A 55-year-old caucasian woman, with bilateral sensorineural hearing loss, came to our attention complaining of severe pain in the fifth digit of the right hand. The pain had been mild during the last year and became acute in the last two months. Clinical examination showed “honeycomb” palmar keratosis, starfish keratosis on the dorsal side of both hands and feet (which the patient had been suffering since the age of five), digital constriction bands in the proximal interphalangea (PIP) joint of the right fifth digit and skin dyschromia (). Neurovascular deficit with pain, paresthesia and hypoesthesia of the fifth finger were also present. Her father, sister and grandmother had the same syndromic pattern. Based on these clinical findings a diagnosis of Vohwinkel syndrome was made. Plain radiographs of the right hand showed periosteal thinning of the proximal phalanx of the fifth digit and soft tissue alteration ().\nMR confirmed the periosteal thinning and showed a lack of visualization of a segment (8 mm) of the extensor tendon at the proximal interphalangeal joint of the fifth digit, compatible with a complete lesion (). Marked thinning of the fifth digit’s flexor tendon, thickening of the flexor tendons of the other fingers, and thinning of their extensor counterparts, were also evident.\nConservative surgical treatment was proposed to the patient, but owing to the high recurrence rate described in the literature she refused this type of approach and preferred amputation of the proximal phalanx of the fifth digit of the right hand.\nIn anesthesia, a skin incision was made through the proximal interphalangeal joint and a capsulotomy was performed. We then proceeded with the amputation and disarticulation of the head of the proximal phalanx, followed by proper hemostasis, tendon plasty procedure and suturing (). The incision was medicated with sterile gauzes, and an elastic dressing was applied.\nPost-surgical follow-up consisted in anterior-posterior and latero-lateral radiographs of the right hand, and an inhospital observation period of 24 hours during which neither vascular nor nervous deficits emerged. Optimal articular range of motion was maintained and pain was greatly reduced. Histological examination showed (severe hyperkeratosis, hypergranulosis, and mild acanthosis, of the cutaneous component consistent with the diagnosis of Vohwinkel Syndrome ().\nAt 15 days follow-up, the surgical wound was clean, no sign of infection was evident, and the patient didn’t complain any pain. At 12-month follow-up, the patient did not report pain, and plain radiographs showed no abnormalities at the site of amputation.
A 12-year-old Cameroonian male adolescent with an uneventful past medical, family and psychosocial histories was referred to the orthopedic department of the National Social Insurance Hospital in Yaoundé, Cameroon for a surgical site infection of a left big toenail leading to a dry gangrene of the affected toe following surgical treatment for an ingrown toenail 36 h before his current hospital presentation.\nThe patient had been suffering from an ingrown nail of the hallux of the left foot for several months. The pain was aggravated by wearing closed shoes and was unremitting to usual analgesics such as paracetamol and diclofenac. Persistent pain caused by the ingrown nail prompted the consult of a general practitioner who proposed a surgical treatment for the patient. His preoperative workups included a complete blood count, prothrombine time, partial thromboplastine time, fasting blood glucose and HIV tests which were all normal. The surgical procedure was performed under local anesthesia containing lidocaine 2% and epinephrine. Intravenous Amoxicilline 1 g and metronidazole 500 mg were administered 30 min before the onset of the surgical procedure. An annular digital block was tied round the necrosed toe. Local anesthesia was infiltrated at the postero-lateral aspect and base of the affected toe. The FROST surgical technique was performed by the general practitioner. The technique entailed an “L-shaped” soft tissue dissection to expose and excise the root of the nail and any abnormal soft tissue associated with it []. There was no intraoperative complication and the patient was discharged home an hour later with an antibiotic regimen consisting of oral amoxicilline 1 g/8 h and metronidazole 500 mg/8 h. The patient returned a day after the operation, with complains of severe pain of the operated toe. He was administered paracetamol and codeine and the wound was dressed (Fig. ). Findings during the dressing were; a very tender amputated toe stump with a black plaque covering 40% of the medial side of the left big toe. A wet dressing of the toe was done using normal saline and the patient was sent back home. On the second postoperative day the persistence of pain and the enlargement of the black plaque into necrosis of the entire toe motivated the referral of the patient to the orthopedic surgical department of the National Social Insurance Hospital in Yaoundé, Cameroon.\nWe received the patient in severe pain rated 8/10 using the visual analogue scale. He was overweight with a body mass index (BMI) of 28.89 kg/m2 all his vital signs were normal. Local examination of the affected toe showed a necrosed (black in colour) and dried left big toe with a loss of sensation (Fig. ). The left big toe also portrayed signs of inflammation such as being swollen, hot and very tender. All distal pulsations were present and of good volume. There were no swollen lymph nodes on examination of both lower limbs. In view of these findings, we made the diagnosis of dry gangrene of the left big toe. After informing the patient’s family members about the pathology and obtaining consent from his parents, we planned a surgical debridement of the necrosed toe. Another laboratory panel performed before the debridement showed C-reactive proteins (CRP) at 96 mg, hemoglobin at 15 g/dl and leucocytosis at 12,000/mm3. Surgical debridement of the necrosed toe was done under a combined saphenous and popliteal nerve block using ropivacaine. Intraoperative findings were necrotic tissues of the entire left big toe (Fig. ). After explanation of the findings to the parents and obtaining a second parental consent, we opted for total amputation of the left big toe rather than surgical debridement. No intraoperative complication occurred. Postoperatively, his treatment consisted of oral ofloxacin 200 mg/12 h, paracetamol 1 g/6 h and tramadol 50 mg/8 h. He was discharged home the same day of the surgery, precisely 11 h after the surgery when the sensitive and motor block induced by the peripheral nerve blocks had waned. Walking physiotherapy sessions were done from the fifth postoperative day to quickly rehabilitate the patient. We equally recommended psychological support by a psychologist due to the trauma associated with the amputated toe. His follow-up was uneventful at 6 months following the ambulatory surgical amputation of his left big toe.