on the hands. The bones of the toes are shorter than the rest of the foot. The fingers, on the contrary, are the largest part of the hand. Because human feet bear the burden of supporting a lot of weight, the metatarsals serve the function of cushioning shock loads.
Another feature of the phalanges of the toes is their easy contact with the ground. Typically, the toes act as support when bending forward and while walking. At the same time, anyone can easily lift their toes off the ground, that is, while standing. The balance is not disturbed at all. Thus, the toes have some flexibility, although this is difficult to compare with the flexibility of the fingers.
As a rule, in length, the first and second toes are almost identical. The big toe of a newborn baby is quite mobile. Over time, this feature is lost in humans. The toe bones are primarily used for support.
Symptoms
In some cases, exostosis of the toe or hand is asymptomatic. If it forms on the side of the finger, it can cause manifestations of soft tissue hyperkeratosis. But since their volume is relatively small, a full-fledged callus is not formed. If you remove areas of thickened skin, the discomfort does not go away, and the tissues soon become keratinized again.
When exostosis reaches a large size, it injures soft tissues and provokes inflammatory processes in the joints. This leads to discomfort or even pain, especially when wearing tight shoes. It can also protrude beyond the physiological boundaries of the finger. When palpated, exostosis is a dense bony protrusion with a smooth or rough surface. This further aggravates the discomfort.
With active growth of the tumor, the phalanx may become deformed, as well as neighboring fingers. This already leads to the development of an aesthetic defect.
At a certain location, exostosis can compress the neurovascular bundle. The consequence of this is local swelling of the finger, a feeling of numbness or goosebumps.
The most common condition is exostosis of the big toe. This may be accompanied by valgus deformation of this finger, which is manifested by its deviation from the normal axis towards neighboring fingers. As a result, 2-3 toes may also become deformed, acquiring a hammer-like shape.
With subungual exostosis, there is a protrusion at the end of the phalanx of the finger, which looks like a thickened subungual ridge. In this case it is observed:
- pain when pressing on the nail, fingertip, or during physical activity;
- impaired nail growth, up to ingrowth or peeling;
- redness of soft tissues;
- callus formation.
Bones of the foot: tarsus
The tarsus is one of the integral elements of the foot. It consists of 2 sections - posterior and anterior. The posterior one is represented by the calcaneus, as well as the talus. The anterior one consists of 3 wedge-shaped bones. It also includes the cuboid and scaphoid bones.
If we consider the anatomy of the posterior region, it is necessary to mention bones such as the calcaneus and talus. The constituent elements of the latter are the body and the head, and between these sections there is a neck (narrow part). On top there is an articular surface, which serves as an articulation with the adjacent part of the limb - the lower leg.
The shape of the calcaneus is elongated, and it is laterally flattened. This is the largest bone of the foot. It consists of a body and a tubercle that can be easily felt by hand. There is a protrusion on the inside that serves as a support for the adjacent talus.
In the anterior section there are sphenoid bones connected to each other. There is also a cuboid and a navicular. The latter is located near the inner edge. From the inside, its surface is lumpy, which, when palpated, allows one to determine the height of the arch of the foot. It has several articular surfaces, with the help of which it articulates with neighboring bones.
The cuboid bone runs along the outer edge and connects to the sphenoid bone. It also comes into direct contact with bones such as the scaphoid and calcaneus, as well as the metatarsal region. There are also 3 wedge-shaped bones - lateral (back), medial and intermediate.
Diagnostics
The appearance of signs of exostosis requires contacting an orthopedist-traumatologist. At the appointment, the doctor carefully examines the finger, palpates the growth and finds out the nature of the symptoms. If a dense bone formation is detected, an x-ray is indicated.
With its help, you can not only diagnose exostosis of the toe, but also evaluate its location and size. The images also provide data on the degree of deformation of the distal phalanges and allow you to plan the most effective course of treatment. In rare cases, CT and MRI are additionally prescribed.
Treatment of exostoses of fingers and toes
To relieve pain and inflammation, patients are prescribed drug therapy. It is selected individually depending on the complexity of the situation and the nature of the patient’s chronic diseases. Most often, NSAIDs are prescribed in the form of ointments, gels, creams or oral forms. But their use does not lead to the resorption of the osteochondral growth, but only helps to eliminate the symptoms.
The only effective way to treat exostosis of the phalanx of the finger is surgery. It is shown when:
- large amounts of exostosis;
- finger deformities;
- persistent pain syndrome;
- the development of complications or the appearance of signs of malignancy.
The operation is not technically difficult and can even be performed under local anesthesia. They mainly resort to the method of marginal resection of the tumor. It involves making a transverse incision in the projection of the bone growth. Its magnitude depends on the size of the formation, but is usually on the order of several millimeters. The soft tissue is carefully separated from the bone to obtain a clear view of the exostosis and accurately determine its boundaries.
After this, using a surgical chisel or other instrument, the growth is carefully removed within healthy tissue. It is important for the surgeon to completely remove the entire tumor along with its cartilaginous cap, since otherwise there is a high risk of relapse. The surgical wound is actively washed with saline to wash out the smallest bone particles, and only then is it sutured and covered with a sterile bandage.
