- Email: [email protected]
Dorsal dislocation of the first metatarsophalangeal joint associated with fractured second metatarsal head: a case report and literature review
Foot and Ankle Surgery 9 (2003) 187–191 www.elsevier.com/locate/fas
Case report
Dorsal dislocation of the first metatarsophalangeal joint associated with fractured second metatarsal head: a case report and literature review M.R. Carmont*, G.L. Cribb, S.M. Hay Department of Trauma and Orthopaedic Surgery, Royal Shrewsbury Hospital, Mytton Oak Lane, Shrewsbury, Shropshire SY3 8XQ, UK Received 7 January 2003; received in revised form 23 March 2003; accepted 1 April 2003
Abstract Dislocations of the first metatarsophalangeal joint are rare. Their diagnosis relies upon subtle radiological features and a high index of suspicion. This case reports a case of first MTPJ dislocation associated with second metatarsal head fracture. It also demonstrates an osteochondral fracture to the metatarsal head resultant of either an avulsion of the sesamometatarsal complex or compression fracture during dislocation. The papers principle message is that significant injuries to the MTPJ can be missed with radiological features mimicking common orthopaedic pathology. Subtle signs may reveal significant injury when imaged further. The discussion features a review of current literature. q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Dislocation; Metatarsophalangeal joint; Osteochondral fracture
1. Introduction Dislocations of the first metatarsophalangeal joint are rare. They classically occur due to forced hyperextension of the first MTPJ. However, in high-energy injuries involving the whole foot, they could be easily overlooked as the diagnosis relies upon subtle radiographic signs. We present a case of dorsal dislocation of the first MTPJ with fibula sesamoid-metatarsal ligament avulsion fracture diagnosed using a CT scan, together with associated with second metatarsal head fracture.
2. Case report A 54 yr old grounds man injured his right foot when an iron gate fell onto the back of his heel, twisting his foot and ankle. On examination the forefoot was very swollen, bruised and tender. There was a superficial laceration to the back of his heel. The toes had normal sensation and capillary refill. * Corresponding author. Tel.: þ 44-1743-261000; fax: þ 44-1743261006. E-mail address: [email protected] (M.R. Carmont).
Although toe movements were painful and reduced, the MTPJs appeared to be clinically congruent. Initial AP and Oblique radiographs (Fig. 1) of the foot revealed a fractured second metatarsal head together with a widened intermetatarsal angle of 188. The appearance of the sesamoids and first MTPJ was atypical. A Lateral radiograph (Fig. 2) suggested the additional injury of dorsal dislocation of the proximal first phalanx. Subsequent CT (Fig. 3) confirmed the dorsal dislocation, a flake avulsion fracture from the lateral aspect of the first metatarsal head and normal tarsometatarsal joint congruity. Under general anaesthesia with image intensifier control, the dislocated MTPJ was reduced using a closed technique, by grasping the proximal phalanx firmly and applying in line traction. The forefoot was subsequently immobilised with a plaster cast. Post reduction check radiographs (Fig. 4) revealed no bony fragment interposition within the MTPJ and the restoration of normal sesamoid appearance. Clinical review at 4 weeks out of plaster revealed pain free MTPJ movements.
3. Discussion Dorsal dislocation of the first MTPJ is a rare but not a new phenomenon with Mouchet reporting two cases in 1931
1268-7731/03/$ - see front matter q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S1268-7731(03)00046-8
188
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191
Fig. 1. (a) AP and (b) Oblique radiographs of the right foot revealing the second metatarsal head fracture and a widened intermetatarsal angle of 188, together with an abnormal appearance of the sesamoids and first MTPJ.
