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Interphalangeal Dislocation of Toes: A Retrospective Case Series and Review of the Literature
The Journal of Foot & Ankle Surgery 50 (2011) 580–584
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Interphalangeal Dislocation of Toes: A Retrospective Case Series and Review of the Literature Isaac B. Yang, MRCS (Ed) 1, Kelvin K.W. Sun, FRCS (Ed) 2, Wai-leung Sha, FRCS (Ed) 3, Kong-san Yu, FRCS (Ed) 4, Yuk-yin Chow, FRACS (Orth), FRCS (Ed) 5 1
Orthopaedic Resident, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong Orthopaedic Specialist, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong Associate Consultant, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong 4 Consultant, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong 5 Chief of Service, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong 2 3
a r t i c l e i n f o
a b s t r a c t
Level of clinical evidence: 4 Keywords: digit fixation fracture injury Kirschner wire phalanx reduction subluxation trauma
Although not uncommon, dislocation of the toes, including that of the great toe, is not commonly reported in published studies. In the present report, we describe a series of 18 patients with toe dislocations managed by our department from January 2001 to December 2007. We considered the radiographic pattern of injury in our series of patients. Of the 18 patients, 10 (55.56%) had their toe dislocations treated by closed reduction with or without internal fixation. Seven patients (38.89%) with complex dislocation, defined as open dislocation or dislocation not amenable to (failed attempt) closed reduction, that required open reduction and internal fixation. One patient (5.56%) with a dislocated toe declined to undergo any form of treatment. Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
Although digital injuries involving the toes are common, to our knowledge, few published reports have described the results of observational findings related to pedal interphalangeal dislocation (1–5). In those reported cases, most were dislocations of the metatarsophalangeal joint of the great toe, mainly due to the postulation of its mobility and longer level arm (6). In the present report, we aimed to describe the results of a retrospective series of 18 patients who presented with interphalangeal joint (IPJ) dislocation involving the toes. To the best of our knowledge, this is the largest case series reported. We suspect that IPJ dislocation is a relatively uncommon injury because of the protection afforded by shoe gear. We hope that through the present case series, it will arouse some attention from the orthopedic community of this seemingly rare but easily treatable injury. As revealed from our case series, these injuries, if recognized early and treated with a proper manipulation technique, can have excellent clinical and radiologic outcomes in terms of stability, overall quality of life, and patient satisfaction.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Isaac B. Yang, MRCS (Ed), Orthopaedic Resident, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR. E-mail address: [email protected] (I.B. Yang).
Patients and Methods Patients with “International Classification of Diseases, Ninth Version, Clinical Modification” diagnostic code (code 838.09, dislocation of toe/great toe) were eligible for inclusion in our retrospective case series. We performed a diagnostic code search through our hospital electronic in-patient record system under the established diagnostic code 838.09 and recruited 18 patients under this code. Their in-patient and outpatient records and plain digital radiographs were reviewed and analyzed. The patients with dislocation of their foot, other than their toes, were excluded from our review. All patients were referred to our service from the Accident and Emergency Department of our hospital. They were admitted through the Accident and Emergency Department to our orthopedic wards. After the initial acute injury phase, the patients were treated by orthopedic specialists in our orthopedic department and subsequently discharged from our wards, with instructions to follow up in our specialty clinic, initially 2 weeks after the injury and then at 1, 3, 6, and 12 months after injury. Our department’s orthopedic specialists examined the toes clinically, and the physical findings were documented accordingly. Radiographs were taken to assess the congruity of the reduced joints. The clinical and radiologic outcomes of these 18 patients were retrospectively analyzed and assessed by us. After reviewing the records of all the patients, we propose 3 categories according to our observation in classifying these injuries according to the mechanism of injury: injury on passive axial loading (e.g., landing on the injured foot); active axial loading (e.g., kick injury); and crush injury (e.g., hit by a heavy falling object without adequate shoe protection). Radiographically, all the patients exhibited a dorsolateral dislocation of the IPJs. We further subclassified the dislocations into 2 broadly different types, according to the original classification by Miki et al (7) for great toe dislocation. Both types of dislocations are caused by plantar plate traction. Different types of dislocation depend on the position of the displaced plantar plates. A type I dislocation implies that the plantar plate is displaced and tugged in between the 2 phalangeal bones. A type II dislocation implies that the plantar plate overrides the proximal phalangeal head, causing the
1067-2516/$ - see front matter Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved. doi:10.1053/j.jfas.2011.04.032
I.B. Yang et al. / The Journal of Foot & Ankle Surgery 50 (2011) 580–584
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Table 1 Summary of patients with interphalangeal joint dislocation of toes (N ¼ 18) Patient No.
