Tag Archives: MPJ dislocations

Unusual Case of Irreducible Fracture Dislocation of Great Toe: A case report

by Vasu Pai MS, D[orth], National board [Orth], FICMR, FRACS, MCh[Orth]1

The Foot and Ankle Online Journal 2 (3): 3

The floating metatarsal is an extremely rare type of injury in which the first metatarsal is dislocated or fractured both proximally and distally. We describe a report of a type of unusual variant of floating metatarsal consisting of fracture to the base of the first metatarsal with an irreducible dislocation of first metatarsophalangeal joint.

Key words: Metatarsal fracture, MTP dislocation, Irreducible dislocation, floating metatarsal.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: February, 2009
Published: March, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0203.0003


Trauma of the foot carries a high potential for chronic secondary disability, especially when misdiagnosed. The floating metatarsal is a unique type of injury in which the first metatarsal is dislocated both proximally and distally. Leibner, et al., first described this unique entity in 1997. [1] Since the first description of this injury, there have been only a few case reports [1-4,7] in the literature, and this entity remains quite rare. We report a variant of such injury where a closed reduction of the metataarsophalangeal (MTP) joint was impossible requiring open reduction and internal fixation for repair.

Case Report

A 45-year-old woman presents to the emergency department after sustaining an injury of her right foot after a fall from a horse. At initial presentation she was in significant pain requiring a large amount of morphine. On examination there was swelling and tenderness to the dorsal aspect of the midfoot.

There was obvious dislocation of the great toe. Sensation and vascularity of the foot were normal, and the skin on the dorsum of the foot was viable.

Radiographs of the injured foot showed dislocation of the first MTP joint with significant displacement of the head of the first MTP joint under the plantar aspect of the foot. (Fig. 1) Additionally, there were minimally displaced fractures of the second and third metatarsal necks.

Figure 1  Preoperative radiographs showing the dorsal dislocation at the MTP joint and fracture of the base of the metatarsal bone.

The patient was operated on the same day. As closed reduction of the MTP joint of the first toe could not be achieved, an open reduction of the MTP joint was performed with a dorso-medial incision . There was buttonholing of the head through the capsule. The intersesamoid ligament had to be divided to reduce the joint. Once reduced, the joint was further stabilized with an oblique Kirschner wire. The capsule was sutured. Intraoperative computerized or C-arm images showed acceptable reduction. The basal fracture of the first metatarsal was reduced and fixed with a wire. (Fig. 2) A below-the-knee cast was applied postoperatively. Progressive weight-bearing was started at 6 weeks after removing the Kirschner wire, and the patient was full weight-bearing at the end of 2 months. At 2 years, the patient is totally symptom-free.

Figure  2  Postoperative radiographs showing the joints reduced anatomically and Kirschner wires in place to stabilize the basal fracture.

Discussion

The capsule of the MTP joint has several reinforcements that contribute to the joint stability: the plantar plate consisting of local thickening of the capsule; medial and lateral collateral ligaments; the tendons of the flexor hallucis longus and brevis, adductor and abductor hallucis, and the extensor hallucis longus and brevis. [5] The joint is relatively unprotected on the dorsal side, making the dorsal dislocation more common.

Concomitant dorsal dislocation was first described by Leibner, et al., in 1997 and was referred to as the “floating metatarsal”. [1] In 2003, Kasmaoui, et al., [2] reported a case of concomitant plantar Lisfranc dislocation and plantar MTP joint dislocation of the hallux.

In 2003, Christodoulou, et al., [6] reported a case of double floating metatarsal—a combined proximal and distal dislocation of two adjacent metatarsals. In 2003, Milankov, et al., [3] reported a case of concomitant plantar tarsometatarsal (Lisfranc) and first and second MTP joint dislocations. Espierrez, et al., [4] in 2003, reported one more case of floating metatarsal with the dislocations in the dorsal direction.

In our patient, the mechanism of injury is probably axial compression. Extension-deforming force on the first toe caused dorsal dislocation of the first MTP joint and the continuing force later applied to the fracture of the base of the first metatarsal.

When undertaking reduction of floating metatarsal, it is important to evaluate the tension on the plantar fascia. In the case of dorsal dislocation, MTP joint reduction should be done first to alleviate the tension on the plantar fascia. [7]

Similarly, in the case of concomitant plantar dislocation, reduction of the proximal side should precede the reduction of the MTP joint. [2] However this rule could not apply to the present case because of the buttonholing.

