Great Toe Research Articles

EP268: DVL2 – A newly identified genetic cause of Robinow syndrome?

Robinow syndrome is a clinically recognizable syndrome characterized by skeletal, genitourinary, and craniofacial findings and, less frequently, cardiac anomalies. The clinical picture is distinctive with short-limbed short stature, distal limb anomalies with broadening of the thumbs and great toes, and craniofacial features including frontal bossing, wide spaced and prominent eyes, and a depressed nasal root with short nose. It is a heterogeneous condition with six established Robinow-associated genes to date - ROR2, NXN, WNT5A, FZD2, DVL1, and DVL3 - all of which are involved in the well-described WNT/planar cell polarity signaling pathway.

Verrucous Carcinoma of the Foot: A Retrospective Study of 19 Cases and Analysis of Prognostic Factors Influencing Recurrence.

This study sought to evaluate a cohort of patients with verrucous carcinoma of the foot with special focus on 5 cases of locally recurrent tumors despite negative margins. Nineteen cases of verrucous carcinoma of the foot were identified through the University of Michigan (Ann Arbor, Michigan) pathology database from 1995 to 2019 and were included in demographic and clinical presentation analyses. Sixteen cases were treated at the University of Michigan and are included in the treatment analyses. A review of medical records was conducted to characterize clinical, surgical, and pathologic features. Recurrent cases were found to have a predilection for nonglabrous skin of the foot and great toe. Otherwise, there was little to differentiate outcomes between recurrent and nonrecurrent groups based on demographic, clinical, surgical, or histopathologic data. Recurrent tumors regrew locally and were not associated with histologic progression to conventional squamous cell carcinoma. Verrucous carcinoma of the nonglabrous surface of the foot should have a higher suspicion for possible local recurrence. Recurrence occurs within months of treatment, deserves early biopsy, and warrants aggressive re-treatment. Future directions should include greater examination of pathologic features and genetic markers to improve management of verrucous carcinoma of the foot.

Differences in Foot Characteristics Between Bharatanatyam Dancers and Age-Matched Non-Dancers.

The ankle-foot complex is the third most common site of pain in Indian dancers. In Bharatanatyam dance, rhythmic stamping performed barefoot at varying speeds may influence the height of the medial longitudinal arch, causing structural alteration of the ankle-foot complex. As little information is available on the ankle-foot complex of Bharatanatyam dancers, the present study was conducted to test the hypothesis that foot characteristics of Bharatanatyam dancers differ from those of non-dancers. Female professional Bharatanatyam dancers (n=21), aged 18-30 years, with a minimum of 8 years of performance experience after completing formal dance training, and 21 control non-dancers participated in this study. Physical foot examination included navicular drop test and Feiss line. Foot geometry and pedobarography were recorded as participants walked barefoot at self-selected walking pace over a pressure-platform. An average of five gait cycles was computed to analyse maximum peak pressure (MPP), pressure time integral, contact time, and foot geometry of the midfoot, forefoot, great toe, and second to fifth toes. Analysis of covariance was performed for intergroup comparison of all variables with gait speed as a covariate. During walking, dancers presented a higher medial-longitudinal-arch, wider midfoot, and wider forefoot (cm) (p<0.001), indicating an over-pronated foot due to lower medial longitudinal arch height. Total plantar peak pressure (kPa) was 37% higher among dancers, whereas MPP was 24% higher on midfoot and 13% higher on forefoot, indicating greater plantar loading during walking. Greater plantar loading and an over-pronated foot during the most commonly performed weight-bearing activity of daily living (e.g., walking) explain the common prevalence of ankle and foot pain among dancers. These findings will inform clinicians and Bharatanatyam dancers on dancer's foot function and guide strategies for prevention and management of foot pain.

Abstract No. : ABS3228: Perfusion index - a novel and objective parameter to predict successful lumbar sympathectomy: a case series.