Age (yr)
Gender
Side
Toe
Reduction
Fixation
Anesthesia
Injury Mechanism
Radiologic Classification
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
16 9 44 18 19 16 33 14 22 14 23 43 33 9 22 13 16 15
Male Male Male Male Male Male Male Male Male Female Male Male Male Male Female Male Male Male
Right Right Right Right Right Right Left Right Left Right Right Right Left Left Right Left Right Left
Great Third Fifth Third Great Great Second Fifth Great Second Fifth Great Fifth Great Fifth Fourth Third Second
Closed Closed Open Closed Closed Closed Open Closed* Open Closed Closed Closed Open Open Closed Closed Open Closed
Kirschner wire Cross toe strapping Cross toe strapping None None Kirschner wire Kirschner wire NA* Kirschner wire Cross toe strapping Kirschner wire Short leg plaster of Paris Kirschner wire Collateral repaired None Kirschner wire Kirschner wire Kirschner wire
General Local General Local Oral analgesics General General Local General Local General Local General General Local General General General
Active axial loading Active axial loading Passive axial loading Passive axial loading Active axial loading Passive axial loading Crush injury Active axial loading Crush injury Crush injury Active axial loading Active axial loading Passive axial loading Active axial loading Passive axial loading Crush injury Passive axial loading Active axial loading
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
*
II I II I I II II I I II I II I I II I I I
Patient opted for conservative management after failed attempt at closed reduction.
typical clinical appearance of a shortened and hyperextended IPJ. These 2 types of dislocation are not mutually exclusive and can be interchangeable on repeated reduction attempts.
Results A total of 18 patients with IPJ dislocations of the toes were identified and are summarized in Table 1. Of the 18 patients, 8 (44.44%) sustained their proximal IPJ (PIPJ) dislocation on landing and 6 (33.33%) sustained an injury as a result of kicking an object. Only 2 patients (11.11%) were injured by a crush injury; 2 other patients (11.11%) had an unknown injury mechanism. These 3 different classifications have a similar type of mechanism of injury. In our experience, we found that most patients (N ¼ 14 [77.77%]) had an hyperextension injury to their PIPJs. It was not shown in our series that the 3 different injury mechanisms had any direct association with the radiologic appearance. The dislocation of 10 patients (55.56%) could be reduced using closed methods. Of these 10 patients, 6 (33.33%) underwent closed reduction without the need for general anesthesia. Of these 6 patients, 5 required local anesthesia. In our series, all 5 patients received a digital block with plain lidocaine. The sixth patient (5.56%) underwent reduction with simple oral analgesics. The remaining 4 patients undergoing closed reduction required general anesthesia. Of the 18 patients, 7 (38.88%) required open reduction, and most (6 of the 7) had an open wound, which inevitably would require reduction of the dislocation using the open method. Only 1 patient (5.56%) had the PIPJ reduced by open methods because of failed closed reduction. One patient (5.56%) who had his fifth PIPJ dislocated (patient 8) had closed reduction fail twice. He was offered open reduction but his parents declined. After reduction, nearly all patients (15 [83.33%] of 18) had their foot immobilized or fixed using either Kirschner wire (K-wire) or splinting. All the patients who required operative intervention under general anesthesia also underwent adjuvant surgical procedures to maintain the reduction. Of the 18 patients, 9 (50%) received K-wires, and 1 patient (5.56%) with a stable PIPJ after reduction was immobilized with cross toe strapping and 1 (5.56%) had the collaterals and avulsed fragments repaired. The great toes and little toes were involved most often, contributing more than 60% of the patients. In our series, 10 (55.55%) of the 18
patients were successfully treated with closed reduction alone. Seven patients (38.89%) required open reduction. Six patients (33.33%) requiring surgical procedures other than simple closed reduction had concomitant injuries, such as an open wound. In only 1 of the 7 patients who required open reduction was the reduction because of reduction failure using closed methods. One patient (5.56%) refused any form of treatment. Most patients (N ¼ 15 [83.33%]) underwent fixation with K-wire or splinting to improve the stability. No patients were lost to follow-up. All patients had normal aligned toes clinically without any sign of instability on examination. In an effort to further clarify our treatment regimen, 2 case reports from our series of 18 patients are described in detail, below.
