什麼是拇指外翻

PatientPlus文章都寫的英國醫生，並基於研究證據，英國和歐洲的指引。它們是專為醫療專業人士使用，所以你會發現語言比條件下小葉更多的技術。
別名：拇abductovalgus ，姆囊炎

問題是大腳趾的橫向偏差，從而把一個外翻畸形在第一蹠趾（ MTP）的聯合。 15-20 °的偏差被認為是不正常的。這個偏差攪得腳的生物力學。這可能會導致第一MTP接頭和大腳趾的關節半脫位，甚至可能重疊的第二個腳趾。

外側半脫位產生的蹠骨頭（拇囊炎）一個突出往往後跟一個充滿液體的囊的發展。這將成為痛苦的，因為它摩擦的鞋。

病理生理學
這是有幫助的考慮，作為校正的生物力學因素可能防止過度內旋畸形和進展：

當行走時，拇指和數字留平行於所述腳的長軸。這是真實的一般，無論怎樣旋前或綁架前掌是。
聯體肌腱內收肌，伸拇長伸肌和拇長屈肌腱的拉力確保拇指和數字保持平行。
關節的位移使肌腱機械優勢，這取代了聯合進一步。當這發生時，張力上（與橫向壓縮）關節的內側面創建的。
內側張力導致韌帶拉，並導致骨增殖的第一蹠骨頭的背內側方面。
橫向張力導致籽骨設備在一個位置脫臼堅持橫向。
發生橫向和內側重塑，這會影響關節軟骨。
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流行病學
拇趾外翻是常見的，但拇趾囊腫的準確患病率是未知的。
經常會有顯著家族史。
女性更經常受到比男性多。
發病率和患病率較低的兒童和年齡的增加而增加。
因為風險因素會影響兩英尺，條件通常是雙邊的，雖然它可以更明顯的一側比另一。

風險因素
鞋類影響拇外翻的發生率： [ 1 ]
發病率較低的成年人誰不穿鞋。然而，這並不意味著該鞋類引起的狀況。
太緊的鞋子可引起疼痛和神經卡壓與拇外翻關係。時尚鞋都可以太緊太窄，要'奉承的腳“ 。
高跟鞋迫使腳，下入鞋，這進一步加劇了問題。不過，值得注意的是，鞋的問題不僅限於時尚的專用追隨者。
來自澳大利亞的一項研究發現，老年人經常穿緊身和不適當的鞋，尤其是老年婦女。 [ 2 ]
有拇外翻的女性中發病率較高。鞋可以解釋這一點。
舞者把一個很大的壓力通過第一MTP接頭，但它是不可能的跳舞會導致拇囊炎。 [ 3 ]
還有記錄在攀岩者發生率較高。 [ 4 ]
相關疾病
有生物力學不穩定的具體原因，包括神經肌肉條件。它可以用各種形式的關節炎有關。這些相關的疾病包括：

痛風。
類風濕關節炎。
銀屑病性關節病。
關節過度活動與諸如埃 - 當洛綜合徵，馬凡綜合徵，唐氏綜合徵和韌帶鬆弛條件。
多發性硬化。
腓骨肌萎縮症。
腦癱。
介紹
介紹通常是疼痛的結果，雖然該條件也不雅觀。疼痛通常是漸進的，並可能已經存在了許多年。疼痛的頻率或持續時間可能最近已經開始增加，活動可能會加劇疼痛。

歷史
患者可能在走路拇MTP接頭深或尖銳的疼痛禮物，並且發作期間特別活動。這表明，關節內軟骨的變性。
有可能是筋骨疼痛的蹠骨頭，由於刺激了鞋。有可能是一個最近增加的畸形或內側突起的大小。
請教一下身體或日常生活活動的限制，了解疼痛的嚴重程度。請問有什麼緩解疼痛。它可以簡單地去除鞋。
有可能是創傷或炎症性關節炎的歷史。
一個罕見的演示文稿燒灼痛或刺痛的姆囊炎，這表明背內側皮神經卡壓神經炎的背側。
患者也可以描述所造成的畸形症狀，如疼痛重疊第二趾，趾間角化病，潰瘍或向內側蹠骨頭，而不囊炎畸形的投訴。
檢查
檢查足部，而承重量，雖然許多檢查都必須同時不負重進行。關注病人的步行路程。這將表明疼痛及難易程度，問題的原因和異常步態可能指向的促成因素或成為條件的結果。

