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Irreducible metatarsophalangeal joint dislocation of the fifth toe in a child
The Foor(l994) 4, 100-101
Irreducible metatarsophalangeal joint dislocation of the fifth toe in a child A. Iossifidis, R. Brueton Rayne Institute, Academic Unit, Orthopaedic Department, St Thomas’ Hospital, Lambeth Palace Road, London, UK S UMMA R Y. An unusual case of an irreducible metatarsopbalangeal joint dislocation of the fifth toe in association with a fracture of the metatarsal in a child is presented. Both buttonholing of the metatarsal head through the medial capsule and angulation of the metatarsal shaft fracture prevented reduction. Open reduction was carried out through a dorsal approach. A mechanism of injury is described which allows the introduction of the ‘linked injury’ concept. This leads to a better insight of the various injury associations of the tarsometatarsophalangeal complex in children.
Metatarsophalangeal dislocations are uncommon injuries that are amenable to closed reduction in most cases.’ Irreducible dislocations of the metatarsophalangeal joint of the lesser toes have been reported in only 4 adult cases. 2-4 This is the first report to date of an irreducible metatarsophalangeal joint dislocation of the fifth toe in a child.
reduction of the dislocated joint. The medial collateral ligament and volar plate were reattached proximally.
DISCUSSION Fracture separation of the epiphysis is the common injury of the toe in children. It would seem that the presence of an open physis protects the adjacent joint from dislocation and explains the rarity of this injury. In this case the mechanism of injury consisted of rotational forces applied to the fixed forefoot and resulted in this unique association of a metatarsal fracture and metatarsophalangeal joint dislocation. Interestingly enough, Wiley’ reported 4 cases in children where indirect forces to a fixed forefoot resulted in metatarsal fractures and tarsometatarsal dislocations. We postulate that there is a common mechanism of injury of the tarsometatarsophalangeal complex in children when the forefoot is fixed and a metatarsal linked injury pattern is found. The length of the distal forefoot that is trapped dictates the type of injury sustained by the foot and is related to the length of the lever arm. Severe forces applied to an immobilized forefoot, particularly by a twisting movement of the body, generate a torque that leads to injuries proximal to the point of entrapment. According to the length of forefoot that is immobilized, metatarsal fractures may be associated with either a metatarsophalangeal dislocation or a tarsometatarsal dislocation. This forms the ‘linked injury’ pattern of metatarsal trauma. When the toes alone are fixed, as in this case, the associated dislocation is distal, while when the
CASE REPORT A 6-year-old boy sustained a minor head injury and injured his right forefoot while playing behind the family car. The patient fell backwards as his right forefoot was pinned to the ground beneath the car wheel. Examination revealed swelling of the forefoot and mild lateral deviation of the fifth toe with intact skin. Radiography of the forefoot demonstrated greenstick fractures of all lesser metatarsal shafts and a dislocation of the fifth metatarsophalangeal joint. The metatarsal head was medially displaced (Figure). With the patient under general anaesthesia, it was not possible to reduce either the fracture of the fifth metatarsal or the dislocated metatarsophalangeal joint by closed manipulation. The joint was therefore exposed through a dorsal approach. The metatarsal head was found to be displaced medially and had buttonholed through the joint capsule with the medial collateral ligament dorsally and the volar plate below. Following release of the medial collateral ligament, the joint was opened. However, it proved impossible to reduce the dislocation until the fracture of the fifth metatarsal had been reduced. Correction of the metatarsal shaft fracture now allowed a stable 100
Irreducible
metatarsophalangeal
joint dislocation
of the fifth toe in a child
101
metatarsals themselves are fixed the dislocation is proximal. This is the first reported instance of a distal dislocation in combination with a metatarsal fracture in a child.
References 1. Heckman
2.
3. 4. 5.
J D. Fractures and dislocations of the foot. In: Rockwood C A Jr, Green D P, eds. Fractures in adults. 2nd ed. Philadelphia: Lippincott, 1984: 1818-1819. Rao J P. Banzon M T. Irreducible dislocation of the metatarsophalangeal joints of the foot. Clin Orthop 1919; 145: 224-226. Murphy J L. Isolated dorsal dislocation of the second metatarsophalangeal joint. Foot Ankle 1980; 1: 30-32 English T A. Dislocation of the metatarsal bone and adjacent toe. J Bone Joint Surg 1964; 46B: 700-704. Wiley J J. Tarso-metatarsal joint injuries in children. J Pediatr Orthop 1981: 1: 255-260.
The authors Mr A.
Iossifidis MD, FRCS (Ed.) Orthopaedic Registrar Mr R. Brueton MD, FRCS, Senior Lecturer Rayne Institute Academic Unit Orthopaedic Department St Thomas’ Hospital Lambeth Palace Road London SE1 7EH UK
FigurepAP radiograph of the right foot demonstrating a metatarsophalangeal dislocation of the fifth toe and greenstick fractures of the lateral metatarsals.
Correspondence SE4 1YQ. UK.
to Mr A. Iossifidis.
