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Fracture–dislocation of the first metatarso–phalangeal joint
Injury, Int. J. Care Injured 31 (2000) 465±466
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Case report
Fracture±dislocation of the ®rst metatarso±phalangeal joint C.I.M. Clark*, C. Reddy, J. Kitson Department of Orthopaedic Surgery, Queen Elizabeth II Hospital, Welwyn Garden City, UK Accepted 7 February 2000
1. Introduction Dislocation of the ®rst metatarsophalangeal (MTP) joint is rare [1]. Dislocation is usually dorsal, with isolated case reports of medial dislocation [2,3]. The most common cause of dorsal dislocation is high-energy force acting from distal to proximal [4]. Concomitant foot injuries sometimes seen are lesser metatarsal neck fracture/MTP joint dislocation, tarsal fracture or Lisfranc-type injuries [4,5]. We present a case of ®rst MTP joint fracture±dislocation, which required open reduction and percutaneous ®xation. There have been no descriptions of this injury in the literature. 2. Case report An 84-year-old woman with long-standing foot-drop presented to our Accident and Emergency Department, having fallen and stubbed her right big toe. X-ray showed a dorso±laterally displaced fracture of the neck of the ®rst metatarsal and plantar dislocation of the MTP joint, with sesamoids intact (Fig. 1a). Closed reduction under sedation failed, and so open reduction was performed under general anaesthesia. Using a dorso±medial incision, the Extensor Hallucis Longus (EHL) tendon was found to be interposed between the transverse and longitudinal elements of the fracture. Following reduction, the fracture was stabilised with two percutaneous Kirschner wires (Fig. 1b). A belowknee walking cast was applied for 3 weeks and reduced to a POP boot for a further 3 weeks, when the wires
were removed. At 4 months, there was clinical and radiological union with no residual pain (Fig. 1c).
3. Discussion The presumed mechanism of injury in this patient was longitudinal force in a slightly plantar-¯exed hallux (secondary to foot-drop), causing dorsal displacement of the metatarsal head and plantar dislocation of the proximal phalanx. Attempted closed reduction of this injury is futile, due to interposition of the EHL tendon. Once the fracture is reduced and ®xed, the MTP joint is stable, due to the integrity of the dorsal tendon and plantar sesamoid complex. We consider this injury pattern an addition to the Jahss classi®cation of ®rst MTP joint dislocations, i.e. Type IV.
References [1] Killian FJ, et al. Dorsal dislocation of the ®rst metatarsophalangeal joint. J Foot Ankle Surg 1997;36(2):132±5. [2] Massary MD, et al. Atypical medial dislocation of the ®rst metatarsophalangeal joint. Foot Ankle Int 1998;19(9):624±6. [3] Nabarro MN, et al. Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report. Foot Ankle Int 1995;16(2):75±8. [4] Brunet JA. Pathomechanics of complex dislocations of the metatarsophalangeal joint. CORR 1996;332:126±31. [5] Leibner ED, et al. Floating metatarsal: concomitant Lisfranc fracture±dislocation and complex dislocation of the ®rst metatarsophalangeal joint. J Trauma 1997;42(3):549±52.
* Corresponding author. 12A St. Luke's Road, London W11 1DP, UK. 0020-1383/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 0 9 - 7
466
C.I.M. Clark et al. / Injury, Int. J. Care Injured 31 (2000) 465±466
Fig. 1. Radiograph showing the initial injury, with dorso±laterally displaced metatarsal head, plantar dislocation of MTP joint and intact sesamoids (a). Further radiographs showing initial reduction (b) and position at 4 months (c).
www.elsevier.com/locate/injury
Case report
Fracture±dislocation of the ®rst metatarso±phalangeal joint C.I.M. Clark*, C. Reddy, J. Kitson Department of Orthopaedic Surgery, Queen Elizabeth II Hospital, Welwyn Garden City, UK Accepted 7 February 2000
1. Introduction Dislocation of the ®rst metatarsophalangeal (MTP) joint is rare [1]. Dislocation is usually dorsal, with isolated case reports of medial dislocation [2,3]. The most common cause of dorsal dislocation is high-energy force acting from distal to proximal [4]. Concomitant foot injuries sometimes seen are lesser metatarsal neck fracture/MTP joint dislocation, tarsal fracture or Lisfranc-type injuries [4,5]. We present a case of ®rst MTP joint fracture±dislocation, which required open reduction and percutaneous ®xation. There have been no descriptions of this injury in the literature. 2. Case report An 84-year-old woman with long-standing foot-drop presented to our Accident and Emergency Department, having fallen and stubbed her right big toe. X-ray showed a dorso±laterally displaced fracture of the neck of the ®rst metatarsal and plantar dislocation of the MTP joint, with sesamoids intact (Fig. 1a). Closed reduction under sedation failed, and so open reduction was performed under general anaesthesia. Using a dorso±medial incision, the Extensor Hallucis Longus (EHL) tendon was found to be interposed between the transverse and longitudinal elements of the fracture. Following reduction, the fracture was stabilised with two percutaneous Kirschner wires (Fig. 1b). A belowknee walking cast was applied for 3 weeks and reduced to a POP boot for a further 3 weeks, when the wires
were removed. At 4 months, there was clinical and radiological union with no residual pain (Fig. 1c).
3. Discussion The presumed mechanism of injury in this patient was longitudinal force in a slightly plantar-¯exed hallux (secondary to foot-drop), causing dorsal displacement of the metatarsal head and plantar dislocation of the proximal phalanx. Attempted closed reduction of this injury is futile, due to interposition of the EHL tendon. Once the fracture is reduced and ®xed, the MTP joint is stable, due to the integrity of the dorsal tendon and plantar sesamoid complex. We consider this injury pattern an addition to the Jahss classi®cation of ®rst MTP joint dislocations, i.e. Type IV.
References [1] Killian FJ, et al. Dorsal dislocation of the ®rst metatarsophalangeal joint. J Foot Ankle Surg 1997;36(2):132±5. [2] Massary MD, et al. Atypical medial dislocation of the ®rst metatarsophalangeal joint. Foot Ankle Int 1998;19(9):624±6. [3] Nabarro MN, et al. Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report. Foot Ankle Int 1995;16(2):75±8. [4] Brunet JA. Pathomechanics of complex dislocations of the metatarsophalangeal joint. CORR 1996;332:126±31. [5] Leibner ED, et al. Floating metatarsal: concomitant Lisfranc fracture±dislocation and complex dislocation of the ®rst metatarsophalangeal joint. J Trauma 1997;42(3):549±52.
* Corresponding author. 12A St. Luke's Road, London W11 1DP, UK. 0020-1383/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 0 9 - 7
466
C.I.M. Clark et al. / Injury, Int. J. Care Injured 31 (2000) 465±466
Fig. 1. Radiograph showing the initial injury, with dorso±laterally displaced metatarsal head, plantar dislocation of MTP joint and intact sesamoids (a). Further radiographs showing initial reduction (b) and position at 4 months (c).