[1]. Since then numerous case reports feature in the literature with a few review articles on the subject [2,3]. In cases of MTPJ dislocation an understanding of the local anatomy together with the radiographic appearance of the sesamoid bones, aids classification and explains and directs reduction techniques. The anatomy of the first MTPJ has been described by Sarrafian [4] and in Gray’s Anatomy [5]. The medial and lateral first MTPJ sesamoids lie within the twin tendons of Flexor Hallucis Brevis inserting into the medial and lateral aspects of the great toe proximal phalanx, with Abductor and Adductor Hallucis, respectively. The sesamoids run within longitudinal grooves on the plantar surface of the metatarsal head on toe flexion and extension. They are attached to the plantar plate and proximal phalanx by sesamophalangeal ligaments, and to the metatarsal head by sesamometatarsal ligaments and finally to each other by an intersesamoid ligament. The first MTPJ capsule or plantar plate is relatively weaker at its metatarsal insertion. The metatarsal heads being linked by the deep transverse intermetatarsal ligament inserting into the capsule of MTPJ. Following traumatic injury only the standard AP and Oblique radiographs of the foot will commonly be requested. In the above case the obvious feature is the fracture of the second metatarsal head. There is also a widened first intermetatarsal angle of 188 and an atypical
position and orientation of the lateral sesamoid but no apparent sesamoid fracture. These radiological features are routinely seen and used by general orthopaedic surgeons during operative decision making on patients with Hallux Valgus and Metatarsus Primus Varus [6]. The subtle increased intersesamoid distance may be missed by none foot specialists being interpreted as atraumatic sesamoid
Fig. 2. Lateral radiograph of the right foot, suggesting a dorsally dislocated first MTPJ together with an apparently dorsally displaced sesamoid.
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191
189
Fig. 4. AP radiograph of the forefoot post reduction, demonstrating the restoration of normal sesamometatarsal radiographic appearance and the absence of bony interposition within the joint. Fig. 3. (a) Coronal CT scan and (b) computerised three-dimensional reconstructions confirming dorsal dislocation of the MTPJ together with avulsion flake fracture from the lateral aspect of the first metatarsal head.
subluxation, unless the films are inspected closely. The films do not clearly show the described double density sign described by previous authors [7,8] resulting from superimposition of the proximal phalanx over the metatarsal head. True appreciation of MTPJ dislocation only becomes apparent on further imaging. First MTPJ dislocations were classified by Jahss in 1980 [9]. Type I, having an intact intersesamoid ligament, usually requiring open reduction [10] via plantar [11,12], dorsal [13 – 15] or medial approach [16] although cases of closed reduction have been reported [17]. Types IIA and B having disrupted intersesamoid ligament and transverse sesamoid fracture, respectively. This original classification has been developed to include: Type IB, with the proximal phalanx in an adducted rather than abducted position [18], Type IIC having increased intersesamoid distance and sesamoid fracture [19]. Jahss has further extended his classification to include a Type III, with dorsal hallux but undisplaced
sesamoids, intact intersesamoid ligament, plantar plate and no sesamoid fracture [20 – 22]. Additional Type II variants have been reported featuring medial bipartite sesamoid fracture, partial intersesamoid ligament rupture and lateral sesamophalangeal joint rupture [23]. In Type II dislocations, structural disruption should permit satisfactory closed reduction, however, in some reports later surgery was required either to remove fragments of bone have remained interposed within the joint [19,23 – 25] or to restore the sesamometatarsal complex [26]. Authors have reported failure of closed reduction in a case of subluxation of the first MTPJ [7] so this appearance should not be treated with complacency. It is well appreciated that the hyperextension mechanism of injury can also lead to dislocation of other MTPJs [8,27,28]. Authors have reported three previous cases of fractured second metatarsal neck [29 –31] and head [32,33] in association with MTPJ dislocations. Additional radiology being either lateral plain radiograph, Computed Tomography or Magnetic Resonance [34] has be used to give additional information on the sesamometatarsal structures. In the above case the CT