Background and Aims:Lumbar sympathectomy interrupts the sympathetic system of the lower limb, thereby augmenting the flow in microcirculation. This block is assessed by resolution of symptoms, reduced nociception, decreased sweating, and rise of local temperature. Perfusion index(PI) can objectively predict a successful block. complex regional pain syndromeMethods:The trend of perfusion index from the ipsilateral great toe of ten patients undergoing diagnostic lumbar sympathectomy for CRPS (6 patients) and peripheral vascular disease (4 patients), was observed and recorded using Mindray Beneview T8 monitor. The PI at zero and thirty minutes was plotted and the percentage of change was calculated.Results:The trend and behaviour of perfusion index in all patients, irrespective of the chronicity and underlying pathology, was consistent. The rise in PI in the lower limb can be taken as an objective marker of a successful lumbar sympathectomy. Further controlled studies are needed to pin down an absolute percentage rise in PI to predict a successful blockade.Conclusion:PI is a novel and promising parameter which is readily available in operating rooms and can objectively demonstrate a successful lumbarsympathectomy.Perfusion index, lumbosacral plexus, sympathectomy, complex regional pain syndrome

EP455: Fetal ultrasound presentation and neonatal diagnosis of Freeman-Sheldon syndrome in son of previously undiagnosed adult male

eP455: Fetal ultrasound presentation and neonatal diagnosis of Freeman-Sheldon syndrome in son of previously undiagnosed adult male

Man With Chronic Foot Pain

A 58-year-old man presented with chronic foot pain after a nonoperatively treated remote gunshot wound of the left great toe, sustained during an altercation. Physical examination revealed a short swollen first ray and crepitus with motion. Radiographs (Figures 1-2) and corresponding computed tomography (CT) (Figures 3-4) demonstrated radiodense fragmentation and osteoarticular destruction.

Operative technique and management of central foot polydactyly

SummaryPolydactyly is characterized by the manifestation of supernumerary digits in the hands and feet. It can be isolated or associated with a genetic syndrome. Based on the location of duplication, it is categorized as preaxial, postaxial, or central. The latter is a rare abnormality, comprising approximately 6% of cases. There is a paucity in the literature regarding this congenital anomaly and its overall management. Nonoperative treatment is generally unsuccessful in managing symptoms such as excessive width, abnormal digit alignment, and growth. Though surgical management addresses the individual patient's needs, general goals include preservation of digits with the greatest axial alignment, resection of symptomatic digits, alignment correction of the remaining great toe, stabilization of the soft tissues, and adequate soft tissue coverage. This study aims to delineate effective operative techniques for central foot polydactyly. Two patient cases are discussed, providing a framework for pre and postoperative care, complications, and outcomes. The techniques detailed offer a straightforward, efficacious, and safe method to reconstruct central foot polydactyly, returning form and function to the patient.

A Solitary Enchondroma of the Great Toe in an Adolescent Male: A Case Report

Solitary enchondromas are benign and usually asymptomatic. Enchondromas are a form of cartilage tumor and have a higher chance of converting into chondrosarcoma. It is difficult to obtain a valid risk estimate, as this requires histopathology and MRI reports. A 17-year-old male presented with swelling over the left great toe since six months, which was insidious in onset, gradually progressive, and associated with intermittent dull aching type of pain. Physical examination revealed bony hard swelling of size 3 x 2.5cm over the left great toe. X-ray was suggestive of lytic lesions, scalloping of the cortex, and whorl of calcification. After confirming the diagnosis through MRI and histopathological examination, the decision was taken to remove whole of the proximal phalanx along with the tumor. Gap was filled up with fibular strut graft. Solitary enchondromas that are aggressively increasing in size should be treated surgically. Bone gap (between the first metatarsal and distal phalanx) caused after removing the tumor can be filled with bone graft or cement depending on the condition of the cortex.

Three-Dimensional Computer-Aided Design Modeling and Printing for Accurate Toe-to-Hand Transplantation

To introduce toe-to-hand transplantation performed with the assistance of both bone and soft tissue modeling using 3-dimensional printing technology. From May 2015 to October 2018, 31 patients (group A, 24 thumbs and 7 fingers) were included. Computed tomography scans were acquired using a spiral computed tomography scanner, and the data were processed with software. Bone, skin, and nail models were created for tailoring the flap taken from the great toe. The impact of foot pathology in terms of pain, disability, and activity restriction was assessed using the Foot Function Index. For comparison, we included 35 patients (group B) who underwent toe-to-hand transplantation without the assistance of 3-dimensional computer-aided modeling. The mean duration of follow-up of groups A and B was 26 months (range, 24-31 months) and 27 months (range, 24-33 months), respectively. The mean Foot Function Index of groups A and B was 5 (range: 0-15) and 17 (range, 0-39), respectively. Three-dimensional computer-aided modeling and printing provide geometric accuracy in toe-to-hand transplantation. It also may reduce the donor foot morbidity by accurate flap designing and harvesting. Therapeutic IV.