Case 1 A 15-year-old student sustained a left foot injury on landing during rope skipping. He complained of pain, swelling, and deformity over the left second toe. The patient had been wearing a pair of sport shoes at the time of injury. He first presented to the Accident and Emergency Department and was diagnosed with a left second toe PIPJ dislocation. Closed reduction was performed but failed. On admission to the orthopedics ward, the physical examination revealed marked swelling over the left second toe, with dorsal subluxation of the PIPJ. The subdermal venous plexus refill time was normal, and no neurologic deficit was detected. He had no external wound (Fig. 1A). The radiographs demonstrated a dorsolateral dislocation of the PIPJ of the left second toe without any associated fracture (Fig. 1B). Closed reduction with the patient under local anesthesia with a digital block was performed under fluoroscopic guidance. The joint was successfully reduced, but redislocation occurred spontaneously after release of the traction force. Another closed reduction was performed with the patient under general anesthesia, supplemented with axial K-wire fixation, which was uneventful (Figs. 2 and 3). He was followed up in our clinic 3 weeks after surgery. He was able to perform full weight bearing walking without pain. Radiographs of his left second toe showed good alignment with congruent PIPJs. Stability was tested after removal of the K-wire. The PIPJ was stable to both dorsiflexion/plantarflexion and varus/valgus stress. Full active and passive range of motion was detected and was comparable with that of all other toes.
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Fig. 1. (A) Clinical photograph showing left second toe PIPJ dislocation showing marked swelling and dorsal translation of joint. (B) Intraoperative radiographs showing dorsolateral dislocation of left second PIPJ.
Case 2 A 16-year-old boy sustained a right third toe injury after accidentally kicking a chair. He complained of immediate pain and swelling over his right third toe after the incident. He attended the Accident and Emergency Department; radiographs were taken and showed a dorsolateral dislocation of the PIPJ of his right third toe. Closed reduction was performed at the Accident and Emergency Department but failed twice. He was then admitted to our unit for additional treatment.
Emergency operation with closed reduction was performed but was not successful and was subsequently converted to open reduction. A dorsal longitudinal incision was made over the right third toe. Reduction was achieved using the open method and was fixed with an axial K-wire. The intraoperative findings showed soft tissue trapped inside the PIPJ and was suspected to be the cause of the failure of the closed reduction. Subsequent follow-up in our clinic showed the right third PIPJ was well reduced with good stability. The K-wire was removed 3 weeks postoperatively. He was subsequently discharged from our
Fig. 2. Clinical photographs showing postoperative state of left second toe with reduced PIPJ and K-wire fixation.
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Fig. 3. Postoperative radiographs showing alignment of reduced PIPJ and position of K-wire.
clinic after a series of regular follow-up sessions up to 12 months as outlined in the protocol to ensure the joint’s stability and congruity. Discussion As simple as the diagnosis and treatment of this injury might seem, these 18 patients were referred to us because of unsuccessful reduction. We believe that a better understanding of the underlying injury mechanism can help us treat this rare, easily treatable but often maltreated, injury. It has been theorized that the injury mechanism is hyperextension and abduction (3,5–8); hence, reduction by simple traction often fails because the plantar plate is trapped inside the joint. The hypothesis concerning the reason simple traction cannot achieve full reduction remains with the stability of the collateral ligaments, as suggested by Miki et al (7). Because no lateral instability of the joint is present in this type of injury, the collateral ligaments become tight when the IP joint is hyperextended at injury. The plantar plate becomes locked inside the joint at its displaced position. These 