Phalanges Research Articles

A Neglected Fracture: Treatment and Infection of Seymour Fractures of the Hallux in the Pediatric Population.

Seymour physeal fractures of the distal phalanx of the Hallux in children are common but rarely described in the literature. There is limited literature investigating how these fractures should be specifically treated. Generally, good results are reported when open fractures are treated with debridement and antibiotics. This large retrospective review evaluates incidence of infection and compares outcomes of various treatments for Seymour physeal fractures of the distal phalanx of the Hallux in children. This study included patients ≤18 years of age treated for Seymour fractures of the Hallux between January 1, 2007, and November 20, 2018, at a single tertiary-care urban children's hospital. Demographic, injury, and treatment data were obtained via a retrospective review of electronic medical records, including closed versus open fracture status, time to treatment, and whether antibiotics were prescribed and taken. Initial radiographic imaging was examined by a single attending surgeon for angulation (degrees) and widening (mm). Outcome variables included the development of infection and the rate and success of healing. One hundred thirty-eight patients were included in our analysis. Most (84/138, 61%) fractures were closed and treated successfully without antibiotics. Treatment for open fractures varied greatly, with many of these fractures undergoing an incision and drainage procedure (I&D) (33/54, 61%) and antibiotic prescription (43/54, 76%). Most (47/54, 87%) open fractures did not develop infection. However, 7/54 open fractures presented with an active infection. Four out of seven (29%) of these fractures did not receive any treatment before infection presentation. Two others who presented with infection both had delayed antibiotics and neither underwent I&D. Fractures that either presented with or developed an infection presented significantly later than those fractures that did not develop infection (P<0.001). Neither angulation nor displacement correlated to the time of healing or development of infection. In our large cohort, the majority of open Seymour fractures of the Hallux treated in a timely manner did not develop infection, regardless of treatment. However, open fractures that presented multiple days after injury had an increased incidence of infection. Thus, for open fractures, we recommend timely antibiotics and I&D. Closed fractures may be treated conservatively, with no indication for reduction or use of antibiotics.

Low field magnetic resonance imaging of palmar osteochondral fragmentation of the distal phalanx

SummaryBackgroundThe presence of palmar osteochondral fragments of the distal phalanx is a newly recognised cause of foot lameness with only a few cases having been reported.ObjectivesTo describe the low field magnetic resonance imaging (MRI) appearance of palmar articular fragmentation of the distal phalanx and concurrent abnormalities of the distal interphalangeal joint (DIPJ); to investigate the prevalence of these fragments in a population of sports and pleasure horses and their potential clinical significance.Study designRetrospective descriptive case series.MethodsThis is a retrospective descriptive case series in which all Sports and Pleasure horses undergoing standing low‐field MRI of the feet between 2015 and 2023 were reviewed. Appearance, location and number of palmar articular fragments were recorded. When a palmar fragment was present, abnormal findings of the DIPJ were graded.ResultsA total of 855 horses underwent MRI examination of one or both front feet. Palmar osteochondral fragmentation of the distal phalanx was identified in four horses (0.4% prevalence), three Lusitanos and one Warmblood. The age range was 4–17 years old. All fragments were located along the palmarolateral margin of the glenoid of the distal phalanx in front feet. Concurrent imaging abnormalities of the joint were present in all four horses.Main limitationsLack of histopathology.ConclusionsThe prevalence of palmar articular fragments of the distal phalanx was low in this population of horses. Palmar osteochondral fragmentation must be considered when evaluating lameness localised to the foot, since it was identified only in lame limbs and associated with other imaging abnormalities of the DIPJ.

Radiographic features and subtypes of congenital thumb duplication type C3 according to Wu et al. and their potential implications for surgical management: new classification and preliminary results