190
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191
scan revealed the presence of a flake of bone close and dorsal to the lateral sesamoid. This cortical flake appears to have originated from the cortical irregularity on the inferolateral aspect of the first metatarsal head forming the lateral longitudinal groove. This fracture could have resulted from either an avulsion of the sesamometatarsal ligaments/plantar plate structures from the metatarsal head or an osteochondral fragment from the lateral longitudinal groove underlying the metatarsal head, described above. The metatarsal flake being chipped off by a compressive force during MTPJ dislocation. This occurs similarly to the well-recognised mechanism of osteochondral bone fragments being fractured off the lateral femoral condyle during patella dislocation [35]. Both these mechanisms of injury have been described in Jahss’s original classification relating to fracture of the sesamoids (IIB), however, in this case the fracture relates to the metatarsal head rather than the sesamoid and thus could be considered to be a further development of the classification. Careful scrutiny of the literature reveals the operative finding of a 2 mm osteochondral fracture associated with first MTPJ dislocation and medial sesamoid fracture [23]. In this case the CT scan confirmed a significantly larger osteochondral fracture from the metatarsal head and no evidence of sesamoid fracture. In our patient the presence of the osteochondral fracture gave additional evidence of sesamometatarsal ligament/plate disruption. According to Jahss’ classification successful closed manipulation confirms this as a Type II injury with a disrupted intersesamoid ligament.
4. Summary This case reports the rare occurrence of first MTPJ dislocation associated with second metatarsal head fracture. It also demonstrates an osteochondral fracture to the metatarsal head resultant of either an avulsion of the sesamometatarsal complex or compression fracture during dislocation. The papers principle message is that significant injuries to the MTPJ can be missed with radiological features mimicking common orthopaedic pathology. Subtle signs may reveal significant injury when imaged further.
Acknowledgements The authors would like to thank the staff of the Postgraduate Medical Institute Library, Royal Shrewsbury Hospital, the Francis Costello Library, The Robert Jones and Agnes Hunt District General Library, Oswestry and the Departments of Radiology and Medical Illustration, Royal Shrewsbury Hospital for their assistance with this research.
References [1] Mouchet A. Deux cas de luxation dorslae complete du gros orteil avec lesions des sesamoids. Rev Orthop 1931;18:221–7. [2] Schenck RC, Heckman JD. Fractures and dislocations of the forefoot: operative and nonoperative treatment. J Am Acad Orthop Surg 1995; 3:70–8. [3] Brunet JA. Pathomechanics of complex dislocations of the first metatarsophalangeal joint. Clin Orthop 1996;332:126 –31. [4] Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographical, functional. Osteology and Myology, Philadelphia: JB Lippincott; 1983. p. 81–7, 193 –8, 219– 30. [5] Gray’s anatomy. In: Roger WS, editor. Skeletal system, 38th ed. London: Churchill Livingstone; 1995 [chapter 6]. [6] Coull R, Stephens MM. Operative decision making in Hallux Valgus. Curr Orthop 2002;16:180– 6. [7] Ando Y, Yasudo M, Okuda H, Komano M. Irreduceable dorsal subluxation of the first