注意，相對於其他腳趾外翻的位置。這可能會改寫，下騎或緊靠下一個腳趾。的接頭的變形可能發生在一個以上的平面。
注意內側突出的關節。紅斑或滑囊表示從鞋子和刺激的壓力。
注意拇MTP關節的運動範圍。正常背屈是65-75 °，蹠屈小於15° 。注意：如果疼痛，捻發音，或兩者都存在。疼痛無捻發音提示滑膜炎。
請注意，建議從步態異常異常摩擦的任何角化。
相關畸形可能包括第二位槌和柔性或剛性平足。第二位的不穩定可能使拇外翻的更快速的發展，因為它是無法作為一個充分的側向支撐。
隨著病人站立注意的話：
在橫向和額葉飛機增加拇外展。
增加內側突出。
更改關節背屈。
另外，還要注意皮膚和外週脈衝的一般狀況。如果手術是要考慮是非常重要的末梢血流量是足夠的癒合。

調查
透視會顯示變形的程度，並且可以指示該關節的半脫位。

在老年病人中其中一個操作的角度看，常規調查須評估適合接受手術。

管理
患者應給予有關拇外翻適當的信息和建議[ 5 ]建議應包括以下內容：

穿合適的鞋（低，寬腳的鞋子） 。
穿上鞋鞋帶或可調節的帶。
避免緊身鞋。
記者了解到，拇趾囊腫是漸進的和非手術治療緩解症狀，但不限制發展。
手術中最重要的指標是痛苦的，沒有畸形，雖然經常會有關於變形關節的外觀的關注。
藥物
鎮痛藥，包括非甾體類抗炎藥，可能會減輕疼痛，使病情更愜意。

類固醇注射到關節可發出疼痛和炎症的一些救濟。

非藥物保守治療
沒有證據來自理療長期受益。

矯形器可以通過撫育糾正一些其他相關畸形的提供一些援助。

手術
保守的結果是非常差，手術可能是一個具有吸引力的選擇。手術可能不會對最終結果產生不利影響延遲，儘管疼痛和患者滿意度與早期手術改善。 [ 6 ]

手術指徵：

一個很痛苦的聯合。
畸形的關節複合體中。
疼痛或困難的鞋類，抑制活性或生活方式的，並且可通過該條件引起的相關聯的足部疾患。
相關的足部疾患包括：

神經炎或神經卡壓。
重疊或背墊相鄰腳趾。
錘狀趾。
拇趾metatarsocuneiform聯合外生骨疣。
Sesamoiditis 。
潰瘍。
炎性病症，如滑囊炎第一蹠骨頭或腱炎。
禁忌症手術治療：

外週動脈疾病。
活動性感染。
活躍性骨關節病。
化膿性關節炎。
缺乏疼痛或畸形。
不遵守。
單獨年齡不應該被看作是一種禁忌，但它通常與其他顯著醫療條件相關聯。
尤其是心血管或呼吸系統疾病等，這使患者處於危險之中的過程中。
操作選項：有大量的手術方案和程序的選擇將取決於這個問題的確切性質。它通常是骨和軟組織的外科手術的組合。

最簡單的是去除骨突出（ exostectomy ）的。另外，凱勒的置換涉及創建一個靈活的關節內側隆起的蹠骨頭通過切除連同一些近節指骨。關節融合術可以考慮。更換關節外翻或拇僵的是一個較新的選項。美國國家衛生研究院和護理卓越（ NICE ）已經給出的步驟表示謹慎的歡迎。

關節鏡是在這家合資及微創關節鏡手術很少表示不太可能是對拇外翻有幫助。 [ 7 ]對微創技術NICE指南承認，微創技術，可對患者的吸引力，但需要進一步的評估。 [ 8 ]

並發症
並發症包括切口延遲癒合，骨畸形癒合或不癒合，神經損傷，血腫，假體的失敗，截骨移位，延遲縫線反應，蜂窩組織炎，骨髓炎，股骨頭缺血性壞死，關節活動受限，拇內翻，並復發。

除了這是與所有外科手術所帶來的風險，尤其是如果患者是老年人。這包括靜脈血栓栓塞。

預測
前景充滿變數，因為是，誰是治療的患者。因此，有足夠的試驗短缺比較的各種形式的處理的結果。 Cochrane綜述發現在其評估或者保守或手術治療很少很好的證據。 [ 9 ]