BackgroundWu et al. introduced a modified radiographic system that allows classification of all forms of CTD with excellent interobserver and intraobserver reliability. No study to date has evaluated the radiographic characteristics of Wu et al. type C3 CTD with osseous attachment at the level of the metacarpal.ObjectiveThis study aimed to evaluate the radiographic features of type C3 CTD according to the system of Wu et al., to describe the different anatomical subtypes of the duplication, and to propose a categorization approach to distinguish diverse surgical strategies based on the radiographic anatomy of this specific subtype of duplication.MethodsWe performed a retrospective analysis of 215 patients (221 thumbs) diagnosed with Wu et al. type C3 CTD at our Institution between 2015 and 2021. We evaluated all CTDs by examining the alignment of the interphalangeal (IP) and metacarpophalangeal (MP) joints and by assessing the presence of abnormal hypertrophic epiphysis of the primary thumb on posteroanterior (PA) radiographs. The proposed classification system has four types: Type I with good alignment of both MP and IP joints, Type II with ulnar deviation of the MP joint, Type III with radial deviation in the MP joint and Type IV with abnormal hypertrophic epiphysis of the distal phalanx of the main thumb with ulnar deviation of the IP joint with or without ulnar deviation of the MP joint.ResultsThere were 140 male and 75 female patients with CTD (221 thumbs). There were 65 left, 144 right and 6 bilateral forms. The right-to-left, male-to-female and unilateral-to-bilateral ratios were 2.2:1, 1.9:1 and 35.8:1 respectively. The mean age at surgery was 22.3 ± 11.8 months (range, 8–80). The proposed classification system allowed the classification of all CTDs (n = 221). Specifically, 53 fingers were classified as Type I (24%), 136 as Type II (61.5%), 21 as Type III (9.5%), and 11 as Type IV (5%).ConclusionThe proposed system is based on radiographic pathoanatomy and complements that of Wu et al. by identifying four distinct subtypes of deformity. It has the potential to improve inter-professional communication and guide surgery in patients with Wu et al. type C3 CTD. However, our results are preliminary and further research is needed to validate them.Level of evidenceIII.

Distal sagittal forelimb conformation in young Walloon horses: Radiographic assessment and its relationship with osteochondral fragments.

Osteochondral fragments within equine joints are commonly encountered and may predispose to lameness and limitation to sport purposes. Factors leading to this condition include genetic, nutritional and environmental conditions. However, few studies have evaluated the impact of conformation traits and their correlation with osteochondrosis. This study, based on the radiographic screenings of young horses born in Wallonia (266 individuals, 532 forelimbs), evaluated the correlation between foot, fetlock conformations of the front limb, height at the withers and presence of osteochondral fragments. Moreover, for all traits significantly associated with the presence of osteochondral fragments, a Receiver Operator Characteristic (ROC) curve, area under the curve and optimal cut-off value were calculated to predict the occurrence of fragments. Mean dorsal hoof wall angle was 52.36°, dorsal and palmar angle of the third phalanx were respectively 49.83° and 2.99°, and dorsal metacarpophalangeal angle 147.99°. Moreover, the prevalence of upright feet, defined as having an inclined profile of >2° steeper in relation to its contralateral counterpart, was 24%. Increased palmar angle of the distal phalanx was significantly correlated (P < 0.05) with presence of fragments located at the dorso-proximal margin of the proximal phalanx. The associated area under the curve was 0.623 (95% CI: 0528-0.717, P < 0.05) and the optimal cut-off value to predict fragment occurrence was 2.95° (sensitivity 77.3%; specificity 52.9%). Furthermore, the third metacarpal bone diameter of the left forelimb and height at the withers were significantly (P < 0.05) correlated with the presence of osteochondral fragments in general and within tarsocrural and metatarsophalangeal joints specifically. The area under the curve was 0.585 (95% CI: 0.513-0.656, P < 0.05) with an optimal cut-off value of 152.5 cm (sensitivity 85.1%; specificity 31.2%) for height at the withers to predict presence of osteochondral fragment; to predict the occurrence of osteochondral fragment in any joint on the basis of the third metacarpal bone diameter, the area under the curve was 0.595 (95% CI: 0.524-0.667, P <0.05) and the optimal cut-off value 34.9 mm (sensitivity 52.5%; specificity 64.9%). This study provides information about phenotypic traits associated with osteochondral fragments in horses. Although the diagnostic accuracy of these traits to detect osteochondral fragment was limited, the identification of more phenotypic characteristics could, in the future, make it possible to generate models for accurately identifying individuals at high risk of osteochondral fragments on the basis of their phenotype.

Design of novel test rig for prosthetic finger distal interphalangeal and phalanx strengths.

