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Dislocation at the metatarsophalangeal joint in association with tarsometatarsal dislocation
The Foot (1993) 3. 202-204
Dislocation at the metatarsophalangeal joint in association with tarsometatarsal dislocation J. N. Brown Royal Hallamshire Hospital, Shefield,
UK
SUMMA R Y. A case is presented in which fracture dislocation at the tarsometatarsal joint is complicated by dislocation of the second metatarsophalangeal (MTP) joint and fractures of the necks of the third and fourth metatarsals. Such a case has not been described previously, although the idea of segmental forefoot injuries has been introduced by English’ who reported two cases in which dislocations occurred at the fourth and fifth MTP joints in association with an injury to the tarsometatarsal joint. This case highlights the fact that the anatomy of the soft tissues of the forefoot must be remembered if reduction proves difficult.
Injuries to the tarsometatarsal joint represent a difficult management problem. Anatomical reduction should be strived for but may not be achieved easily in all cases. Attention must be given to associated forefoot injuries and an understanding of the anatomy of the soft tissues is required if accurate reduction is to be achieved.
wires were used to maintain the reduction together with plaster cast immobilisation. The wires were removed at 4 weeks, the plaster at 7 weeks and the patient recovered with no complications. At review 18 months later the patient complained of persistent foot pain during heavy activities or when walking on uneven ground but no joint instability was demonstrable. The resultant X-rays are shown in Figure 2.
CASE REPORT DISCUSSION
A 51-year-old gentleman was involved in a head on collision while driving a car. He had anticipated the impact and was braking heavily as he collided with a bus, leaving his right foot on the brake pedal. As he alighted from his car to inspect the damage he felt severe pain in his right foot and noticed that he could not put his foot to the ground in a normal manner. Subsequent X-rays revealed a partial divergent pattern of injury to the tarsometatarsal joint with fracture of the medial cuneiform and dislocation of the bases of the lesser ray metatarsals. This was complicated by dislocation of the second MTP joint and fractures of the necks of the third and fourth metatarsals (Fig. 1). Under general anaesthetic the second metatarsal base was irreducible by closed methods and so an open procedure was performed. After reduction of the first metatarsal the base of the second metatarsal could be manipulated into its correct position but it was not possible to reduce the second MTP joint. However, once the remaining lesser metatarsal bases were manipulated into a satisfactory position the second MTP joint was reduced with ease. Kirschner
Fracture-dislocations of the tarsometatarsal joints (Lisfranc joints) occur as a result of direct compressive forces or indirect rotational or sheer forces.2*3 The stability of these joints is largely due to the strong plantar ligaments together with the bony contour of the joints (with key stoning of the base of the second metatarsal in the cuneiforms) and a high degree of violence is often required to produce the injury patterns seen. Originally equestrian accidents were largely implicated but in the last few decades motor accidents have been the more common cause. Treatment has been aimed at anatomical reduction and maintaining reduction with either Kirshner wires or screws.4’5 A general anaesthetic is often required to provide adequate analgesia and muscle relaxation in order to achieve reduction. Some cases require open reduction if closed manipulation fails and this is usually due to osteochondral fragments within the joint space blocking anatomical alignment. In 1964 English reported 2 cases in which reduction 202
Dislocation
at the metatarsophalangeal
Fig. 1 -Standard non-weightbearing AP radiograph of the foot on presentation. A divergent pattern of fracture dislocation is seen at the tarsometatarsal joint together with dislocation of the second metatarsal head and fractures of the third and fourth metatarsal heads. There is a discrepancy in length of the second metatarsal and the gap between the intermediate cuneiform and second digit because of the pull of the intrinsic musculature of the foot on the toe.