預防
生物力學因素校正可以防止過度內旋和畸形進展。明智的鞋類可能有助於防止發展中的一些，但不是全部的情況。

提供反饋
進一步閱讀與參考
蹠趾關節置換拇趾的; NICE臨床指南（ 2005）
拇外翻及拇趾外翻手術，骨科Wheeless '教科書
佩雷拉上午，梅森L時，斯蒂芬斯的MM ;拇外翻的發病機制。骨與關節損傷雜誌。 2011年9月7條; 93 （ 17 ） :1650 - 61 。 DOI ： 10.2106/JBJS.H.01630 。
門斯HB ，莫里斯ME ;鞋的特點和老年人足部問題。老年學。 2005年9月至十月， 51 （ 5 ） :346 -51 。
肯尼迪JG ， Collumbier JA ，拇趾囊腫的舞者。臨床運動醫學雜誌。 2008年4月， 27 （ 2 ） :321- 8 。 DOI ： 10.1016/j.csm.2007.12.004 。
Schoffl V， Kupper噸;在攀岩腳受傷。世界中華骨科。 2013 10月18日， 4 （ 4 ） :218- 228 。
拇趾外翻; NICE中正， 2012年9月
Torkki M， Malmivaara A， Seitsalo S，等;拇外翻：即時操作與1年帶或不帶矯形器等待： 209例患者的隨機對照試驗。物理學骨科SCAND 。 2003四月; 74（2） :209- 15 。
Debnath說英國， Hemmady的MV ，哈里哈蘭K表; 【適應症】用於與第一蹠趾關節鏡技術。踝關節詮釋。 2006年12 ， 27 （ 12 ） :1049 - 54 。
採用微創技術拇外翻手術矯正; NICE的介入治療指南（ 2010年2月）
法拉利Ĵ ，希金斯太平紳士，在此之前的TD ;干預治療拇外翻（ abductovalgus ）和拇趾囊腫。科克倫數據庫系統牧師2004年（ 1 ） ： CD000964 。
免責聲明：本文僅供參考，不應該用於醫療狀況的診斷或治療。教育管理信息系統已使用的所有合理的謹慎編制的信息，但不保證其準確性。請教醫生或其他保健專業人士進行診斷的醫療條件和待遇。有關詳細信息，請參閱我們的條件。

原創作者：
理查德·德雷珀博士當前版本：
科林博士整潔審稿人：
約翰·考克斯博士
上次檢查時間：
20/11/2013文檔ID：
1359 （ V24 ） © EMIS

PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than thecondition leaflets.

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Synonyms: hallux abductovalgus, bunion

The problem is lateral deviation of the great toe so as to put a valgus deformity on the first metatarsophalangeal (MTP) joint. A deviation of 15-20° is considered abnormal. This deviation upsets the biomechanics of the foot. It may cause subluxation of the first MTP joint and the great toe may even overlap the second toe.

Lateral subluxation produces a prominence on the metatarsal head (bunion) often followed by the development of a fluid-filled bursa. This becomes painful as it rubs against the shoe.

Pathophysiology

It is helpful to consider this, as correction of the biomechanical factors may prevent excessive pronation and progression of the deformity:

• When walking, the hallux and digits stay parallel to the long axis of the foot. This is true generally regardless of how pronated or abducted the forefoot is.


• The pull of the conjoined adductor tendon, extensor hallucis longus, and flexor hallucis longus tendons ensures that the hallux and digits remain parallel.


• Displacement of the joint gives the tendons mechanical advantage and this displaces the joint further. As this occurs, tension is created on the medial aspect of the joint (with compression laterally).


• Medial tension causes ligaments to pull and cause the bone to proliferate on the dorsomedial aspect of the first metatarsal head.


• Lateral tension causes the sesamoid apparatus to stick in a dislocated position laterally.


• Remodelling occurs laterally and medially and this affects joint cartilage.

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Epidemiology

• Bunions are common but the exact prevalence of bunions is unknown.


• There is often a significant family history.


• Women are more often affected than men.


• The incidence and prevalence is lower in children and increases with age.

Because the risk factors affect both feet, the condition is usually bilateral, although it may be more marked on one side than the other.

Risk factors

• Footwear affects the incidence of hallux valgus:^[1]
  
  
  
  • The incidence is lower in adults who do not wear shoes. However, this does not mean that the footwear causes the condition.
  
  
  • Tight shoes can cause pain and nerve entrapment in association with hallux valgus. Fashionable shoes can be too tight and too narrow, to 'flatter the foot'.
  