metatarsophalangeal joint. A case report. J Orthop Trauma 2002;16(2):134–6. [8] Gentless J, Joshi P, Caselli M, Giorgini R. First and second metatarsophalangeal joint dislocations. J Am Podiatr Med Assoc 1992;82(12):630 –2. [9] Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1980;1:15–21. [10] Sage R, Holloway P. Type I dorsal dislocation of the first metatarsophalangeal joint. J Am Podiatr Assoc 1985;75:215. [11] Salamon PB, Gelberman RH, Huffer JM. Dorsal dislocation of the metatarsophalangeal joint of the great toe. JBJS 1974;56A(5): 1073–5. [12] Giannikas AC, Papachristou G, Papavasiliou N, Nikifordis P. Dorsal dislocation of the first metatarsophalangeal joint. JBJS 1975;57B: 384 –6. [13] Hussain A. Dislocation of the first metatarsophalangeal joint with fracture of the fibula sesamoid. A case report. Clin Orthop 1999;359: 209 –12. [14] Yu EC, Garfin SR. Closed dorsal dislocation of the metatarsophalangeal joint of the great toe. Clin Orthop 1984;185: 237– 40. [15] Lewis AG, DeLee JC. Type 1 complex dislocation of the first metatarsophalangeal joint-open reduction through a dorsal approach. JBJS 1984;66A:1120–3. [16] DeCasas R, Mesa F. Irreducible dorsal dislocation of the metatarsophalangeal joint of the hallux. Arch Orthop Trauma Surg 1990;109: 173 –4. [17] Mata SG, Hidalgo A, Grande MM. Dorsal dislocation of the first metatarsophalangeal joint. Int Orthop 1994;66:1120 –3. [18] Lantor H, Borovoy MA. A new classification of first metatarsophalangeal joint dislocations (type IB). J Foot Surg 1987;26: 75 –7. [19] Copeland CL, Kanat IO. A new classification for traumatic dislocations of the first metatarsophalangeal joint: type IIC. J Foot Surg 1991;30:234 –7. [20] Jahss MH. Disorders of the foot and ankle; medical and surgical management, 2nd ed. Part IV. The Adult Foot, vol. 2. Philadelphia: WB Saunders; 1991. p. 1124–7. [21] Tondera EK, Baker CC. Closed reduction of a rare type III dislocation of first metatarsophalangeal joint. J Manipulative Physiol Ther 1996; 19:475–9. [22] Killian FJ, Carpenter BB, Mostone E. Dorsal dislocation of the first metatarsophalangeal joint. J Foot Ankle Surg 1997;36(2): 131 –5. [23] Hall RL, Saxby T, Vandemark RM. A new type of dislocation of the first metatarsophalangeal joint: a case report. Foot Ankle 1992;13: 540 –5. [24] Konkel KF, Muehlstein JH. Unusual fracture-dislocation of the great toe. J Trauma 1975;15:733.
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191 [25] Good JJ, Weinfeld GD, Yu GV. Fracture-dislocation of the metatarsophalangeal joint: open reduction through a medial incisional approach. J Foot Ankle Surg 2001;40(5):311– 7. [26] Nabarro MN, Powell J. Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report. Foot Ankle Int 1995;16(2):75–8. [27] Murphy JL. Isolated dorsal dislocation of the second metatarsophalangeal joint. Foot Ankle 1980;1(1):30–2. [28] Dutkowsky J, Freeman III BL. Fracture-dislocation of the articular surface of the third metatarsal head. Foot Ankle 1981;2:153–5. [29] Daniel WL, Beck EL, Duggar GE, Bennett AJ. Traumatic dislocation of the first metatarsophalangeal joint. A case report. J Am Podiatr Assoc 1976;66:97–100. [30] McKinley LM, Davis GL. Locked dislocation of the great toe. J Louisiana State Med Soc 1975;127:389– 90.
191
[31] Rao JP, Banzon MT. Irreducible dorsal dislocation of the metatarsophalangeal joints of the foot. Clin Orthop 1979;(145):224– 6. [32] Garcia Mata S, Hidalgo Overjero AM, Martinez Grande M. Dorsal dislocation of the first metatarsophalangeal joint. Int Orthop 1988;12: 237–8. [33] Deluca FN, Kenmore PI. Bilateral dorsal dislocations of the metatarsophalangeal joints of the great toes with a loose body in one of the joints. J Trauma 1975;15(8):737 –9. [34] Karasick D, Schweitzer ME. Disorders of the hallux sesamoid complex: MR features. Skeletal Radiol 1998;27(8):411 –8. [35] Scuderi GR, Scott WN, Insall JN, editors. Rockwood and Green’s fractures in adults, 4th ed. Dislocations and subluxations of the patella, vol. 2. Philadelphia: Lippincott/Raven; 1996. p. 2041 [chapter 29].