of the bases of the metatarsals was the key to reduction of dislocated fourth and fifth MTP joints.’ Undoubtedly in the above report the interossei muscles were the block to initial reduction. Adduction and abduction in the foot occur with respect to the second metatarsal. The attachments of the interossei may be remembered through the use of the formula ‘PAD and DAB’.6 The second metatarsal has no plantar interossei to adduct the second digit but it does possess two dorsal interossei to facilitate abduction (medially and laterally). Each dorsal interosseous muscle takes origin from both bones of its own intermetatarsal space. The first dorsal interosseous is inserted into the medial side of the proximal phalanx of the second toe while the second dorsal interosseous inserts into the lateral side, both tendons giving a slip into the dorsal extensor expansion. It can thus be seen that the above injury to the tarsometatarsal joint causing
joint in association
with tarsometatarsal
dislocation
203
Fig. 2-Radiographic appearance of the foot 18 months after injury. There is diastasis between the bases of the Hurst and second metatarsals and signs of osteoarthrosis despite accurate open reduction at the time of injury. The deformity of the third metatarsal neck is as a result of the initial fracture.
proximal migration of the shafts of the metatarsals together with divergence of the shafts will in effect shorten the interossei so that when dislocation at the MTP joint occurs reduction will be difficult. This problem was found in the above case and only after reduction of the bases of the metatarsals was it possible to overcome the pull of the intrinsic musculature allowing reduction of the MTP joint.
Acknowledgment The help Hallamshire
of the Medical Illustration Hospital, Sheffield is gratefully
Department. acknowledged.
References English T A. Dislocations of the metatarsal bone and adjacent toe. J Bone Joint Surg 1964; 46(B): 700-704. Wilson D W. Injuries of the tarsometatarsal joints, eitiology, classification and results of treatment. J Bone Joint Surg 1972; 54(B): 677-686. Hardcastle P H, Reschauer R, Kutscha-Lissberg E, Schffmann W. Injuries to the tarsometatarsal joint.
Royal
204 The Foot Incidence, classification and treatment. J Bone Joint Surg 1982; 64(B): 349-356. 4. Myerson M S, Fisher R T, Burgess A R, Kenzora J E. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986; 6: 225-242. 5. Arntz C T, Veith R G, Hansen S T. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg 1988; 70(A): 173-181. 6. Last R J. Anatomy regional and applied, 6E. Edinburgh: Churchill Livingstone, 1981.
The author Mr J. N. Brown Orthopaedic Registrar Department of Orthopaedics Doncaster Royal Infirmary Doncaster DN2 5LT UK
Dislocation at the metatarsophalangeal joint in association with tarsometatarsal dislocation J. N. Brown Royal Hallamshire Hospital, Shefield,
UK
SUMMA R Y. A case is presented in which fracture dislocation at the tarsometatarsal joint is complicated by dislocation of the second metatarsophalangeal (MTP) joint and fractures of the necks of the third and fourth metatarsals. Such a case has not been described previously, although the idea of segmental forefoot injuries has been introduced by English’ who reported two cases in which dislocations occurred at the fourth and fifth MTP joints in association with an injury to the tarsometatarsal joint. This case highlights the fact that the anatomy of the soft tissues of the forefoot must be remembered if reduction proves difficult.
Injuries to the tarsometatarsal joint represent a difficult management problem. Anatomical reduction should be strived for but may not be achieved easily in all cases. Attention must be given to associated forefoot injuries and an understanding of the anatomy of the soft tissues is required if accurate reduction is to be achieved.
wires were used to maintain the reduction together with plaster cast immobilisation. The wires were removed at 4 weeks, the plaster at 7 weeks and the patient recovered with no complications. At review 18 months later the patient complained of persistent foot pain during heavy activities or when walking on uneven ground but no joint instability was demonstrable. The resultant X-rays are shown in Figure 2.