2 anatomic disadvantages would therefore make manual repositioning difficult. We favor the reduction method suggested by Stienstra and Derner (9). Stienstra and Derner (9) suggested that the correct method for manual reduction is by dorsiflexing the toe initially to exaggerate the deformity. Then, maintaining the toe in the dorsiflexed position, dorsal traction should be applied, followed by a plantarflexion motion, which would produce a palpable and audible click of the repositioned IPJ. Woon (10) recently published his percutaneous technique in reducing the incarcerated sesamoid in patients with great toe IPJ dislocation. However, in our experience, with a proper manipulative technique, instrument-assisted closed reduction might not be necessary. Redislocation was also commonly described after manual repositioning, such as was seen in our illustrative cases. This could have resulted from the laxity of collateral ligaments after reduction. The inherent instability of the joint was further aggravated by the possible rupture of the capsule and the plantar plate. In our experience, most
of our patients required fixation of the PIPJ with either K-wire or splinting, as recommended by Hojyo et al (11). Most injuries can be treated by overexaggerating the dislocation by dorsiflexion initially, such as in our illustrated case, followed by traction and plantarflexion. This usually produces an audible click, which signifies the repositioning of the dislocated joint. All open dislocations or dislocations that failed closed reduction should proceed to open method reduction. Postreduction splinting or K-wire fixation is recommended. The K-wires were removed earlier than our usual practice in our series because we propose that the aim of K-wire fixation is for maintenance of the reduction position only. Maintenance of the reduction position improves the joint stability, avoids additional redislocation, and aids soft tissue healing. The usual longer period of K-wire fixation was not recommended owing to the increased risk of infection and soft tissue damage. A number of methodologic shortcomings threaten the validity of our conclusions. For instance, our classification system was subject to patient recall bias and ascertainment bias because relying on the information recorded in the medical record could also have influenced our results. Moreover, recall bias could have influenced our patients’ report of their outcomes and previous toe injury. Our results could have also been biased because the treating surgeons also determined the radiographic outcomes. Finally, we only undertook a descriptive analysis and did not attempt to explain our observations using inferential statistical analyses. The present series was reported in the hope of arousing interest and serve as a reference for surgeons and emergency physicians to review and revisit this rare type of injury. However minor this injury might seem, it is an injury that results in morbidity such as persistent pain owing to acquired instability, early degenerative changes (12), recurrent dislocations, and juxta-articular soft tissue injury. In conclusion, the dislocation of the IPJ of the toe is a rare injury. Rare as it is, our experience showed that this injury is treatable with an achievable manipulation method. Proper manipulation techniques will reduce the soft tissue insult and allow a more successful
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reduction. The patients in whom closed reduction failed or with an open dislocation will require open reduction. Fixation of the reduced joint is recommended for better joint stability. References 1. DeLee JC. Fractures and dislocations of the foot, in Surgery of the Foot, edited by RA Mann, ed. 5, pp 807-808, CV Mosby, St. Louis, 1986. 2. DeLee JC. Fractures and dislocations of the foot, in Surgery of the Foot, edited by RA Mann, pp 1701-1703, Mosby Year Book, St.Louis, 1993. 3. Katayama M, Murakami Y, Takahashi H. Irreducible dorsal dislocation of the toe. J Bone Joint Surg (Am) 70-A:769–770, 1988. 4. Myerson MS. Injuries to the forefoot and toes, in Disorders of the Foot and Ankle, pp 2268-2269, edited by MH Jahss, WB Saunders, Philadelphia, 1991. 5. Jahss MH. Chronic and recurrent dislocations of the fifth toe. Foot Ankle 1:275– 278, 1981.