Testing is one of the most significant phases of any engineering process, the last process followed by conceptualization, designing, and fabricating. If the testing outcomes are not genealogy sensible measurables, then eventually it calls for a redesign overhaul. Existing testing equipment to analyze the load and failures are conventional digital universal testing machines with minimum jigs and fixtures. In addition, the existing fixtures cannot be adapted to the anatomy of a human finger. Consequently, the present work explores the best possible design of a jig for testing the naturally articulated movement of a human finger (prosthetic wear-on). Furthermore, the present jig design checks a wide range of parameters such as freedom of motion, a path along with curvature, load, failures, and intermittent positions of applied load, which is adaptable to existing universal testing machines available for broader applications.

Assessment of Fracture Line Angle in Mallet Fractures.

Background: Surgery is often offered to patients with mallet fractures that have a large, displaced fragment and/or joint subluxation. However, the surgical approach remains a subject of debate, and surgery is frequently associated with unsatisfactory outcomes. We felt that the angle formed by the fracture line and the long axis of the distal phalanx on a lateral view radiograph (fracture line angle [FLA]) could be useful in determining the appropriate treatment strategy. The aim of this study was to assess the FLA and its distribution in mallet fractures. Methods: Three researchers measured the mallet FLA and the percentage of articular surface (PAS) involved in the lateral radiographs of 103 patients with a mallet fracture. Results: There was a strong correlation between the mallet FLA and the percentage of joint surface involvement between the three researchers. The mean FLA was 42.59° (±11.54) and it ranged from -1 to +1 standard deviation in 73 individuals (70.87%). The FLA varied over a wide range, while clustering near the average value. The average PAS involvement was 46.5% (±8.7%). There was no correlation between FLA and PAS involvement (p > 0.05). Conclusions: It is possible to quantify the mallet FLA accurately and consistently. It varies widely, regardless of the PAS involvement. When choosing the type of treatment and making prognostic predictions, the mallet FLA may be a helpful guide. Level of Evidence: Level IV (Diagnostic).

The Origin of H. s. denisovan and Their Dispersal Across Iran

Before the early 2000s, anthropologists spoke of two taxa existing in the Late Middle and Early Upper Pleistocene: anatomically modern humans in Africa and Neanderthals associated with the Mousterian industry in Eurasia. Therefore, all Eurasian Paleolithic sites dating to that period were believed to be Mousterian and were associated with Neanderthals. In 2010, owing to the sequencing of mtDNA from a fragment of the distal phalanx of the hand found in Denisova Cave, a third species was introduced, genetically different from both anatomically modern humans and Neanderthals. This new taxon was termed H. s. denisovan—or simply Denisovan. Further studies showed that this population dispersed in the Late Middle and Early Upper Pleistocene across vast territories of Central and Southeast Asia. A question arose as to where Denisovans had originated and which routes they had taken to get to the Altai. A series of articles forthcoming in this journal will address these questions. The first of them focuses on the origin of Denisovans on the basis of H. heidelbergensis and on their migration via Iran to Central Asia.

A new species of frog of the genus Noblella Barbour, 1930 (Amphibia: Strabomantidae) from the Cordillera del Cóndor, Ecuador.

We describe a new species of leaflitter frog of the genus Noblella from southern Ecuador, province of Zamora Chinchipe. The new species is diagnosed from all its congeners by having one or two tubercles on the upper eyelids; distal phalanges strongly T-shaped; phalangeal formula on hands 2-2-3-3; phalangeal formula on feet 2-2-3-4-3; heel with a small subconical tubercle; disc on all toes with papillae; dorsum brown or brown with gray, with V-shaped inverted or scattered irregular darker marks. We include a detailed description of its osteology and a study of its phylogenetic relationships. Finally, we evaluate its conservation status and discuss the threats that are currently impacting at the type locality.

Delayed Correction of Intra-articular Lateral Head Fracture of the Proximal Phalanx of the Great Toe in Children.