Efficacy of Hallux Valgus Deformity Correction Exercise Program in Young Females

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Hallux valgus deformity mostly seen in females because of high heels and tight/narrow shoes. Previous studies have focused on surgical treatment, orthosis, footwear modifications and tapping, but this not correct valgus deformity and causes certain complications. No studies are conducted showing proper exercise program effective in decreasing the valgus angle. The purpose of this study was to determine the efficacy of hallux valgus deformity correction exercise program in young females. &lt;strong&gt;Objectives:&lt;/strong&gt; To determine the efficacy of hallux valgus deformity correction exercise program in young females. Methods: 24 female subjects with mild and moderate hallux valgus angle were divided, in group A (experimental) treated with deformity correction exercises, mobilization, stretching and group B (control) with toe spread out and short foot exercises. A goniometer was used to determine the valgus angle of great toe. Visual analogue scale for the pain and functional limitations was evaluated by using Foot and Ankle Disability Index. &lt;strong&gt;Results:&lt;/strong&gt; On comparing both groups, there was no statistically significant difference seen in pre interventional values. In post interventional values, there was significant difference seen with p value for pain at rest (&amp;lt;0.0001) and on activity (&amp;lt;0.0001), goniometric range of motion of great toe of right (&amp;lt;0.0002) and left side (&amp;lt;0.0003), foot and ankle disability index score (&amp;lt;0.0238). &lt;strong&gt;Conclusion:&lt;/strong&gt; The conducted study shows that deformity correction exercises, stretching and mobilization had more beneficial effects than toe spread out and short foot exercises for correcting the deformity.&lt;/p&gt;

Acute gouty arthritis attacks induced by a great toe injury: a case report and literature review

Introduction: Gouty arthritis usually occurs in patients with hyperuricemia and can be induced by a variety of factors. Here, we describe a case of acute gouty arthritis attacks induced by a great toe injury and was successfully treated by benzbromarone and ibuprofen. Patient concerns: A 27-year-old Asian man with hyperuricemia informed us his first metatarsophalangeal joint of left foot began to redness and swelling, accompanied by severe pain presented 8 days after the toenail injury. Diagnoses: Laboratory tests confirmed as gouty arthritis with no signs of infection, but serum uric acid was significantly higher than normal at 523 μmol/L. Interventions: Drug treatment was adopted, including benzbromarone 100 mg daily, ibuprofen pills 75mg twice a day, and sodium bicarbonate tablets 0.5g three times a day. Outcomes: All of his symptoms of acute gouty arthritis attacks gradually disappear after drug treatment for a week and blood uric acid had dropped to 87 μmol/L two weeks later. Conclusion: When patients with a broken great toe present with symptoms of first metatarsophalangeal joint began to redness and swelling, accompanied by severe pain, acute gouty arthritis attacks should also be considered, and the drug treatment is effective. Abbreviation: GA = Gouty arthritis, MSU = Monosodium urate, ESRD = End-stage renal disease.

Fetal Varicella Syndrome

Fetal varicella syndrome (FVS) is an extremely rare condition of the newborn, characterized by cutaneous scars, limb defects, ocular, and central nervous system abnormalities. It follows maternal varicella infection during early pregnancy. We are reporting a 4-day-old female child who presented with a linear, depressed, erythematous, localized scarring over the right knee with hypoplasia of the right lower limb and malformed right great toe. Clinical presentation of her right foot was resembling congenital talipes equinovarus. Mother had a history of varicella during the first trimester of pregnancy. Ocular examination revealed subretinal hypopigmented exudation with scanty vitreous hemorrhage and tunica vasculosa lentis seen on indirect ophthalmoscopy in the right eye. Ultrasonic A/B scan of the right eye was suggestive of microphthalmia. We confirmed the diagnosis of FVS based on characteristic history, clinical features, and varicella-zoster IgG antibodies were positive.

