56.10 Amputating through the foot and toes

This is one of the less useful amputations, its main use is in crush injuries of a patient’s toes. Its advantage is that if he fills the front of his shoe with cotton wool, he can walk reasonably well without a prosthesis. Try to preserve as much of his metatarsals as you can. If you cannot preserve them, do a Syme’s amputation, or amputate below his knee. If necessary, you can amputate as far back as their bases. Don’t try to amputate through his tarsus, because the stump will tilt. If you can preserve his dorsiflexors, he will have a reasonable stump, if you lose them, his foot may go into plantar flexion.

Amputating through the metatarsals is sometimes indicated in leprosy with very distal ulcers under the heads of the metatarsals. It is a poor amputation for arterial gangrene, which usually needs an amputation below the knee, or even above it.

Amputate toes in the same way as the fingers (75.24). Preserve a patient’s big toe, if you can, because it has considerable functional value, particularly in the ’take off’ of normal walking. Its most important part is the head of the first metatarsal, so preserve this if you can, even if it does mean cobbling up the remains of an injured foot. The distal phalanx of the big toe matters much less.

Amputating a patient’s second toe soon causes severe hallux valgus, but amputating his third, fourth and fifth will cause him little disability.

Figure 56.15: METATARSAL AMPUTATION. This is one of the less useful amputations, its main use is in crush injuries of a patient’s toes. After Rob and Smith with kind permission.