Conservative treatment of intra-articular lateral head fracture of the proximal phalanx (LHFPP) of the great toe in young children has a high rate of nonunion, leading to hallux valgus interphalangeus (HVIP). This study presents a case series of surgically managed, late-diagnosed LHFPP, highlighting the difficulties of the surgery and presenting satisfactory results. Nine unilateral cases (8 late-diagnosed and 1 acute) were treated by open reduction and Kirchner wire fixation. The average time from trauma to surgery was 2.9 years (range, 0.5-10.1 years) in our late-diagnosed cases. The average age at the time of operation was 9.2 years (range, 3.4-16.3 years). The causes of injury were various. Intraoperative findings were reviewed through medical records and photographs. Pre- and postoperative HVIP angle, American Orthopedic Foot and Ankle Society (AOFAS) score, and range of motion of the interphalangeal joint were measured and compared statistically. Progressive HVIP was a chief complaint in all 8 late-diagnosed cases. Bony fragment size depended on the time elapsed after trauma (fragments increased in size due to ossification of cartilage) with a mean of 23.5% articular involvement. Four cases required bone graft, and union was achieved in all cases. The mean HVIP angle improved from a mean of 17.8° to 10.5°. The average AOFAS score and range of motion were significantly improved after surgery. Although LHFPP is rare and difficult to diagnose, even cases detected long after the initial trauma can be successfully treated, albeit with difficulty. All 9 of our patients had successful outcomes when treated by open reduction and internal fixation.

Enhancing cell phone security through finger vein biometric authentication systems

The growing demand for secure mobile devices has led to the widespread adoption of biometric technologies. While personal identification numbers (PINs), passwords, gridlock patterns to safeguard phones and facial recognition have become common, they have certain limitations in terms of security and user convenience. These conventional security measures are riddled with susceptibilities, such as password pilferage, memory lapses in authentication details, and user mistakes in grid pattern creation. Due to the rising occurrence of cell phone incursions and theft, there is an urgent requirement for a strong security system that not only defends data but also shields the device itself. This paper proposes a resilient finger vein biometric security system as a more effective substitute for knowledge-based and password-based authentication techniques. The implementation of finger vein biometrics as a novel approach to enhancing cell phone security. The method employs infrared (IR) light transmission to capture the vein patterns and shadows resulting from the different thicknesses of finger muscles, bones, and tissues. The unique vascular patterns in fingers are difficult to forge, offering a higher level of security compared to other biometric systems. The simulations we conducted indicate an identification accuracy rate of 93.82%, indicating that this technique provides a substantial enhancement in preventing unauthorized access and theft of cell phones. This study examines the technology behind finger vein biometrics, its integration into mobile devices, and the security advantages it offers.

Analysis of the Structural Organization of the Human Finger Phalanges Using Anatomical Network Models

Despite the fact that the morphogenetic mechanisms of human finger transformation during ontogenesis are currently known, the issues of how they are organized into a complex integrated structure of the distal hand remains open. This question remains unanswered for several reasons, including the lack of consensus on conceptual definitions and approaches, as well as tools for assessing and comparing variations in several anatomical parts of the hand. The aim of the study was to investigate the structural organization of the human finger phalanges using anatomical network analysis (AnNA). Material and methods. In this study, the authors applied the IGRAPH package functions in the R data analysis programming environment for AnNA. Network modeling and layout were performed using the Fruchterman-Reingold algorithm. Analysis of the structure, as well as modularity and integration in the networks, was performed using the spin-glass algorithm. X-ray osteometric indices of the I–V fingers phalanx length were used to assess AnNA in 100 men and 100 women of the middle age without traumatic changes, deformations, and developmental deviations. Results. AnNA demonstrates a two-level organization of the distal hand in the form of a proximal module including the proximal phalanges and a distal module combining the middle and distal phalanges. When comparing the features of the network models of the distal hand, it was found that in women, the organization of the finger phalanges is characterised by higher morphological integration and modularity (modularity 0.43) than in men (modularity 0.38). orphological modularity and integration are organizing factors in the structure of the finger phalanges of the human distal hand. Conclusion. The study results demonstrate that the structural organization of the finger phalanges of the human hand is a system of individual anatomical modules of the phalanges.

Distal Phalanx Reconstruction with Bone Graft and Free SCIP Flap

Distal Phalanx Reconstruction with Bone Graft and Free SCIP Flap

Clinical Treatment Progress for Large Metacarpal and Phalangeal Bone Defects.

Large metacarpal and phalangeal bone defects are a hot topic for orthopedic surgeons due to its high clinical incidence, disability rate, and postsurgical amputation rate, along with its difficult treatment, long treatment course, high cost, and poor effect, all of which have a negative impact on the appearance and function of the patient's hands. There are currently a variety of treatment options for large metacarpal and phalangeal bone defects, each with its own benefits and drawbacks. However, there is no treatment method capable of perfectly resolving all the problems of patients with these defects. In this paper, the authors introduce several common plans for and progress of large metacarpal and phalangeal bone defect treatment.

