proximal phalanx fracture foot orthobullets11 Apr proximal phalanx fracture foot orthobullets
9(5): p. 308-19. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Injuries to this bone may act differently than fractures of the other four metatarsals. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. Diagnosis is made with plain radiographs of the foot. Author disclosure: No relevant financial affiliations. Proximal phalanx fractures often present with apex volar angulation. Indications. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. If the bone is out of place, your toe will appear deformed. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. The metatarsals are the long bones between your toes and the middle of your foot. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Phalangeal fractures are the most common foot fracture in children. Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensation an indication of nerve injury, Head which makes a joint with the base of the toe, Neck the narrow area between the head and the shaft, Base which makes a joint with the midfoot. Fractures of the toes and forefoot are quite common. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. Healing of a broken toe may take 6 to 8 weeks. Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. Objective Evidence Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. Patients with lesser toe fractures with angulation of more than 20 in the dorsoplantar plane, more than 10 in the mediolateral plane, or more than 20 rotational deformity should also be referred.6,23,24. While celebrating the historic victory, he noticed his finger was deformed and painful. The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. toe phalanx fracture orthobulletsdaniel casey ellie casey. High-impact activities like running can lead to stress fractures in the metatarsals. A Jones fracture has a higher risk of nonunion and requires at least six to eight weeks in a short leg nonweight-bearing cast; healing time can be as long as 10 to 12 weeks. Unlike an X-ray, there is no radiation with an MRI. Surgery is not often required. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Copyright 2023 Lineage Medical, Inc. All rights reserved. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. Fractures of multiple phalanges are common (Figure 3). Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for four to six weeks. All material on this website is protected by copyright. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? This is called a "stress fracture.". During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Diagnosis is made with plain radiographs of the foot. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. Epub 2012 Mar 30. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. The proximal phalanx is the phalanx (toe bone) closest to the leg. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. (Right) An intramedullary screw has been used to hold the bone in place while it heals. Patient examination; . There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Continue to learn and join meaningful clinical discussions . Proper . from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. 2 ). Nondisplaced tuberosity avulsion fractures can generally be treated with compressive dressings (e.g., Ace bandage, Aircast; Figure 11), with initial follow-up in four to seven days.2,3,6 Weight bearing and range-of-motion exercises are allowed as tolerated. If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. Stress fractures can occur in toes. Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. A standard foot series with anteroposterior, lateral, and oblique views is sufficient to diagnose most metatarsal shaft fractures, although diagnostic accuracy depends on fracture subtlety and location.7,8 However, musculoskeletal ultrasonography can provide a quick bedside assessment without radiation exposure that accurately assesses overt and subtle nondisplaced fractures. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. Most fractures can be seen on a routine X-ray. The patient notes worsening pain at the toe-off phase of gait. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). He undergoes closed reduction and pinning shown in Figure B to correct alignment. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Physical examination reveals marked tenderness to palpation. Clin J Sport Med, 2001. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. While many Phalangeal fractures can be treated non-operatively, some do require surgery. If there is a break in the skin near the fracture site, the wound should be examined carefully. Differential Diagnosis The same mechanisms that produce toe fractures. Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. toe phalanx fracture orthobulletsforeign birth registration ireland forum. This webinar will address key principles in the assessment and management of phalangeal fractures. Ulnar gutter splint/cast. For acute metatarsal shaft fractures, indications for surgical referral include open fractures, fracture-dislocations, multiple metatarsal fractures, intra-articular fractures, and fractures of the second to fifth metatarsal shaft with at least 3 mm displacement or more than 10 angulation in the dorsoplantar plane. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. angel academy current affairs pdf . Tuberosity avulsion fractures are generally found in zone 1 and do not extend into the joint between the fourth and fifth metatarsal bases (Figures 7 and 9). Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: (OBQ11.63) Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. A combination of anteroposterior and lateral views may be best to rule out displacement. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction. Although tendon injuries may accompany a toe fracture, they are uncommon. and S. Hacking, Evaluation and management of toe fractures. A proximal phalanx is a bone just above and below the ball of your foot. Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. If the bone is out of place, your toe will appear deformed. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. After the splint is discontinued, the patient should begin gentle range-of-motion (ROM) exercises with the goal of achieving the same ROM as the same toe on the opposite foot. Clinical Features 11(2): p. 121-3. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). Metacarpal Fractures Hand Orthobullets Fractures Of The Proximal Fifth Metatarsal Radiopaedia Fifth Metacarpal Fractures Statpearls Ncbi Bookshelf Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. They typically involve the medial base of the proximal phalanx and usually occur in athletes. - See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; (OBQ09.156) 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. protected weightbearing with crutches, with slow return to running. Copyright 2023 American Academy of Family Physicians. However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. Some metatarsal fractures are stress fractures. The proximal phalanx is the toe bone that is closest to the metatarsals. Reduction of fractures in children can usually be accomplished by simple traction and manipulation; open reduction is indicated if a satisfactory alignment is not obtained. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. 21(1): p. 31-4. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. (SBQ17SE.89) Ulnar side of hand. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. This content is owned by the AAFP. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the foot. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. The video will appear on the video dashboard once complete. This webinar will address key principles in the assessment and management of phalangeal fractures. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. A, Dorsal PIPJ fracture-dislocation. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Patients have localized pain, swelling, and inability to bear weight on the. Foot Ankle Int, 2015. The nail should be inspected for subungual hematomas and other nail injuries. Copyright 2003 by the American Academy of Family Physicians. (OBQ05.209) Healing rates also vary considerably depending on the age of the patient and comorbidities. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. Radiographs often are required to distinguish these injuries from toe fractures. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). PMID: 22465516. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 24(7): p. 466-7. . Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. Methods: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. X-rays. Kay, R.M. Distal metaphyseal. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. Toe and forefoot fractures often result from trauma or direct injury to the bone. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. The talus has a head, constricted neck, and body. Radiographs are shown in Figure A. What is the most likely diagnosis? Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. Hatch, R.L. Because it is the longest of the toe bones, it is the most likely to fracture. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. Because it is the longest of the toe bones, it is the most likely to fracture. Epidemiology Incidence If you have an open fracture, however, your doctor will perform surgery more urgently. J AmAcad Orthop Surg, 2001. Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes.
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