6. Nelson TL, Uggen W. Irreducible dorsal dislocation of the interphalangeal joint of the great toe. Clin Orthop 157:110–112, 1981. 7. Miki T, Yamamuro T, Kitai T. An irreducible dislocation of the great toedReport of two cases and review of literature. Clin Orthop 230:200–226, 1988. 8. Leung HB, Wong WC. Irreducible dislocation of the hallucal interphalangeal joint. Hong Kong Med J 8:295–299, 2002. 9. Stienstra JJ, Derner R. Closed reduction of a proximal interphalangeal joint dislocation. J Foot Surg 29:385–387, 1990. 10. Woon CY. Dislocation of the interphalangeal joint of the great toe: Is percutaneous reduction of an incarcerated sesamoid an option? A report of two cases. J Bone Joint Surg Am 92:1527–1560, 2010. 11. Hojyo H, Naagata K, Narahara T, Yamanaka K, Ikuta H, Inoue H. Two cases of irreducible dislocation of the interphalangeal joint of the great toe with interposition of sesamoid bone. Seikeigeka 34:820, 1983. 12. Mashatori M, Goto M, Tanaka K, Smith RA, Kokubun S. Neglected irreducible dislocation of the interphalangeal joint of the great toe: A case report. J Foot Ankle Surg 45:271–274, 2006.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Interphalangeal Dislocation of Toes: A Retrospective Case Series and Review of the Literature Isaac B. Yang, MRCS (Ed) 1, Kelvin K.W. Sun, FRCS (Ed) 2, Wai-leung Sha, FRCS (Ed) 3, Kong-san Yu, FRCS (Ed) 4, Yuk-yin Chow, FRACS (Orth), FRCS (Ed) 5 1
Orthopaedic Resident, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong Orthopaedic Specialist, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong Associate Consultant, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong 4 Consultant, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong 5 Chief of Service, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong 2 3
a r t i c l e i n f o
a b s t r a c t
Level of clinical evidence: 4 Keywords: digit fixation fracture injury Kirschner wire phalanx reduction subluxation trauma
Although not uncommon, dislocation of the toes, including that of the great toe, is not commonly reported in published studies. In the present report, we describe a series of 18 patients with toe dislocations managed by our department from January 2001 to December 2007. We considered the radiographic pattern of injury in our series of patients. Of the 18 patients, 10 (55.56%) had their toe dislocations treated by closed reduction with or without internal fixation. Seven patients (38.89%) with complex dislocation, defined as open dislocation or dislocation not amenable to (failed attempt) closed reduction, that required open reduction and internal fixation. One patient (5.56%) with a dislocated toe declined to undergo any form of treatment. Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
Although digital injuries involving the toes are common, to our knowledge, few published reports have described the results of observational findings related to pedal interphalangeal dislocation (1–5). In those reported cases, most were dislocations of the metatarsophalangeal joint of the great toe, mainly due to the postulation of its mobility and longer level arm (6). In the present report, we aimed to describe the results of a retrospective series of 18 patients who presented with interphalangeal joint (IPJ) dislocation involving the toes. To the best of our knowledge, this is the largest case series reported. We suspect that IPJ dislocation is a relatively uncommon injury because of the protection afforded by shoe gear. We hope that through the present case series, it will arouse some attention from the orthopedic community of this seemingly rare but easily treatable injury. As revealed from our case series, these injuries, if recognized early and treated with a proper manipulation technique, can have excellent clinical and radiologic outcomes in terms of stability, overall quality of life, and patient satisfaction.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Isaac B. Yang, MRCS (Ed), Orthopaedic Resident, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR. E-mail address: [email protected] (I.B. Yang).
Patients and Methods Patients with “International Classification of Diseases, Ninth Version, Clinical Modification” diagnostic code (code 838.09, dislocation of toe/great toe) were eligible for inclusion in our retrospective case series. We performed a diagnostic code search through our hospital electronic in-patient record system under the established diagnostic code 838.09 and recruited 18 patients under this code. Their in-patient and outpatient records and plain digital radiographs were reviewed and analyzed. The patients with dislocation of their foot, other than their toes, were excluded from our review. All patients were referred to our service from the Accident and Emergency Department of our hospital. They were admitted through the Accident and Emergency Department to our orthopedic wards. After the initial acute injury phase, the patients were treated by orthopedic specialists in our orthopedic department and subsequently discharged from our wards, with instructions to follow up in our specialty clinic, initially 2 weeks after the injury and then at 1, 3, 6, and 12 months after injury. Our department’s orthopedic specialists examined the toes clinically, and the physical findings were documented accordingly. Radiographs were taken to assess the congruity of the reduced joints. The clinical and radiologic outcomes of these 18 patients were retrospectively analyzed and assessed by us. After reviewing the records of all the patients, we propose 3 categories according to our observation in classifying these injuries according to the mechanism of injury: injury on passive axial loading (e.g., landing on the injured foot); active axial loading (e.g., kick injury); and crush injury (e.g., hit by a heavy falling object without adequate shoe protection). Radiographically, all the patients exhibited a dorsolateral dislocation of the IPJs. We further subclassified the dislocations into 2 broadly different types, according to the original classification by Miki et al (7) for great toe dislocation. Both types of dislocations are caused by plantar plate traction. Different types of dislocation depend on the position of the displaced plantar plates. A type I dislocation implies that the plantar plate is displaced and tugged in between the 2 phalangeal bones. A type II dislocation implies that the plantar plate overrides the proximal phalangeal head, causing the
1067-2516/$ - see front matter Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved. doi:10.1053/j.jfas.2011.04.032
I.B. Yang et al. / The Journal of Foot & Ankle Surgery 50 (2011) 580–584
581
Table 1 Summary of patients with interphalangeal joint dislocation of toes (N ¼ 18) Patient No.