A two-headed accessory muscle on the sole of the foot

Anatomical variations include the absence of a muscle or tendon or its presence as an accessory muscle or tendon. Clinically, anatomic variations play an important role in diagnosis and theraphy. In anatomy dissection laboratory, during routine dissection for educational purposes, a 83 -year- old male cadaver was dissected and a two-headed accessory muscle was observed on the plantar surface of the left foot. The medial and lateral heads of the muscle were observed close to the medial and lateral plantar neurovascular bundles. The accessory muscle was pierced by the tendon of the flexor digitorum longus muscle and both muscles were inserted to the distal phalanx of the fifth toe. The variations of the accessory muscles should be taken into consideration in surgical interventions, since, they may change the course of the intervention or as in the case of abductor hallucis muscle, they may be used in reconstructive procedures as grafts. Therefore, it is crucial for surgeons, orthopedic physicians, and anatomists to have a detailed knowledge of the intrinsic muscles of the foot.22-07-2024

The Effects of Onychectomy (Declawing) on Forearm and Leg Myology in a Kinkajou (Potos flavus).

Recently, onychectomy, the "declaw" surgery in which all or part of the distal phalanges are removed, has been shown to have significant effects on the forearm muscles of felids. While this surgery should clearly affect the limb muscles (especially those that insert on the removed or modified bone), these effects have not been studied beyond felids or in the hindlimb. To that end, we herein evaluated the muscle architecture of a kinkajou (Potos flavus) that was declawed on all four of its limbs and compared its anatomy to that of intact specimens and the felid findings. As expected, some of the declawed kinkajou's muscles were substantially different from those of the intact specimens, and as was seen in felids, its digital muscles appear to have been weaker. However, unlike in the felids, the declawed kinkajou had relatively larger forearm muscles. Also, contrary to expectation, the leg muscles of the declawed kinkajou were not substantially different, perhaps reflecting important differences in limb use. Future analyses should examine this anatomy in other declawed kinkajou specimens and also look at the effects of this surgery in other taxa, for instance, non-arboreal relatives of the kinkajou as well as other arboreal taxa.

ThermoGrasp: Enabling Localized Thermal Feedback on Fingers for Precision Grasps in Virtual Reality

The increasing interest in thermal haptic feedback devices, particularly for virtual reality (VR) applications, highlights the need for more immersive user experiences. However, replicating precise thermal sensations on the fingers remains challenging due to the complexity of finger joints and movements. In this paper, we introduce ThermoGrasp, a novel thermal display designed to enhance VR experiences by providing realistic thermal feedback during precision object grasping. ThermoGrasp is a modular wearable device that targets controlled thermal feedback on the distal phalanges. The implications of designing its VR application were assessed through two experimental studies. The first study focused on the device's ability to accurately convey thermal sensations across different fingers during various precision grasps. The second study investigated the overall haptic experience in VR, examining the impact of thermal feedback on user immersion and realism during interactions with objects of varying temperatures. Participants' subjective responses were analyzed based on factors such as autotelicity, expressiveness, immersion, realism, and harmony. The findings indicate that precise, localized thermal feedback significantly enhances the VR experience, offering a marked improvement over traditional haptic feedback methods.

Ecomorphological study of Caribou (Rangifer tarandus caribou) distal phalanx: Insights from 3D geometric morphometrics for paleoenvironmental reconstructions

Reindeer mobility patterns exhibit significant variability in modern ecosystems, especially between open and wooded environments. This variability makes it difficult to reconstruct past reindeer migration patterns, which is key to understand the role of reindeer herds in the sustenance and territorial organization of Prehistoric hunter-gatherer societies. By examining morphology associated with different habitats and movement patterns, insights into prehistoric reindeer behavior can be obtained. Investigating the relationship between locomotor anatomy and substrate type in present-day animals allows for paleoecological inferences, as previous research indicates that an animal's environment affects bone morphology. In the present study, 3D geometric morphometrics is employed to examine the influence of habitat type and mobility patterns on distal phalanx morphology from extant caribou (Rangifer tarandus caribou). Our analysis reveals significant morphological adaptations linked to different habitats (boreal forest, mountain, and tundra) and mobility types (sedentary, migratory, and altitudinal). However, the potential impact of sex remains uncertain due to incomplete data. The significant variations in shape and size of caribou distal phalanges across different habitats and mobility types underscore the complex interactions between morphology, ecology, and evolutionary pressures.