When examining a patient with MTP joint injury, one should always look for injury at the tarsometatarsal joint and vice versa, because various concomitant injuries are possible and misdiagnosis can cause long-term secondary disability.

References

1. Leibner ED, Mattan Y, Shaoul J, Nyska M. Floating metatarsal: concomitant Lisfranc fracture dislocation and complex dislocation of the first metatarsophalangeal joint. J Trauma 42:549 – 552, 1997.
2. Kasmaoui EH, Bousselmame N, Bencieba D, Boussouga M, Lazrek K, Taobane H. A floating metatarsal. A rare traumatic injury. Acta Orthop Belgica 69: 295 – 297, 2003.
3. Milankov M, Miljkovic N, Popovic N. Concomitant planar tarsometatarsal and metatarsophalangeal joint dislocations. Arch Orthop Trauma 123:95 – 97, 2003.
4. Espierrez CJ, Martinez AA, Herrera A, Panisello JJ. The floating metatarsal: first metatarsophalangeal joint dislocation with associated Lisfranc dislocation. J Foot Ankle Surg 42: 309 –311, 2003.
5. Salamon PB, Gelberman RH, Huffer JM. Dorsal dislocation of the metatarsophalangeal joint of the great toe. J Bone Joint Surg 56A:1073 – 1075, 1974.
6. Christodoulou A, Ploumis A, Terzidis I, Koukoulidis. Double floating metatarsal—a combined proximal and distal dislocation of two adjacent metatarsals. J Orthop Trauma 17: 527 – 530, 2003.
7. Shetty MS, Bhardwaja P, Pinto J Isolated Floating First Metatarsal:Report of an Unusual Injury. Foot Ankle Surg. 46 [3]:185 – 7, 2007.


Address correspondence to: Dr. Vasu Pai, Gisborne Hospital, Ormand Road, Gizborne, New Zealand.
E-mail: vasuchitra@gmail.com

Orthopaedic Specialist, Gisborne, Hospital, Ormand Road, Gisborne, New Zealand.

© The Foot and Ankle Online Journal, 2009

Irreducible Dislocation of the Metatarsophalangeal Joints of the Foot: A Case Report

by Vasu Pai, MS, D (Ortho), National board (Orth), FICMR, FRACS (Orth), MCh (Orth)1 , Ralph Mitchell Bsc (hons)2, Vishal Pai, M.B., Chb3

The Foot & Ankle Journal 1 (5): 5

A case report describes a 21 year-old male who jumped off a roof and sustained a fracture dislocation of the talonavicular joint and associated lesser metatarsophalangeal joint (MPJ) dislocations. Attempts at closed reduction of the lesser MPJ dislocations were unsuccessful. Open reduction was performed and stabilized with k-wire fixation. This case illustrates the difficulty in attempting closed reduction of multiple lesser MPJ dislocation. The anatomical mechanism of injury and structures as they play a role in preventing successful closed reduction is reviewed.

Key words: Lesser metatarsophalangeal joint dislocations, MPJ dislocations

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org

Accepted: April 2008
Published: May 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0005

Dislocation of metatarsophalangeal joints of the lesser toes is a rare injury. This article describes a case of unreduced second and third metatarsophalangeal joint dislocations. This case illustrates the difficulty of closed reduction and diagnosis in the presence multiple foot injuries. Only few cases of lesser metatarsophalangeal joint dislocations been reported in the literature. [1,2]

Case Report

A 21 year-old male jumped off the roof and landed on his feet. He presented with a fracture dislocation of the talus of the left foot. (Fig.1)

Figure 1   Left foot injury with Talar dislocation and talar head fracture.

There is also an apparent dislocation of the great toe in the right foot. The great toe was reduced in the emergency department. He was then taken to the operating theatre to reduce and stabilize the talar dislocation.

After fixation of the left ankle, it was revealed that the right second and third toes were slightly deformed and swollen. The head of the second and third metatarsal bones were felt along the ball of the foot. A radiograph confirmed a frank dislocation of second and third metatarsophalangeal joints with dorsal displacement of the phalanx. (Figs. 2AB)

 

Figures 2AB    Anteroposterior X-rays of the right foot showing dislocation of second and third metatarsophalangeal joints.