Age (yr)
Gender
Side
Toe
Reduction
Fixation
Anesthesia
Injury Mechanism
Radiologic Classification
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
16 9 44 18 19 16 33 14 22 14 23 43 33 9 22 13 16 15
Male Male Male Male Male Male Male Male Male Female Male Male Male Male Female Male Male Male
Right Right Right Right Right Right Left Right Left Right Right Right Left Left Right Left Right Left
Great Third Fifth Third Great Great Second Fifth Great Second Fifth Great Fifth Great Fifth Fourth Third Second
Closed Closed Open Closed Closed Closed Open Closed* Open Closed Closed Closed Open Open Closed Closed Open Closed
Kirschner wire Cross toe strapping Cross toe strapping None None Kirschner wire Kirschner wire NA* Kirschner wire Cross toe strapping Kirschner wire Short leg plaster of Paris Kirschner wire Collateral repaired None Kirschner wire Kirschner wire Kirschner wire
General Local General Local Oral analgesics General General Local General Local General Local General General Local General General General
Active axial loading Active axial loading Passive axial loading Passive axial loading Active axial loading Passive axial loading Crush injury Active axial loading Crush injury Crush injury Active axial loading Active axial loading Passive axial loading Active axial loading Passive axial loading Crush injury Passive axial loading Active axial loading
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
*
II I II I I II II I I II I II I I II I I I
Patient opted for conservative management after failed attempt at closed reduction.
typical clinical appearance of a shortened and hyperextended IPJ. These 2 types of dislocation are not mutually exclusive and can be interchangeable on repeated reduction attempts.
Results A total of 18 patients with IPJ dislocations of the toes were identified and are summarized in Table 1. Of the 18 patients, 8 (44.44%) sustained their proximal IPJ (PIPJ) dislocation on landing and 6 (33.33%) sustained an injury as a result of kicking an object. Only 2 patients (11.11%) were injured by a crush injury; 2 other patients (11.11%) had an unknown injury mechanism. These 3 different classifications have a similar type of mechanism of injury. In our experience, we found that most patients (N ¼ 14 [77.77%]) had an hyperextension injury to their PIPJs. It was not shown in our series that the 3 different injury mechanisms had any direct association with the radiologic appearance. The dislocation of 10 patients (55.56%) could be reduced using closed methods. Of these 10 patients, 6 (33.33%) underwent closed reduction without the need for general anesthesia. Of these 6 patients, 5 required local anesthesia. In our series, all 5 patients received a digital block with plain lidocaine. The sixth patient (5.56%) underwent reduction with simple oral analgesics. The remaining 4 patients undergoing closed reduction required general anesthesia. Of the 18 patients, 7 (38.88%) required open reduction, and most (6 of the 7) had an open wound, which inevitably would require reduction of the dislocation using the open method. Only 1 patient (5.56%) had the PIPJ reduced by open methods because of failed closed reduction. One patient (5.56%) who had his fifth PIPJ dislocated (patient 8) had closed reduction fail twice. He was offered open reduction but his parents declined. After reduction, nearly all patients (15 [83.33%] of 18) had their foot immobilized or fixed using either Kirschner wire (K-wire) or splinting. All the patients who required operative intervention under general anesthesia also underwent adjuvant surgical procedures to maintain the reduction. Of the 18 patients, 9 (50%) received K-wires, and 1 patient (5.56%) with a stable PIPJ after reduction was immobilized with cross toe strapping and 1 (5.56%) had the collaterals and avulsed fragments repaired. The great toes and little toes were involved most often, contributing more than 60% of the patients. In our series, 10 (55.55%) of the 18
patients were successfully treated with closed reduction alone. Seven patients (38.89%) required open reduction. Six patients (33.33%) requiring surgical procedures other than simple closed reduction had concomitant injuries, such as an open wound. In only 1 of the 7 patients who required open reduction was the reduction because of reduction failure using closed methods. One patient (5.56%) refused any form of treatment. Most patients (N ¼ 15 [83.33%]) underwent fixation with K-wire or splinting to improve the stability. No patients were lost to follow-up. All patients had normal aligned toes clinically without any sign of instability on examination. In an effort to further clarify our treatment regimen, 2 case reports from our series of 18 patients are described in detail, below.
