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The floating metatarsal: first metatarsophalangeal joint dislocation with associated lisfranc dislocation
The Floating Metatarsal: First Metatarsophalangeal Joint Dislocation With Associated Lisfranc Dislocation Jorge Cuenca Espie´rrez, MD,1 A´ngel Antonio Martı´nez, MD,2 Antonio Herrera, MD,3 and Juan Jose´ Panisello, MD4 The authors report a case of an irreducible dorsal dislocation of the first metatarsophalangeal joint, with concomitant Lisfranc dislocation and fractures of the second, third, and fourth metatarsals. This combination has been reported only once in the literature. This extremely rare combined injury results in a floating metatarsal. Open reduction of the metatarsophalangeal joint dislocation and fixation of Lisfranc joint and metatarsal fractures with Kirschner wires was performed. One year after surgery, the patient is active and the first metatarsophalangeal joint is asymptomatic, but there is mild pain in the Lisfranc joint. ( The Journal of Foot & Ankle Surgery 42(5):309 –311, 2003) Key words: first metatarsophalangeal join, Lisfranc fracture/dislocation, floating metatarsal
T he floating metatarsal injury was first described by Leibner et al (1). They reported the case of a patient whose first metatarsal was dislocated proximally from the first metatarsocuneiform joint with a concomitant dislocation of the first metatarsophalangeal joint. The proposed mechanism of injury was a direct longitudinal force on the metatarsal head with the hallux toe in extension. To our knowledge, this has been the only case of floating metatarsal reported to date. We report another case of this extremely rare injury. Case Report A 20-year-old man was involved in an automobile accident. He was an unrestrained driver and presented with pain and deformity of his right foot. There were no other reported injuries. Physical examination showed a cavoid deformity of the foot with a fixed hyperextension of the great toe. There was significant forefoot and midfoot edema without blistering. Sensation and pulses were preserved. Radiographs showed a dorsomedial dislocation of the proximal phalanx of the great toe, associated with lateral From the Department of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Zaragoza, Spain. Address correspondence to: Jorge Cuenca Espie´rrez, C/Lasala Valde´s, 25, 1°, Zaragoza 50006, Spain. E-mail: [email protected] 1 Orthopedic Surgeon. 2 Orthopedic Surgeon. 3 Chief of Service. 4 Orthopedic Surgeon. Copyright © 2003 by the American College of Foot and Ankle Surgeons 1067-2516/03/4205-0011$30.00/0 doi:10.1053/S1067-2516(03)00308-9
dislocation of the Lisfranc joint complex and fracture of the second, third, and fourth metatarsals (Figs. 1 and 2). The sesamoids did not appear to be separated. A closed reduction was not attempted in the emergency room. Five hours after the accident, and under general anesthesia, a closed reduction of the first metatarsophalangeal joint was attempted without success. Open reduction through a medial approach was performed. The sesamoids, still connected by the intact intersesamoid ligament, were situated between the proximal phalanx and the metatarsal head. Manual distal traction on the toe and with plantar retraction placed on the intersesamoid ligament allowed reduction. Kirschner wire fixation was used to stabilize the Lisfranc joint at the first, second, third, and fifth tarsometatarsal joints. The fourth metatarsal neck fracture and proximal subluxation had resumed anatomic alignment. The fractures of the second and third metatarsal necks were fixated with the same wire that crossed the proximal articulations (Fig. 3). A short-leg non-weightbearing plaster cast was used for 8 weeks, after which the Kirschner wires were removed without anesthesia. One year after the surgery, the patient has been fully active. The first metatarsophalangeal joint is asymptomatic, but there is mild pain at the Lisfranc joint. Radiographs show moderate degenerative changes of Lisfranc joint (Fig. 4).
Discussion The mechanism of injury of our case was similar to the case of Leibner et al (1). An axial load caused hyperex-
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FIGURE 3 Dorsoplantar radiograph showing reduced metatarsophalangeal and Lisfranc joints. The Lisfranc joint and the second and third metatarsals have been fixed with Kirschner wires.
FIGURE 1 Dorsoposterior radiograph showing the dislocation of the proximal phalanx of the first toe and the lateral dislocation of the tarsometatarsal joint.
FIGURE 2 Lateral radiograph shows the dorsal dislocation of the proximal phalanx and the cavoid posture of the foot.
tension of the great toe. The hallux, with its sesamoids still attached to the base of the proximal phalanx, dislocated over the dorsum of the metatarsal head. The medial and lateral slips of the flexor hallucis brevis and the respective abductor and adductor hallucis tendons, separated to either side of the metatarsal head, laid tautly to 310
THE JOURNAL OF FOOT & ANKLE SURGERY
FIGURE 4 Anteroposterior radiograph showing moderate degenerative arthritis of the Lisfranc joint 1 year later (photo enhanced to visualize arthrosis).
either side of the metatarsal neck. This is a type I dislocation, according to Jahss classification (2), which is usually irreducible on closed manipulation. The continu-
ing force was transferred to the metatarsal, which was plantarflexed on the midfoot, causing the Lisfranc dislocation and metatarsal fractures. Dorsal (3,4), plantar (5,6), and medial approaches (7) have been used to reduce first metatarsophalangeal joint. We chose a medial approach because it allows a good visualization of all affected structures, avoiding plantar scars and damage of the neurovascular bundle. Once the first metatarsophalangeal joint has been reduced, subsequent Lisfranc dislocation management became easier. When examining patients with first metatarsophalangeal joint dislocation, the clinician must keep in mind that a tarsometatarsal injury may coexist. Careful examination of the entire foot is necessary because clinical and radiographic evidence of tarsometatarsal dislocations usually is not as evident as that of the metatarsophalangeal dislocation. Radiographs must include the whole foot. The use of 10° and 20° external oblique views, as advocated by Myerson (8), can visualize subtle widening of the first intermetatarsal interspace.