Case report
Dorsal dislocation of the first metatarsophalangeal joint associated with fractured second metatarsal head: a case report and literature review M.R. Carmont*, G.L. Cribb, S.M. Hay Department of Trauma and Orthopaedic Surgery, Royal Shrewsbury Hospital, Mytton Oak Lane, Shrewsbury, Shropshire SY3 8XQ, UK Received 7 January 2003; received in revised form 23 March 2003; accepted 1 April 2003
Abstract Dislocations of the first metatarsophalangeal joint are rare. Their diagnosis relies upon subtle radiological features and a high index of suspicion. This case reports a case of first MTPJ dislocation associated with second metatarsal head fracture. It also demonstrates an osteochondral fracture to the metatarsal head resultant of either an avulsion of the sesamometatarsal complex or compression fracture during dislocation. The papers principle message is that significant injuries to the MTPJ can be missed with radiological features mimicking common orthopaedic pathology. Subtle signs may reveal significant injury when imaged further. The discussion features a review of current literature. q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Dislocation; Metatarsophalangeal joint; Osteochondral fracture
1. Introduction Dislocations of the first metatarsophalangeal joint are rare. They classically occur due to forced hyperextension of the first MTPJ. However, in high-energy injuries involving the whole foot, they could be easily overlooked as the diagnosis relies upon subtle radiographic signs. We present a case of dorsal dislocation of the first MTPJ with fibula sesamoid-metatarsal ligament avulsion fracture diagnosed using a CT scan, together with associated with second metatarsal head fracture.
2. Case report A 54 yr old grounds man injured his right foot when an iron gate fell onto the back of his heel, twisting his foot and ankle. On examination the forefoot was very swollen, bruised and tender. There was a superficial laceration to the back of his heel. The toes had normal sensation and capillary refill. * Corresponding author. Tel.: þ 44-1743-261000; fax: þ 44-1743261006. E-mail address: [email protected] (M.R. Carmont).
Although toe movements were painful and reduced, the MTPJs appeared to be clinically congruent. Initial AP and Oblique radiographs (Fig. 1) of the foot revealed a fractured second metatarsal head together with a widened intermetatarsal angle of 188. The appearance of the sesamoids and first MTPJ was atypical. A Lateral radiograph (Fig. 2) suggested the additional injury of dorsal dislocation of the proximal first phalanx. Subsequent CT (Fig. 3) confirmed the dorsal dislocation, a flake avulsion fracture from the lateral aspect of the first metatarsal head and normal tarsometatarsal joint congruity. Under general anaesthesia with image intensifier control, the dislocated MTPJ was reduced using a closed technique, by grasping the proximal phalanx firmly and applying in line traction. The forefoot was subsequently immobilised with a plaster cast. Post reduction check radiographs (Fig. 4) revealed no bony fragment interposition within the MTPJ and the restoration of normal sesamoid appearance. Clinical review at 4 weeks out of plaster revealed pain free MTPJ movements.
3. Discussion Dorsal dislocation of the first MTPJ is a rare but not a new phenomenon with Mouchet reporting two cases in 1931
1268-7731/03/$ - see front matter q 2003 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S1268-7731(03)00046-8
188
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191
Fig. 1. (a) AP and (b) Oblique radiographs of the right foot revealing the second metatarsal head fracture and a widened intermetatarsal angle of 188, together with an abnormal appearance of the sesamoids and first MTPJ.