Assessment and Evaluation of Diabetic Foot using Biothesiometry and Artificial Neural Networks

Introduction: Diabetes is a common disorder that is prevalent in the general population. As it advances, it causes a multitude of consequences, some of which are fatal. Diabetic Neuropathy (DN) is one such illness that causes nerve damage, and it is quickly recognised and diagnosed using a technique known as biothesiometry. Aim: To create an assessment tool based on an Artificial Neural Network (ANN) that evaluates diabetic foot based on Vibration Perception Threshold (VPT) values. Materials and Methods: This experimental and predictive study was done using VPT values for 696 controlled and diabetic groups selected by purposive sampling. The VPT was measured by a biothesiometre. A metal probe was placed under the foot of the person and the voltage was increased gradually from zero and the transition from no vibration to the point of vibration is marked as VPT. Average of three measurements were taken to calculate the VPT value of the given patient. This involves the VPT value which helps in the assessment of severity of the condition. The recorded data was fed as an input to the ANN model which predicted the average VPT value of the left and right foot. Furthermore, the ANN model was assessed my means of statistical measures and parameters. Results: The results of the study confirmed the correlation between the values of VPT acquired at different points of the foot and the coefficient for the left and right foot was found to be 0.99549 and 1.0000 respectively. Furthermore, the efficiency of the proposed ANN model was assessed using statistical measures like Mean Square Error (MSE), Mean Absolute Error (MAE), Square Sum Error (SSE) and Coefficient of determination (R2 ). The predicted values were very close to the experimental VPT results, and the correlation coefficient R are 0.99549 and 0.99975 for the left and right foots respectively, which shows the best settlement. Conclusion: The study concluded that VPT acquired from the foot of diabetic patients is useful in categorising the level of severity of DN. Furthermore, the results of ANN model proved that there exists a strong correlation between the average VPT values of left and right foot and those that are acquired from different points of the foot such as Great Toe, First metatarsal, Third metatarsal, Fifth metatarsal, In step and heel which concluded the study to be effective in the assessment and diagnosis of DN.

Fifth Metatarsal Bunionette Correction Using a Stable Intramedullary Device

Category:Lesser ToesIntroduction/Purpose:Fifth metatarsal osteotomies for correction of a bunionette deformity are stabilized with a variety of techniques. The fifth metatarsal is a small bone with a unique blood supply and anatomy. Most of the described osteotomies are distal, making stable fixation technically demanding. The use of minimal incision surgery (MIS), also presents further challenges in the placement of stable fixation and current recommendations are to use either no fixation or intramedullary Kirschner wire fixation. Extensive translational osteotomies have not had documentation on healing as have first metatarsal osteotomies. This paper presents the results of 2 fellowship-trained orthopedic surgeons utilizing a new surgical implant that is both intramedullary and intramedullary. The patients were assessed with an endpoint of radiographic healing.Methods:A consecutive series of 21 de-identified patients who underwent a fifth metatarsal osteotomy for bunionette correction were radiographically followed until healing. Each patient was pre-operatively classified following the Coughlin classification of bunionette deformity. Postoperative radiographic assessments were made to include: 1. Bridging bone 2. The formation of medial bridging from the metatarsal head to the shaft. 3. Change in the 4-5 Intermetatarsal angle. Also, there was made a notation of complications: Time to weight-bearing, pain, and function were not assessed. There was only a small sample of patients that were treated with an isolated bunionette procedure. The other procedures were impactful and would skew the functional results. We also evaluated for hardware complaints that would need removal.Results:19 patients, 21 feet were evaluated with ages ranging from 51-77 years (Avg 63 years). 17 women and 2 men. Only one patient was a revision of prior surgery. Only 4 patients had an isolated bunionette correction. The other surgical procedures including; double osteotomy bunionectomy, distal metatarsal osteotomies (MIS), phalanx osteotomies of the great and lesser toes, Lapidus bunionectomy, first metatarsophalangeal arthrodesis. Coughlin grading; one Grade one, ten Grade 2, ten Grade 3. The average time to radiographic healing was 8 weeks. 5 patients underwent a traditional open incision and a chevron osteotomy with a saw, the remainder of the osteotomies were percutaneous transverse osteotomies performed with a 2x12mm Shannon burr.The mean 4-5 intermetatarsal angle improved from 10 degrees preoperatively to 3 degrees at follow-up. The amount of shift varied whether the lateral eminence was or was not excised. The numbers are not large and meaningful statistics are difficult to extrapolate.Conclusion:This is the first documented use of a novel surgical implant designed specifically for fifth metatarsal osteotomies used for bunionette correction. The implant is simple to use, provides for stability to prevent malunion and nonunions. It is low profile and has not caused irritation requiring removal in this pilot group. It is versatile and can be used with either an MIS approach and a transverse osteotomy or a classic open incision with a chevron osteotomy.