Case 1 A 15-year-old student sustained a left foot injury on landing during rope skipping. He complained of pain, swelling, and deformity over the left second toe. The patient had been wearing a pair of sport shoes at the time of injury. He first presented to the Accident and Emergency Department and was diagnosed with a left second toe PIPJ dislocation. Closed reduction was performed but failed. On admission to the orthopedics ward, the physical examination revealed marked swelling over the left second toe, with dorsal subluxation of the PIPJ. The subdermal venous plexus refill time was normal, and no neurologic deficit was detected. He had no external wound (Fig. 1A). The radiographs demonstrated a dorsolateral dislocation of the PIPJ of the left second toe without any associated fracture (Fig. 1B). Closed reduction with the patient under local anesthesia with a digital block was performed under fluoroscopic guidance. The joint was successfully reduced, but redislocation occurred spontaneously after release of the traction force. Another closed reduction was performed with the patient under general anesthesia, supplemented with axial K-wire fixation, which was uneventful (Figs. 2 and 3). He was followed up in our clinic 3 weeks after surgery. He was able to perform full weight bearing walking without pain. Radiographs of his left second toe showed good alignment with congruent PIPJs. Stability was tested after removal of the K-wire. The PIPJ was stable to both dorsiflexion/plantarflexion and varus/valgus stress. Full active and passive range of motion was detected and was comparable with that of all other toes.
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Fig. 1. (A) Clinical photograph showing left second toe PIPJ dislocation showing marked swelling and dorsal translation of joint. (B) Intraoperative radiographs showing dorsolateral dislocation of left second PIPJ.
Case 2 A 16-year-old boy sustained a right third toe injury after accidentally kicking a chair. He complained of immediate pain and swelling over his right third toe after the incident. He attended the Accident and Emergency Department; radiographs were taken and showed a dorsolateral dislocation of the PIPJ of his right third toe. Closed reduction was performed at the Accident and Emergency Department but failed twice. He was then admitted to our unit for additional treatment.
Emergency operation with closed reduction was performed but was not successful and was subsequently converted to open reduction. A dorsal longitudinal incision was made over the right third toe. Reduction was achieved using the open method and was fixed with an axial K-wire. The intraoperative findings showed soft tissue trapped inside the PIPJ and was suspected to be the cause of the failure of the closed reduction. Subsequent follow-up in our clinic showed the right third PIPJ was well reduced with good stability. The K-wire was removed 3 weeks postoperatively. He was subsequently discharged from our
Fig. 2. Clinical photographs showing postoperative state of left second toe with reduced PIPJ and K-wire fixation.
I.B. Yang et al. / The Journal of Foot & Ankle Surgery 50 (2011) 580–584
583
Fig. 3. Postoperative radiographs showing alignment of reduced PIPJ and position of K-wire.
clinic after a series of regular follow-up sessions up to 12 months as outlined in the protocol to ensure the joint’s stability and congruity. Discussion As simple as the diagnosis and treatment of this injury might seem, these 18 patients were referred to us because of unsuccessful reduction. We believe that a better understanding of the underlying injury mechanism can help us treat this rare, easily treatable but often maltreated, injury. It has been theorized that the injury mechanism is hyperextension and abduction (3,5–8); hence, reduction by simple traction often fails because the plantar plate is trapped inside the joint. The hypothesis concerning the reason simple traction cannot achieve full reduction remains with the stability of the collateral ligaments, as suggested by Miki et al (7). Because no lateral instability of the joint is present in this type of injury, the collateral ligaments become tight when the IP joint is hyperextended at injury. The plantar plate becomes locked inside the joint at its displaced position. These 2 anatomic disadvantages would therefore make manual repositioning difficult. We favor the reduction method suggested by Stienstra and Derner (9). Stienstra and Derner (9) suggested that the correct method for manual reduction is by dorsiflexing the toe initially to exaggerate the deformity. Then, maintaining the toe in the dorsiflexed position, dorsal traction should be applied, followed by a plantarflexion motion, which would produce a palpable and audible click of the repositioned IPJ. Woon (10) recently published his percutaneous technique in reducing the incarcerated sesamoid in patients with great toe IPJ dislocation. However, in our experience, with a proper manipulative technique, instrument-assisted closed reduction might not be necessary. Redislocation was also commonly described after manual repositioning, such as was seen in our illustrative cases. This could have resulted from the laxity of collateral ligaments after reduction. The inherent instability of the joint was further aggravated by the possible rupture of the capsule and the plantar plate. In our experience, most