[1]. Since then numerous case reports feature in the literature with a few review articles on the subject [2,3]. In cases of MTPJ dislocation an understanding of the local anatomy together with the radiographic appearance of the sesamoid bones, aids classification and explains and directs reduction techniques. The anatomy of the first MTPJ has been described by Sarrafian [4] and in Gray’s Anatomy [5]. The medial and lateral first MTPJ sesamoids lie within the twin tendons of Flexor Hallucis Brevis inserting into the medial and lateral aspects of the great toe proximal phalanx, with Abductor and Adductor Hallucis, respectively. The sesamoids run within longitudinal grooves on the plantar surface of the metatarsal head on toe flexion and extension. They are attached to the plantar plate and proximal phalanx by sesamophalangeal ligaments, and to the metatarsal head by sesamometatarsal ligaments and finally to each other by an intersesamoid ligament. The first MTPJ capsule or plantar plate is relatively weaker at its metatarsal insertion. The metatarsal heads being linked by the deep transverse intermetatarsal ligament inserting into the capsule of MTPJ. Following traumatic injury only the standard AP and Oblique radiographs of the foot will commonly be requested. In the above case the obvious feature is the fracture of the second metatarsal head. There is also a widened first intermetatarsal angle of 188 and an atypical
position and orientation of the lateral sesamoid but no apparent sesamoid fracture. These radiological features are routinely seen and used by general orthopaedic surgeons during operative decision making on patients with Hallux Valgus and Metatarsus Primus Varus [6]. The subtle increased intersesamoid distance may be missed by none foot specialists being interpreted as atraumatic sesamoid
Fig. 2. Lateral radiograph of the right foot, suggesting a dorsally dislocated first MTPJ together with an apparently dorsally displaced sesamoid.
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191
189
Fig. 4. AP radiograph of the forefoot post reduction, demonstrating the restoration of normal sesamometatarsal radiographic appearance and the absence of bony interposition within the joint. Fig. 3. (a) Coronal CT scan and (b) computerised three-dimensional reconstructions confirming dorsal dislocation of the MTPJ together with avulsion flake fracture from the lateral aspect of the first metatarsal head.
subluxation, unless the films are inspected closely. The films do not clearly show the described double density sign described by previous authors [7,8] resulting from superimposition of the proximal phalanx over the metatarsal head. True appreciation of MTPJ dislocation only becomes apparent on further imaging. First MTPJ dislocations were classified by Jahss in 1980 [9]. Type I, having an intact intersesamoid ligament, usually requiring open reduction [10] via plantar [11,12], dorsal [13 – 15] or medial approach [16] although cases of closed reduction have been reported [17]. Types IIA and B having disrupted intersesamoid ligament and transverse sesamoid fracture, respectively. This original classification has been developed to include: Type IB, with the proximal phalanx in an adducted rather than abducted position [18], Type IIC having increased intersesamoid distance and sesamoid fracture [19]. Jahss has further extended his classification to include a Type III, with dorsal hallux but undisplaced
sesamoids, intact intersesamoid ligament, plantar plate and no sesamoid fracture [20 – 22]. Additional Type II variants have been reported featuring medial bipartite sesamoid fracture, partial intersesamoid ligament rupture and lateral sesamophalangeal joint rupture [23]. In Type II dislocations, structural disruption should permit satisfactory closed reduction, however, in some reports later surgery was required either to remove fragments of bone have remained interposed within the joint [19,23 – 25] or to restore the sesamometatarsal complex [26]. Authors have reported failure of closed reduction in a case of subluxation of the first MTPJ [7] so this appearance should not be treated with complacency. It is well appreciated that the hyperextension mechanism of injury can also lead to dislocation of other MTPJs [8,27,28]. Authors have reported three previous cases of fractured second metatarsal neck [29 –31] and head [32,33] in association with MTPJ dislocations. Additional radiology being either lateral plain radiograph, Computed Tomography or Magnetic Resonance [34] has be used to give additional information on the sesamometatarsal structures. In the above case the CT
190
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191
scan revealed the presence of a flake of bone close and dorsal to the lateral sesamoid. This cortical flake appears to have originated from the cortical irregularity on the inferolateral aspect of the first metatarsal head forming the lateral longitudinal groove. This fracture could have resulted from either an avulsion of the sesamometatarsal ligaments/plantar plate structures from the metatarsal head or an osteochondral fragment from the lateral longitudinal groove underlying the metatarsal head, described above. The metatarsal flake being chipped off by a compressive force during MTPJ dislocation. This occurs similarly to the well-recognised mechanism of osteochondral bone fragments being fractured off the lateral femoral condyle during patella dislocation [35]. Both these mechanisms of injury have been described in Jahss’s original classification relating to fracture of the sesamoids (IIB), however, in this case the fracture relates to the metatarsal head rather than the sesamoid and thus could be considered to be a further development of the classification. Careful scrutiny of the literature reveals the operative finding of a 2 mm osteochondral fracture associated with first MTPJ dislocation and medial sesamoid fracture [23]. In this case the CT scan confirmed a significantly larger osteochondral fracture from the metatarsal head and no evidence of sesamoid fracture. In our patient the presence of the osteochondral fracture gave additional evidence of sesamometatarsal ligament/plate disruption. According to Jahss’ classification successful closed manipulation confirms this as a Type II injury with a disrupted intersesamoid ligament.