Radiographic Evaluation of Isolated Continuous Compression Staples for Akin Osteotomy Fixation

Category:Bunion; OtherIntroduction/Purpose:The use of continuous compression implants (nitinol staples) in orthopaedic surgery has increased secondary to advances in metal alloy engineering. Biomechanical studies provide useful data supporting the theoretical use of nitinol staples in the foot and ankle. However, clinical data is limited. The purpose of this study was to determine the overall effectiveness, both clinically and radiographically, of continuous compression implants (nitinol staples) to achieve bony healing in the medially based, closing-wedge osteotomy of the proximal phalanx of the great toe (Akin osteotomy).Methods:A retrospective chart review was performed on 104 patients (107 feet) who underwent an Akin osteotomy using nitinol staples between January 1st, 2018 and February 20th, 2020. The primary outcome variable was radiographic evidence of healing on x-ray. X-rays were independently reviewed by three board-certified foot and ankle surgeons. All investigators were blinded towards the x-rays, and x-rays were randomized in terms of timing from surgery. Each investigator reviewed digital radiographs independently and recorded their radiographic finding responses. Osteotomies were deemed healed if greater than 50% of the osteotomy contained bridging bone. A partially healed osteotomy was defined as some bridging bone, but less than 50% of the overall osteotomy site, and a nonunion was defined as no healing seen radiographically, broken hardware, or loss of reduction.Results:Radiographic union (partial or full) was seen in 95% of Akin osteotomies (96/101) based on our parameters, with no loss of initial reduction. Only 2.8% (3/107) of the patient population had unplanned return to the operating room for reasons associated with the Akin osteotomy: one infection (0.9%), one irritable hardware removal (0.9%), and one traumatic disruption of fixation (0.9%). None of the eligible staples (0/106) were found to be fractured upon radiographic analysis. Smokers and diabetics represented 4.8 and 8.7 percent of the patient population, respectively.Conclusion:Since its inception in 1925, the Akin osteotomy has been described using several types of fixation methods. The results of this retrospective study show that continuous compression implants (nitinol staples) are a viable option for Akin osteotomy fixation, with low rates of complications (2.8%, 3/107) and high healing rates (95%, 96/101). Staples are lower profile, eliminating hardware irritation and potential secondary surgeries, are technically less demanding, and time of application is decreased when compared to other fixation methods. They offer the benefit of continuous compression of the fusion site, as well, and are rigid enough to maintain reduction.

Comparison of Physical Function and Pain Levels of Hallux Rigidus Patients before and after Synthetic Cartilage Implant vs Arthrodesis Surgery

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) versus arthrodesis (AD) for treatment of hallux rigidus using the Patient Reported Outcome Measurement Information System (PROMIS).Methods:Pre- and postoperative PROMIS PF and PI t-scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t-scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow up point. Final follow-up scores were analyzed using independent sample t-tests.Results:Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at mean 33 (14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. Mean age of the SCI cohort was younger than the AD cohort (57.5 versus 61.5 years-old, p = 0.01). Average PF t-scores were higher in the SCI cohort compared to AD cohort at baseline (47.1 versus 43.9, respectively; p = 0.01) and at final follow up (51.4 versus 45.9, respectively; p < 0.01). A main effect of superior improvement in PF was detected in SCI group (+4.3) versus AD group (+2) across time intervals (p < 0.01). PI t-scores were similar between the two procedures across time points.Conclusion:The SCI cohort reported superior PF t-scores at all follow-up time points compared to the arthrodesis group. No differences were found for PI or complication rates between the two treatment groups during this study timeframe.