  
  • High heels force the foot down into the shoe and this further aggravates the problem. However, it is worth noting that footwear problems are not limited to thededicated followers of fashion.
  
  
  • A study from Australia found that old people often wear tight and inappropriate footwear, especially older women.^[2]
  
  
  
  


• There is higher incidence of hallux valgus in women. Footwear may account for this.


• Dancers put a great deal of stress through the first MTP joint but it is unlikely that dancing causes bunions.^[3]


• There is also a higher incidence recorded in rock climbers.^[4]

Associated diseases

There are specific causes of biomechanical instability, including neuromuscular conditions. It may be associated with arthritis of various forms. These associated diseases include:

• Gout.


• Rheumatoid arthritis.


• Psoriatic arthropathy.


• Joint hypermobility with conditions such as Ehlers-Danlos syndrome, Marfan's syndrome, Down's syndrome and ligamentous laxity.


• Multiple sclerosis.


• Charcot-Marie-Tooth syndrome.


• Cerebral palsy.

Presentation

Presentation is usually as a result of pain, although the condition is also unsightly. Pain is usually progressive and may have been present for many years. The frequency or duration of pain may have recently started to increase, and activity may exacerbate the pain.

History

• A patient may present with a deep or sharp pain in the hallux MTP joint on walking, and exacerbation during particular activities. This suggests degeneration of the intra-articular cartilage.


• There may be an aching pain in the metatarsal head due to irritation by shoes. There may be a recent increase in the size of the deformity or medial bump.


• Ask about limitation of physical or daily living activities to understand the severity of the pain. Ask what relieves the pain. It may be simply removing shoes.


• There may be a history of trauma or inflammatory arthritis.


• A rarer presentation is burning pain or tingling in the dorsal aspect of the bunion, which indicates entrapment neuritis of the medial dorsal cutaneous nerve.


• The patient may also describe symptoms caused by the deformity, such as a painful overlapping second toe, interdigital keratosis, or ulceration to the medial metatarsal head, without complaint of the bunion deformity.

Examination

Examine the foot whilst bearing weight, although much of the examination will have to be performed whilst not weight bearing. Watch the patient walk. This will indicate the degree of pain and difficulty that the problem causes and abnormal gait may point to a contributory factor or be the result of the condition.

• Note the position of the hallux relative to the other toes. It may be overriding, under-riding or abutting the next toe. Distortion of the joint may occur in more than one plane.


• Note the medial prominence of the joint. Erythema or bursa indicates pressure from shoes and irritation.


• Note the range of movement of the hallux MTP joint. Normal dorsiflexion is 65-75° with plantar flexion less than 15°. Note if pain, crepitation, or both are present. Pain without crepitation suggests synovitis.


• Note any keratosis that suggests abnormal friction from abnormal gait.


• Associated deformities may include second digit hammertoes and flexible or rigid flat foot. Instability of the second digit may allow a more rapid progression of hallux valgus, as it is unable to act as an adequate lateral buttress.


• With the patient standing note any:
  
  
  
  • Increase of hallux abduction in the transverse and frontal planes.
  
  
  • Increase in medial prominence.
  
  
  • Change in dorsiflexion of the joint.
  
  
  
  

Also, note the general condition of skin and peripheral pulses. If surgery it to be contemplated it is imperative that peripheral blood flow be adequate for healing.

Investigations

X-ray will show the degree of deformity and may indicate subluxation of the joint.

In an elderly patient in whom an operation is considered, routine investigations are required to assess suitability for operation.

Management

Patients should be given appropriate information and advice about hallux valgus.^[5] Advice should include the following:

• Wear appropriate shoes (low, wide-fitting shoes).


• Wear shoes with laces or an adjustable strap.


• Avoid tight-fitting shoes.


• Understand that bunions are progressive and that non-surgical treatments alleviate symptoms but do not limit progression.


• The most important indication for surgery is pain, not deformity, although there will often be concern about the appearance of the deformed joint.

Drugs

Analgesics, including non-steroidal anti-inflammatory drugs, may reduce pain and make the condition more bearable.

A steroid injection into the joint may give some relief of pain and inflammation.

Nondrug conservative treatment

There is no evidence of long-term benefit from physiotherapy.

Orthotics may provide some relief by tending to correct some of the other associated deformities.

Surgery

The result of conservative management is so poor that surgery may be an attractive option. Surgery may be delayed without an adverse effect on the final outcome, although pain and patient satisfaction are improved with early operation.^[6]

Indications for surgery:

• A painful joint.