If a patient is diagnosed with deformity of the phalanges of the fingers, a corrective osteotomy is indicated. The operation involves not only removing the osteochondral exostosis, but also cutting the bone, followed by juxtaposition of the resulting fragments in such a position that the phalanx acquires an anatomically correct shape. The bone is fixed with special metal systems in a given position, after which the wound is sutured and covered with a sterile bandage.
Ligamentous apparatus
This apparatus is represented by a number of joints - ankle, talus, interphalangeal and others:
- The ankle includes the talus and tibia bones. It has the shape of a block. Provides flexion and extension of the foot, and in a fairly flexible form up to a right angle (90 degrees). The ankle is securely strengthened by ligaments that are located on both sides - above and below. Also on the inner surface there is a deltoid ligament, which has the shape of a conventional triangle. On the outer surface there are other ligaments that run towards the heel and talus bones.
- The subtalar provides articulation between the calcaneus and the talus and can be found in the posterior region. It has the shape of a conventional cylinder, partly reminiscent of a spiral. There is a thin capsule around the joint - it contains small ligaments.
- The talocaleonavicular is located between the calcaneus and talus bones. This joint is shaped like a ball. Moreover, it moves simultaneously with the subtalar joint, since together with it it forms a functional joint. Both joints are strengthened with the help of an interosseous ligament (the so-called syndesmosis).
- Tarsometatarsal - several small joints that are located between the bones of the main sections (tarsus and metatarsus). Basically they have a flat shape, mobility is functionally limited.
- Metatarsophalangeal joints are spherical joints with relatively low mobility. They consist of the heads of the metatarsals and provide flexion and extension of all toes.
- Interphalangeal - small joints between individual phalanges. Provides full finger mobility.
Rehabilitation
The duration and complexity of the recovery period are determined by the type of surgery performed. After marginal resection, discharge can be carried out on the day of surgery, but patients are advised to limit physical activity for 2 days. Drug therapy is also prescribed to reduce the risk of developing infectious complications and eliminate pain. After 2 days, a dressing is required, the stitches are removed after 7-10 days.
When performing a corrective osteotomy, recovery is more complex and lengthy. It involves immobilization of the operated finger, which is necessary for the healing of an artificial fracture.
Thus, exostoses of the fingers and toes are a rare phenomenon, but can significantly reduce the level of physical activity, cause cosmetic defects, pain, and generally worsen the quality of life. The solution to the problem is only possible through surgery. In this case, the operation is usually simple and does not require complex recovery. The main thing is to contact an orthopedic traumatologist as soon as possible after signs of exostosis appear, before its active growth provokes deformation of the fingers.
Valgus deformity of 1 toe (Hallux abducto valgus)
Surgical treatment:
Operations for hallux valgus have been known since the time of Hippocrates.
Throughout the history of orthopedics, there are more than 300 different surgical techniques for treating hallux valgus. Of course, many of them today are considered ineffective, many are very traumatic (sometimes crippling). These operational techniques are becoming a thing of the past, although it can be stated with regret that “old-time” operations are still widely used (our country is no exception). Well, let's not talk about sad things... After all, the 21st century is here! The choice of surgical treatment method depends on the degree of valgus deformity of the 1st toe and is always purely individual for each patient. It is an individual approach and careful preoperative planning that ensure a positive outcome of the operation.
In my practice of surgical treatment of feet, I used various types of surgical tactics for reconstruction of hallux valgus deformity of the 1st toe. At the beginning of his surgical career, he used operations performed only on the soft tissues of the foot, without sawing through the bones or using any fixators (for example, the MacBride operation). But such operations turned out to be completely ineffective, since there was a high percentage of relapses (repeated deformities of 1 finger).
Mini-invasive (percutaneous, percutaneous) surgery for hallux valgus deformity of the 1st toe: This method of surgical treatment of hallux valgus is based on the elimination of hallux valgus deformity of the 1st toe without skin incisions (mini-punctures). The essence of this technique: the “bone” is removed from small punctures using bone drills; in certain places, the bones of the foot are sawed off, thereby reducing the deformation of the first toe. This technique does not require any internal fixation (no screws, no knitting needles, no staples).
These are low-traumatic operations with a high cosmetic effect (no wounds or scars).
After analyzing the results of the operations, I came to a disappointing conclusion: it is impossible to completely eliminate the deformity of the first toe, make the foot narrower and more graceful with the help of such operations. It turns out that this is just a cosmetic semi-operation; in the future, the growth of the “bone” is inevitable... Therefore, I refused to use a mini-invasive technique when reconstructing the hallux valgus deformity of the 1st toe; I believe that this method does not provide a 100% correction effect for hallux valgus. Yes, I use minimally invasive techniques in forefoot surgery. They have proven themselves to be excellent for deformities of small toes (hammer deformities of 2-3-4 toes), metatarsalgia, corns, or in combination with open operations for severe deformities of all toes.
Well, now about removing the “bone” with a laser!!! I didn’t want to write about this, but half of the patients, having read on the Internet, ask about this “wonderful” method of surgery... I want to reveal a terrible secret and convey it to everyone: laser surgery to remove a “bone” on one finger does not exist!!! This is either PR or a laser called a mini-invasive method for reconstructing hallux valgus deformity (I wrote about this method above).
In principle, in medicine there is laser surgery, which is used, for example, in ophthalmology, dermatology, urology... But sawing through a bone with a laser is already fantastic! In a word, STAR WARS! Therefore, my dears, do not believe everything that is written on the Internet!