Painful Hallux Sesamoid: A Pictorial Review

AbstractSesamoids are small bony structures that are either partially or completely embedded in a tendon. Sesamoid bones are found at multiple places in body but most common sites are in foot, with the most consistent location being the metatarsophalangeal joint of great toe. Various pathologies affecting the sesamoid bones of hallux can be a cause of long-standing forefoot pain and discomfort. Imaging helps in diagnosis of these conditions at an early stage. Imaging also helps in differentiating these pathologies from normal variants like bipartite sesamoid bone.

MTP Arthrodesis: Percutaneous Interfragmentary Screw Placement and Nerve Injury

Category:Basic Sciences/Biologics; Midfoot/ForefootIntroduction/Purpose:Iatrogenic cutaneous nerve injury is the most common complication encountered in foot and ankle surgery with limited evidence to inform surgeons on neuroprotective techniques. The purpose of this study was to assess risk for injury to the dorsomedial cutaneous nerve (DCN) during insertion of percutaneous interfragmentary screws used in metatarsophalangeal (MTP) arthrodesis.Methods:Ten mid-tibia fresh frozen cadaver specimens were obtained for execution of this study. All cadavers were grossly and radiographically inspected for any evidence of existing pathology or prior operative intervention. Percutaneous placement of interfragmentary screw in both distal to proximal and proximal to distal fashion was performed. Only the skin was incised before reaming and screw placement. After screw placement, dissection of the great toe was conducted. The distance between the screws and the DCN was obtained. The DCN was also inspected for injury.Results:A total of 10 cadavers were included. The average age of our population was 64 (+- 12.6). Males represented 80% of our included specimens. Injury to the DCN was not reported using the proximal to distal screw fixation. The mean distance from the dorsal cutaneous nerve using proximal to distal interfragmentary screw fixation was 7.45+- 3.85 mm compared to 4.30+-2.71 mm in the distal to proximal screw. Distal to proximal screw fixation was associated with 10% risk of nerve injury with no nerve injuries occurring at the site of proximal to distal screws.Conclusion:In our cadaver study, proximal to distal screw fixation seems to offer neuroprotection in the setting of MTP arthrodesis. The DCN is known to have many anatomic variants, and DCN injuries can be a pretext for painful neuroma formation. Surgeons should consider careful dissection to the joint capsule in effort to decrease the risk of neurogenic injury when placing interfragmentary screws in MTP arthrodesis.

The accuracy of first metatarsophalangeal joint palpation guided injections. An arthrography cadaveric study

BackgroundInjectable glucocorticoids are widely used in the management of foot pathology, in particular for the treatment of osteoarthritis of the great toe - hallux limitus/rigidus. Injections can be performed using anatomical (blind) guided methods or performed with needle placement aided by the use diagnostic imaging with ultrasound or fluoroscopy, with or without the use of contrast media. AimPalpation and image guided injection techniques have been studied in other joints of the body but less so for the first metatarsophalangeal joint of the foot, where palpation guidance is commonly performed. The aim of this study was to investigate the injection accuracy of palpation guided injections of the first metatarsophalangeal joint in six cadaveric feet using radio-opaque contrast media. MethodsThe injection equipment consisted of a 2.5 ml Luer lock syringe and a 23-gauge needle used to inject iohexol (Omnipaque 300) into the first metatarsophalangeal joint in six cadaveric specimens. The needle was placed into the joint space by a single practitioner using palpation guidance. The contrast media was injected under live (cine) view without further movement or ingress of the needle. The injectate was considered accurate if the media coated the inside of the synovial membrane and/or outlined the joint shape. FindingsFailure of technique was seen in one of six feet, and extravasation of contrast media beyond the joint margins noted in three out of six feet. ConclusionsFurther study on a large sample of live subjects using a variance of technique is required to expand the confidence of these findings but the high failure rate calls into question the confidence of palpation guided techniques for injection of the first metatarsophalangeal joint.

Median Nail Dystrophy due to Habit Tic: A Case Report

Median dystrophy of nails may present with diagnostic difficulty. We present a case of a 30-year old male with multiple serial transverse ridges involving the median part of the bilateral great toe nails and the right thumb nail of approximately 10 years duration. On probing, the patient was found to have the habit of picking over the proximal nail folds. Habit of tic may not be noticed by the patient, however, may be the cause of dystrophy of nails.