Unravelling a hidden pathology of a vertebral fracture in a teenage girl

BackgroundAlthough the skeleton remains a common target of primary hyperparathyroidism, the classic bone disease “osteitis fibrosa cystica” is currently rare due to early diagnosis. This case represents severe classic bone manifestations of primary hyperparathyroidism due to delayed diagnosis and delayed medical attention.Case presentationA 19-year-old young female was symptomatically managed for chronic back pain and nonspecific bone pain in the small joints of both hands over 2 months by a general practitioner. The patient had delayed seeking for treatment for 3 months. Later, she was evaluated for tuberculosis, hematological malignancies and rheumatic disorders following a fractured T12 vertebra and underwent pedicle screw fixation. However, clinical examination and investigations, including biochemistry, imaging and histology, ruled out the above conditions. Unfortunately, serum calcium level was not performed at the initial presentation. Later, primary hyperparathyroidism was diagnosed on the basis of moderate hypercalcaemia and elevated intact PTH levels (2064 pg/ml). She had sufficient vitamin D levels and normal kidney function. Her DXA scan revealed severe secondary osteoporosis with the lowest Z score of -8 at the total lumbar spine. Ultrasonography of the thyroid revealed a hypo echoic mass in the left lower neck, and localization studies with technetium-99 m sestamibi and 4D-CT revealed a left inferior parathyroid adenoma (1.6 × 1.5 × 1.6 cm). CT scan also revealed brown tumors in the mandible and vertebrae and diffuse bony changes in the skull, sternum, humerus and vertebrae. Her radiographs revealed subperiosteal bone resorption on the radial aspects of the middle and distal phalanges and brown tumors in both the ulna and fibula. We excluded MEN and other hereditary syndromes in our patient with a personal and family history and with a normal pituitary hormone profile because of poor resources for genetic testing. She underwent parathyroid adenoma excision, and the postoperative period was complicated with hungry bone syndrome, requiring high doses of calcium and active vitamin D supplements. These supplements were gradually weaned off over 6 months, and she recovered with normal biochemical investigations. Histology revealed parathyroid adenoma without malignant features.ConclusionIn developing countries where routine calcium screening is not available, clinicians should be aware of various manifestations of primary hyperparathyroidism to allow diagnosis as soon as possible without delay to prevent further progression, as it is a treatable condition.

A Splinter of Petrarch’s Cupboard and Laura’s Finger Bone. The Making of a Historical Relic in the Age of Sentimentalism

A Splinter of Petrarch’s Cupboard and Laura’s Finger Bone. The Making of a Historical Relic in the Age of Sentimentalism

Hallux Dorsal Curvature of the Distal Phalanx and Its Possible Implications for the Dorsal Osteophyte.

Background and Objective: The dorsal osteophyte on the distal phalanx of the first toe (hallux) is a reactive bony protrusion that may be associated with pathologies such as onychocryptosis or pincer nail. This study aims to describe and analyze the correlation between three novel measurements-dorsal osteophyte height (HDO), distal phalangeal hyperextension (DPHA), and distal phalangeal curvature (DCDP)-and to evaluate the impact of minimally invasive surgery on the dorsal osteophyte using fluoroscopic data. Materials and Methods: A total of 125 fluoroscopic images were analyzed. Baseline measurements for the variables were compared between groups. The key variables included distal phalanx curvature, distal phalanx hyperextension, and dorsal osteophyte height. Results: The analysis revealed statistically significant differences in the main group effect for distal phalanx curvature (F [2, 122] = 7.54, p < 0.001), distal phalanx hyperextension (F [2, 122] = 28.90, p < 0.001), and dorsal osteophyte height (F [2, 122] = 13.64, p < 0.001). Significant correlations were found between distal phalanx curvature and distal phalanx hyperextension, as well as between distal phalanx hyperextension and dorsal osteophyte height. However, no significant correlation was observed between distal phalanx curvature and dorsal osteophyte height. Conclusions: The findings suggest that minimally invasive dorsal osteophyte surgery effectively restores the distal phalanx to normal conditions, as indicated by the variables studied.