• Deformity of the joint complex.


• Pain or difficulty with footwear, inhibition of activity or lifestyle, and associated foot disorders that can be caused by this condition.

Associated foot disorders include:

• Neuritis or nerve entrapment.


• Overlapping or underlapping an adjacent toe.


• Hammer toes.


• Hallux metatarsocuneiform joint exostosis.


• Sesamoiditis.


• Ulceration.


• Inflammatory conditions, such as bursitis or tendonitis of the first metatarsal head.

Contra-indications to surgery:

• Peripheral arterial disease.


• Active infection.


• Active osteoarthropathy.


• Septic arthritis.


• Lack of pain or deformity.


• Lack of compliance.


• Age alone should not be seen as a contra-indication but it is often associated with other significant medical conditions.


• Other disease, especially of the cardiovascular or respiratory system, that puts the patient at risk during the procedure.

Operative options: there are a large number of surgical options and the choice of procedure will depend upon the precise nature of the problem. It is usually a combination of bone and soft tissue surgery.

The simplest is the removal of the bony prominence (exostectomy). Alternatively, Keller's arthroplasty involves creating a flexible joint by excision of the medial eminence of the metatarsal head together with some of the proximal phalanx. Arthrodesis of the joint may be considered. Replacement of the joint for hallux valgus or hallux rigidus is a more recent option. The National Institute for Health and Care Excellence (NICE) has given the procedure a cautious welcome.

Arthroscopy is rarely indicated in this joint and less invasive arthroscopic surgery is unlikely to be helpful for hallux valgus.^[7] NICE guidance on minimal access techniques acknowledges that less invasive techniques may be attractive to patients but need further evaluation.^[8]

Complications

Complications include delayed healing of the incision, osseous malunion or non-union, nerve damage, haematoma, failure of a prosthesis, displacement of the osteotomy, delayed suture reaction, cellulitis, osteomyelitis, avascular necrosis, limitation of joint motion, hallux varus, and recurrence.

In addition to this are the risks associated with all surgery, especially if the patient is elderly. This includes venous thromboembolism.

Prognosis

The outlook is highly variable, as is that of the patients who are treated. Hence there is a shortage of adequate trials to compare the outcomes of the various forms of treatment. A Cochrane review found very little good evidence on which to assess either conservative or operative treatments.^[9]

Prevention

Correction of the biomechanical factors may prevent excessive pronation and progression of the deformity. Judicious footwear may help prevent progression in some, but not all, cases.

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Further reading & references

• Metatarsophalangeal joint replacement of the hallux; NICE Clinical Guideline (2005)


• Hallux Valgus and Bunion Surgery; Wheeless' Textbook of Orthopaedics

1. Perera AM, Mason L, Stephens MM; The pathogenesis of hallux valgus. J Bone Joint Surg Am. 2011 Sep 7;93(17):1650-61. doi: 10.2106/JBJS.H.01630.


2. Menz HB, Morris ME; Footwear characteristics and foot problems in older people. Gerontology. 2005 Sep-Oct;51(5):346-51.


3. Kennedy JG, Collumbier JA; Bunions in dancers. Clin Sports Med. 2008 Apr;27(2):321-8. doi: 10.1016/j.csm.2007.12.004.


4. Schoffl V, Kupper T; Feet injuries in rock climbers. World J Orthop. 2013 Oct 18;4(4):218-228.


5. Bunions; NICE CKS, September 2012


6. Torkki M, Malmivaara A, Seitsalo S, et al; Hallux valgus: immediate operation versus 1 year of waiting with or without orthoses: a randomized controlled trial of 209 patients. Acta Orthop Scand. 2003 Apr;74(2):209-15.


7. Debnath UK, Hemmady MV, Hariharan K; Indications for and technique of first metatarsophalangeal joint arthroscopy. Foot Ankle Int. 2006 Dec;27(12):1049-54.


8. Surgical correction of hallux valgus using minimal access techniques; NICE Interventional Procedure Guideline (February 2010)


9. Ferrari J, Higgins JP, Prior TD; Interventions for treating hallux valgus (abductovalgus) and bunions. Cochrane Database Syst Rev. 2004;(1):CD000964.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see ourconditions.

Original Author: Dr Richard Draper	Current Version: Dr Colin Tidy	Peer Reviewer: Dr John Cox
Last Checked: 20/11/2013	Document ID: 1359 (v24)	© EMIS