4. Summary This case reports the rare occurrence of first MTPJ dislocation associated with second metatarsal head fracture. It also demonstrates an osteochondral fracture to the metatarsal head resultant of either an avulsion of the sesamometatarsal complex or compression fracture during dislocation. The papers principle message is that significant injuries to the MTPJ can be missed with radiological features mimicking common orthopaedic pathology. Subtle signs may reveal significant injury when imaged further.
Acknowledgements The authors would like to thank the staff of the Postgraduate Medical Institute Library, Royal Shrewsbury Hospital, the Francis Costello Library, The Robert Jones and Agnes Hunt District General Library, Oswestry and the Departments of Radiology and Medical Illustration, Royal Shrewsbury Hospital for their assistance with this research.
References [1] Mouchet A. Deux cas de luxation dorslae complete du gros orteil avec lesions des sesamoids. Rev Orthop 1931;18:221–7. [2] Schenck RC, Heckman JD. Fractures and dislocations of the forefoot: operative and nonoperative treatment. J Am Acad Orthop Surg 1995; 3:70–8. [3] Brunet JA. Pathomechanics of complex dislocations of the first metatarsophalangeal joint. Clin Orthop 1996;332:126 –31. [4] Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographical, functional. Osteology and Myology, Philadelphia: JB Lippincott; 1983. p. 81–7, 193 –8, 219– 30. [5] Gray’s anatomy. In: Roger WS, editor. Skeletal system, 38th ed. London: Churchill Livingstone; 1995 [chapter 6]. [6] Coull R, Stephens MM. Operative decision making in Hallux Valgus. Curr Orthop 2002;16:180– 6. [7] Ando Y, Yasudo M, Okuda H, Komano M. Irreduceable dorsal subluxation of the first metatarsophalangeal joint. A case report. J Orthop Trauma 2002;16(2):134–6. [8] Gentless J, Joshi P, Caselli M, Giorgini R. First and second metatarsophalangeal joint dislocations. J Am Podiatr Med Assoc 1992;82(12):630 –2. [9] Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1980;1:15–21. [10] Sage R, Holloway P. Type I dorsal dislocation of the first metatarsophalangeal joint. J Am Podiatr Assoc 1985;75:215. [11] Salamon PB, Gelberman RH, Huffer JM. Dorsal dislocation of the metatarsophalangeal joint of the great toe. JBJS 1974;56A(5): 1073–5. [12] Giannikas AC, Papachristou G, Papavasiliou N, Nikifordis P. Dorsal dislocation of the first metatarsophalangeal joint. JBJS 1975;57B: 384 –6. [13] Hussain A. Dislocation of the first metatarsophalangeal joint with fracture of the fibula sesamoid. A case report. Clin Orthop 1999;359: 209 –12. [14] Yu EC, Garfin SR. Closed dorsal dislocation of the metatarsophalangeal joint of the great toe. Clin Orthop 1984;185: 237– 40. [15] Lewis AG, DeLee JC. Type 1 complex dislocation of the first metatarsophalangeal joint-open reduction through a dorsal approach. JBJS 1984;66A:1120–3. [16] DeCasas R, Mesa