Closed reduction was initially attempted by hyperextending the phalanges and by applying pressure against the bases of phalanges. Multiple attempts at closed reduction failed.

The metatarsophalangeal joints were exposed by making a dorsal longitudinal incision between the third and fourth metatarsals. The extensor tendon was retracted and the anterior capsule was opened. The fibrocartilaginous plantar plate was found to be lying between the metatarsal head and base of proximal phalanges. The flexor digitorum longus and flexor digitorum brevis tendons were found along the lateral side of the metatarsal neck and the lumbrical tendon was found along the medial side of metatarsal. An attempt at closed reduction was unsuccessful. The fibrocartilaginous plate on the plantar surface and the deep transverse metatarsal ligament on the dorsal surface of the neck of the metatarsal were divided.

Flexor tendons were retracted laterally and lumbrical tendons were retracted medially with the bone lever. The metatarsal head reduced with ease and the reduction was stabilized with transarticular K wires. (Figs. 3AB)

 

Figures 3AB  Anteroposterior and oblique views of the right foot showing maintenance of reduction of the second and third metatarsophanalgeal joints.

The foot was then placed in a short leg cast. Soon after the swelling had subsided, a walking heel was added and the patient was discharged encouraged to fully weight bear. The cast was removed in 6 weeks.

The patient was asymptomatic and able to dorsiflex the toes without pain. The patient was last seen 11 months postoperatively when full range of motion was restored.

Discussion

The metatarsophalangeal articulations are of the condyloid joint. The plantar ligaments are thick, dense, fibrous structures known as the plantar plate. The plantar plate lies on the plantar surfaces of the joints in the intervals between the collateral ligaments, to which they are connected; they are loosely united to the metatarsal bones, but very firmly to the bases of the first phalanges. [3]

Forcible dorsiflexion of the proximal phalanx over the metatarsal head is the most common mechanism of injury. [1]  The metatarsal head is forced through the plantar plate. The proximal phalanx comes to lie dorsally. The metatarsal head is trapped between the flexor digitorum longus and the flexor digitorum brevis tendons laterally and lumbrical tendons medially. The configuration of structures including the fibrocartilaginous plate on the plantar surface and the dorsal capsule and deep transverse metatarsal ligament on the dorsal surface form a noose around the metatarsal head on dislocation. This situation is somewhat similar to that encountered in the irreducible dislocation of the metacarpophalangeal joint of the finger. [4] (Fig.4)

Figure 4   MCP dislocation of the hand [Kaplan].  Metacarpophalangeal dislocations  [Kaplan] occur most often in the index finger.

The configuration of structures around the metatarsal head makes closed reduction of the dislocation virtually impossible. The fibrocartilaginous plate and deep transverse metatarsal ligament and dorsal capsule have to be divided to facilitate the reduction of dislocation.

This dislocation is easy to miss as the deformity may be subtle and patient may have significant other injuries. The patient may complain of less pain from the dislocation in the presence of other injuries. [2]  Careful radiological assessment and appropriate treatment is required.

References

1. Rao J,. Banzon M., Irreducible Dislocation of the Metatarsophalangeal Joints of the Foot. Clin Orthop 224-6, 145,1979
2. Leung WY, Wong SH, Lam JJ, Ip FK, Ko PS. Presentation of a missed injury of a metatarsophalangeal joint dislocation in the lesser toes. J Trauma 50(6):1150-2, Jun 2001.
3. Canale ST : Campbell’s Operative Orthopedics, 10th edition, St. Louis, C.V. Mosby Co., 2003
4. Kaplan EB: Dislocation of metacarpophalangeal joint. J Bone Joint Surg 39A:1081, 1957.


Address correspondence to: Dr. Vasu Pai, MS, D (Orth), National board (Orth), FICMR (Orth), FRACS (Orth), MCh (Orth). Orth Consultant, Gisborne Hospital, NZ 00 64 27 276 5889, vasuchitra@gmail.com.

1Orthopaedic Specialist, Gisborne Hospital, Ormand, Road, Gisborne, New Zealand.
2Medical Student, Warwick University, Coventry, UK.
3House Surgeon, Middlemore Hospital, Auckland, New Zealand.

© The Foot & Ankle Journal, 2008