CASE REPORT DISCUSSION
A 51-year-old gentleman was involved in a head on collision while driving a car. He had anticipated the impact and was braking heavily as he collided with a bus, leaving his right foot on the brake pedal. As he alighted from his car to inspect the damage he felt severe pain in his right foot and noticed that he could not put his foot to the ground in a normal manner. Subsequent X-rays revealed a partial divergent pattern of injury to the tarsometatarsal joint with fracture of the medial cuneiform and dislocation of the bases of the lesser ray metatarsals. This was complicated by dislocation of the second MTP joint and fractures of the necks of the third and fourth metatarsals (Fig. 1). Under general anaesthetic the second metatarsal base was irreducible by closed methods and so an open procedure was performed. After reduction of the first metatarsal the base of the second metatarsal could be manipulated into its correct position but it was not possible to reduce the second MTP joint. However, once the remaining lesser metatarsal bases were manipulated into a satisfactory position the second MTP joint was reduced with ease. Kirschner
Fracture-dislocations of the tarsometatarsal joints (Lisfranc joints) occur as a result of direct compressive forces or indirect rotational or sheer forces.2*3 The stability of these joints is largely due to the strong plantar ligaments together with the bony contour of the joints (with key stoning of the base of the second metatarsal in the cuneiforms) and a high degree of violence is often required to produce the injury patterns seen. Originally equestrian accidents were largely implicated but in the last few decades motor accidents have been the more common cause. Treatment has been aimed at anatomical reduction and maintaining reduction with either Kirshner wires or screws.4’5 A general anaesthetic is often required to provide adequate analgesia and muscle relaxation in order to achieve reduction. Some cases require open reduction if closed manipulation fails and this is usually due to osteochondral fragments within the joint space blocking anatomical alignment. In 1964 English reported 2 cases in which reduction 202
Dislocation
at the metatarsophalangeal
Fig. 1 -Standard non-weightbearing AP radiograph of the foot on presentation. A divergent pattern of fracture dislocation is seen at the tarsometatarsal joint together with dislocation of the second metatarsal head and fractures of the third and fourth metatarsal heads. There is a discrepancy in length of the second metatarsal and the gap between the intermediate cuneiform and second digit because of the pull of the intrinsic musculature of the foot on the toe.
of the bases of the metatarsals was the key to reduction of dislocated fourth and fifth MTP joints.’ Undoubtedly in the above report the interossei muscles were the block to initial reduction. Adduction and abduction in the foot occur with respect to the second metatarsal. The attachments of the interossei may be remembered through the use of the formula ‘PAD and DAB’.6 The second metatarsal has no plantar interossei to adduct the second digit but it does possess two dorsal interossei to facilitate abduction (medially and laterally). Each dorsal interosseous muscle takes origin from both bones of its own intermetatarsal space. The first dorsal interosseous is inserted into the medial side of the proximal phalanx of the second toe while the second dorsal interosseous inserts into the lateral side, both tendons giving a slip into the dorsal extensor expansion. It can thus be seen that the above injury to the tarsometatarsal joint causing
joint in association
with tarsometatarsal
dislocation
203
Fig. 2-Radiographic appearance of the foot 18 months after injury. There is diastasis between the bases of the Hurst and second metatarsals and signs of osteoarthrosis despite accurate open reduction at the time of injury. The deformity of the third metatarsal neck is as a result of the initial fracture.
proximal migration of the shafts of the metatarsals together with divergence of the shafts will in effect shorten the interossei so that when dislocation at the MTP joint occurs reduction will be difficult. This problem was found in the above case and only after reduction of the bases of the metatarsals was it possible to overcome the pull of the intrinsic musculature allowing reduction of the MTP joint.
Acknowledgment The help Hallamshire
of the Medical Illustration Hospital, Sheffield is gratefully
Department. acknowledged.
References English T A. Dislocations of the metatarsal bone and adjacent toe. J Bone Joint Surg 1964; 46(B): 700-704. Wilson D W. Injuries of the tarsometatarsal joints, eitiology, classification and results of treatment. J Bone Joint Surg 1972; 54(B): 677-686. Hardcastle P H, Reschauer R, Kutscha-Lissberg E, Schffmann W. Injuries to the tarsometatarsal joint.
Royal
204 The Foot Incidence, classification and treatment. J Bone Joint Surg 1982; 64(B): 349-356. 4. Myerson M S, Fisher R T, Burgess A R, Kenzora J E. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986; 6: 225-242. 5. Arntz C T, Veith R G, Hansen S T. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg 1988; 70(A): 173-181. 6. Last R J. Anatomy regional and applied, 6E. Edinburgh: Churchill Livingstone, 1981.
The author Mr J. N. Brown Orthopaedic Registrar Department of Orthopaedics Doncaster Royal Infirmary Doncaster DN2 5LT UK