7 Darling
Road,
London
Irreducible metatarsophalangeal joint dislocation of the fifth toe in a child A. Iossifidis, R. Brueton Rayne Institute, Academic Unit, Orthopaedic Department, St Thomas’ Hospital, Lambeth Palace Road, London, UK S UMMA R Y. An unusual case of an irreducible metatarsopbalangeal joint dislocation of the fifth toe in association with a fracture of the metatarsal in a child is presented. Both buttonholing of the metatarsal head through the medial capsule and angulation of the metatarsal shaft fracture prevented reduction. Open reduction was carried out through a dorsal approach. A mechanism of injury is described which allows the introduction of the ‘linked injury’ concept. This leads to a better insight of the various injury associations of the tarsometatarsophalangeal complex in children.
Metatarsophalangeal dislocations are uncommon injuries that are amenable to closed reduction in most cases.’ Irreducible dislocations of the metatarsophalangeal joint of the lesser toes have been reported in only 4 adult cases. 2-4 This is the first report to date of an irreducible metatarsophalangeal joint dislocation of the fifth toe in a child.
reduction of the dislocated joint. The medial collateral ligament and volar plate were reattached proximally.
DISCUSSION Fracture separation of the epiphysis is the common injury of the toe in children. It would seem that the presence of an open physis protects the adjacent joint from dislocation and explains the rarity of this injury. In this case the mechanism of injury consisted of rotational forces applied to the fixed forefoot and resulted in this unique association of a metatarsal fracture and metatarsophalangeal joint dislocation. Interestingly enough, Wiley’ reported 4 cases in children where indirect forces to a fixed forefoot resulted in metatarsal fractures and tarsometatarsal dislocations. We postulate that there is a common mechanism of injury of the tarsometatarsophalangeal complex in children when the forefoot is fixed and a metatarsal linked injury pattern is found. The length of the distal forefoot that is trapped dictates the type of injury sustained by the foot and is related to the length of the lever arm. Severe forces applied to an immobilized forefoot, particularly by a twisting movement of the body, generate a torque that leads to injuries proximal to the point of entrapment. According to the length of forefoot that is immobilized, metatarsal fractures may be associated with either a metatarsophalangeal dislocation or a tarsometatarsal dislocation. This forms the ‘linked injury’ pattern of metatarsal trauma. When the toes alone are fixed, as in this case, the associated dislocation is distal, while when the
CASE REPORT A 6-year-old boy sustained a minor head injury and injured his right forefoot while playing behind the family car. The patient fell backwards as his right forefoot was pinned to the ground beneath the car wheel. Examination revealed swelling of the forefoot and mild lateral deviation of the fifth toe with intact skin. Radiography of the forefoot demonstrated greenstick fractures of all lesser metatarsal shafts and a dislocation of the fifth metatarsophalangeal joint. The metatarsal head was medially displaced (Figure). With the patient under general anaesthesia, it was not possible to reduce either the fracture of the fifth metatarsal or the dislocated metatarsophalangeal joint by closed manipulation. The joint was therefore exposed through a dorsal approach. The metatarsal head was found to be displaced medially and had buttonholed through the joint capsule with the medial collateral ligament dorsally and the volar plate below. Following release of the medial collateral ligament, the joint was opened. However, it proved impossible to reduce the dislocation until the fracture of the fifth metatarsal had been reduced. Correction of the metatarsal shaft fracture now allowed a stable 100
Irreducible
metatarsophalangeal
joint dislocation
of the fifth toe in a child
101
metatarsals themselves are fixed the dislocation is proximal. This is the first reported instance of a distal dislocation in combination with a metatarsal fracture in a child.
References 1. Heckman
2.
3. 4. 5.
J D. Fractures and dislocations of the foot. In: Rockwood C A Jr, Green D P, eds. Fractures in adults. 2nd ed. Philadelphia: Lippincott, 1984: 1818-1819. Rao J P. Banzon M T. Irreducible dislocation of the metatarsophalangeal joints of the foot. Clin Orthop 1919; 145: 224-226. Murphy J L. Isolated dorsal dislocation of the second metatarsophalangeal joint. Foot Ankle 1980; 1: 30-32 English T A. Dislocation of the metatarsal bone and adjacent toe. J Bone Joint Surg 1964; 46B: 700-704. Wiley J J. Tarso-metatarsal joint injuries in children. J Pediatr Orthop 1981: 1: 255-260.
The authors Mr A.
Iossifidis MD, FRCS (Ed.) Orthopaedic Registrar Mr R. Brueton MD, FRCS, Senior Lecturer Rayne Institute Academic Unit Orthopaedic Department St Thomas’ Hospital Lambeth Palace Road London SE1 7EH UK
FigurepAP radiograph of the right foot demonstrating a metatarsophalangeal dislocation of the fifth toe and greenstick fractures of the lateral metatarsals.
Correspondence SE4 1YQ. UK.
to Mr A. Iossifidis.
7 Darling
Road,
London