of our patients required fixation of the PIPJ with either K-wire or splinting, as recommended by Hojyo et al (11). Most injuries can be treated by overexaggerating the dislocation by dorsiflexion initially, such as in our illustrated case, followed by traction and plantarflexion. This usually produces an audible click, which signifies the repositioning of the dislocated joint. All open dislocations or dislocations that failed closed reduction should proceed to open method reduction. Postreduction splinting or K-wire fixation is recommended. The K-wires were removed earlier than our usual practice in our series because we propose that the aim of K-wire fixation is for maintenance of the reduction position only. Maintenance of the reduction position improves the joint stability, avoids additional redislocation, and aids soft tissue healing. The usual longer period of K-wire fixation was not recommended owing to the increased risk of infection and soft tissue damage. A number of methodologic shortcomings threaten the validity of our conclusions. For instance, our classification system was subject to patient recall bias and ascertainment bias because relying on the information recorded in the medical record could also have influenced our results. Moreover, recall bias could have influenced our patients’ report of their outcomes and previous toe injury. Our results could have also been biased because the treating surgeons also determined the radiographic outcomes. Finally, we only undertook a descriptive analysis and did not attempt to explain our observations using inferential statistical analyses. The present series was reported in the hope of arousing interest and serve as a reference for surgeons and emergency physicians to review and revisit this rare type of injury. However minor this injury might seem, it is an injury that results in morbidity such as persistent pain owing to acquired instability, early degenerative changes (12), recurrent dislocations, and juxta-articular soft tissue injury. In conclusion, the dislocation of the IPJ of the toe is a rare injury. Rare as it is, our experience showed that this injury is treatable with an achievable manipulation method. Proper manipulation techniques will reduce the soft tissue insult and allow a more successful
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reduction. The patients in whom closed reduction failed or with an open dislocation will require open reduction. Fixation of the reduced joint is recommended for better joint stability. References 1. DeLee JC. Fractures and dislocations of the foot, in Surgery of the Foot, edited by RA Mann, ed. 5, pp 807-808, CV Mosby, St. Louis, 1986. 2. DeLee JC. Fractures and dislocations of the foot, in Surgery of the Foot, edited by RA Mann, pp 1701-1703, Mosby Year Book, St.Louis, 1993. 3. Katayama M, Murakami Y, Takahashi H. Irreducible dorsal dislocation of the toe. J Bone Joint Surg (Am) 70-A:769–770, 1988. 4. Myerson MS. Injuries to the forefoot and toes, in Disorders of the Foot and Ankle, pp 2268-2269, edited by MH Jahss, WB Saunders, Philadelphia, 1991. 5. Jahss MH. Chronic and recurrent dislocations of the fifth toe. Foot Ankle 1:275– 278, 1981.
6. Nelson TL, Uggen W. Irreducible dorsal dislocation of the interphalangeal joint of the great toe. Clin Orthop 157:110–112, 1981. 7. Miki T, Yamamuro T, Kitai T. An irreducible dislocation of the great toedReport of two cases and review of literature. Clin Orthop 230:200–226, 1988. 8. Leung HB, Wong WC. Irreducible dislocation of the hallucal interphalangeal joint. Hong Kong Med J 8:295–299, 2002. 9. Stienstra JJ, Derner R. Closed reduction of a proximal interphalangeal joint dislocation. J Foot Surg 29:385–387, 1990. 10. Woon CY. Dislocation of the interphalangeal joint of the great toe: Is percutaneous reduction of an incarcerated sesamoid an option? A report of two cases. J Bone Joint Surg Am 92:1527–1560, 2010. 11. Hojyo H, Naagata K, Narahara T, Yamanaka K, Ikuta H, Inoue H. Two cases of irreducible dislocation of the interphalangeal joint of the great toe with interposition of sesamoid bone. Seikeigeka 34:820, 1983. 12. Mashatori M, Goto M, Tanaka K, Smith RA, Kokubun S. Neglected irreducible dislocation of the interphalangeal joint of the great toe: A case report. J Foot Ankle Surg 45:271–274, 2006.