F. Irreducible dorsal dislocation of the metatarsophalangeal joint of the hallux. Arch Orthop Trauma Surg 1990;109: 173 –4. [17] Mata SG, Hidalgo A, Grande MM. Dorsal dislocation of the first metatarsophalangeal joint. Int Orthop 1994;66:1120 –3. [18] Lantor H, Borovoy MA. A new classification of first metatarsophalangeal joint dislocations (type IB). J Foot Surg 1987;26: 75 –7. [19] Copeland CL, Kanat IO. A new classification for traumatic dislocations of the first metatarsophalangeal joint: type IIC. J Foot Surg 1991;30:234 –7. [20] Jahss MH. Disorders of the foot and ankle; medical and surgical management, 2nd ed. Part IV. The Adult Foot, vol. 2. Philadelphia: WB Saunders; 1991. p. 1124–7. [21] Tondera EK, Baker CC. Closed reduction of a rare type III dislocation of first metatarsophalangeal joint. J Manipulative Physiol Ther 1996; 19:475–9. [22] Killian FJ, Carpenter BB, Mostone E. Dorsal dislocation of the first metatarsophalangeal joint. J Foot Ankle Surg 1997;36(2): 131 –5. [23] Hall RL, Saxby T, Vandemark RM. A new type of dislocation of the first metatarsophalangeal joint: a case report. Foot Ankle 1992;13: 540 –5. [24] Konkel KF, Muehlstein JH. Unusual fracture-dislocation of the great toe. J Trauma 1975;15:733.
M.R. Carmont et al. / Foot and Ankle Surgery 9 (2003) 187–191 [25] Good JJ, Weinfeld GD, Yu GV. Fracture-dislocation of the metatarsophalangeal joint: open reduction through a medial incisional approach. J Foot Ankle Surg 2001;40(5):311– 7. [26] Nabarro MN, Powell J. Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report. Foot Ankle Int 1995;16(2):75–8. [27] Murphy JL. Isolated dorsal dislocation of the second metatarsophalangeal joint. Foot Ankle 1980;1(1):30–2. [28] Dutkowsky J, Freeman III BL. Fracture-dislocation of the articular surface of the third metatarsal head. Foot Ankle 1981;2:153–5. [29] Daniel WL, Beck EL, Duggar GE, Bennett AJ. Traumatic dislocation of the first metatarsophalangeal joint. A case report. J Am Podiatr Assoc 1976;66:97–100. [30] McKinley LM, Davis GL. Locked dislocation of the great toe. J Louisiana State Med Soc 1975;127:389– 90.
191
[31] Rao JP, Banzon MT. Irreducible dorsal dislocation of the metatarsophalangeal joints of the foot. Clin Orthop 1979;(145):224– 6. [32] Garcia Mata S, Hidalgo Overjero AM, Martinez Grande M. Dorsal dislocation of the first metatarsophalangeal joint. Int Orthop 1988;12: 237–8. [33] Deluca FN, Kenmore PI. Bilateral dorsal dislocations of the metatarsophalangeal joints of the great toes with a loose body in one of the joints. J Trauma 1975;15(8):737 –9. [34] Karasick D, Schweitzer ME. Disorders of the hallux sesamoid complex: MR features. Skeletal Radiol 1998;27(8):411 –8. [35] Scuderi GR, Scott WN, Insall JN, editors. Rockwood and Green’s fractures in adults, 4th ed. Dislocations and subluxations of the patella, vol. 2. Philadelphia: Lippincott/Raven; 1996. p. 2041 [chapter 29].