References 1. Leibner ED, Mattan Y, Shaoul J, Nyska M. Floating metatarsal: concomitant Lisfranc fracture-dislocation and complex dislocation of the first metatarsophalangeal joint. J Trauma 42:549 –552, 1997 2. Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1:15–21, 1980 3. Lewis AG, DeLee JC. Type-I complex dislocation of the first metatarsophalangeal joint. Open reduction through a dorsal approach. J Bone Joint Surg 66A:1120 –1123, 1984 4. Yu EC, Garfin SR. Closed dorsal dislocation of the metatarsophalangeal joint of the great toe. A surgical approach and case report. Clin Orthop 185:237–240, 1984 5. Giannikas AC, Papachristou G, Papavasiliou N, Nikiforidis P, Hartofilakidis-Garofalidis G. Dorsal dislocation of the first metatarso-phalangeal joint. Report of four cases. J Bone Joint Surg 57B:384 –386, 1975 6. Salamon PB, Gelberman RH, Huffer JM. Dorsal dislocation of the metatarsophalangeal joint of the great toe. J Bone Joint Surg 56A:1073– 1075, 1974 7. DeCasas R, Mesa F. Irreducible dorsal dislocation of the metatarsophalangeal joint of the hallux. Arch Orthop Trauma Surg 109:173–174, 1990 8. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am 20:655– 664, 1989
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T he floating metatarsal injury was first described by Leibner et al (1). They reported the case of a patient whose first metatarsal was dislocated proximally from the first metatarsocuneiform joint with a concomitant dislocation of the first metatarsophalangeal joint. The proposed mechanism of injury was a direct longitudinal force on the metatarsal head with the hallux toe in extension. To our knowledge, this has been the only case of floating metatarsal reported to date. We report another case of this extremely rare injury. Case Report A 20-year-old man was involved in an automobile accident. He was an unrestrained driver and presented with pain and deformity of his right foot. There were no other reported injuries. Physical examination showed a cavoid deformity of the foot with a fixed hyperextension of the great toe. There was significant forefoot and midfoot edema without blistering. Sensation and pulses were preserved. Radiographs showed a dorsomedial dislocation of the proximal phalanx of the great toe, associated with lateral From the Department of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Zaragoza, Spain. Address correspondence to: Jorge Cuenca Espie´rrez, C/Lasala Valde´s, 25, 1°, Zaragoza 50006, Spain. E-mail: [email protected] 1 Orthopedic Surgeon. 2 Orthopedic Surgeon. 3 Chief of Service. 4 Orthopedic Surgeon. Copyright © 2003 by the American College of Foot and Ankle Surgeons 1067-2516/03/4205-0011$30.00/0 doi:10.1053/S1067-2516(03)00308-9
dislocation of the Lisfranc joint complex and fracture of the second, third, and fourth metatarsals (Figs. 1 and 2). The sesamoids did not appear to be separated. A closed reduction was not attempted in the emergency room. Five hours after the accident, and under general anesthesia, a closed reduction of the first metatarsophalangeal joint was attempted without success. Open reduction through a medial approach was performed. The sesamoids, still connected by the intact intersesamoid ligament, were situated between the proximal phalanx and the metatarsal head. Manual distal traction on the toe and with plantar retraction placed on the intersesamoid ligament allowed reduction. Kirschner wire fixation was used to stabilize the Lisfranc joint at the first, second, third, and fifth tarsometatarsal joints. The fourth metatarsal neck fracture and proximal subluxation had resumed anatomic alignment. The fractures of the second and third metatarsal necks were fixated with the same wire that crossed the proximal articulations (Fig. 3). A short-leg non-weightbearing plaster cast was used for 8 weeks, after which the Kirschner wires were removed without anesthesia. One year after the surgery, the patient has been fully active. The first metatarsophalangeal joint is asymptomatic, but there is mild pain at the Lisfranc joint. Radiographs show moderate degenerative changes of Lisfranc joint (Fig. 4).
Discussion The mechanism of injury of our case was similar to the case of Leibner et al (1). An axial load caused hyperex-
VOLUME 42, NUMBER 5, SEPTEMBER/OCTOBER 2003
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FIGURE 3 Dorsoplantar radiograph showing reduced metatarsophalangeal and Lisfranc joints. The Lisfranc joint and the second and third metatarsals have been fixed with Kirschner wires.
FIGURE 1 Dorsoposterior radiograph showing the dislocation of the proximal phalanx of the first toe and the lateral dislocation of the tarsometatarsal joint.
FIGURE 2 Lateral radiograph shows the dorsal dislocation of the proximal phalanx and the cavoid posture of the foot.
tension of the great toe. The hallux, with its sesamoids still attached to the base of the proximal phalanx, dislocated over the dorsum of the metatarsal head. The medial and lateral slips of the flexor hallucis brevis and the respective abductor and adductor hallucis tendons, separated to either side of the metatarsal head, laid tautly to 310
THE JOURNAL OF FOOT & ANKLE SURGERY
FIGURE 4 Anteroposterior radiograph showing moderate degenerative arthritis of the Lisfranc joint 1 year later (photo enhanced to visualize arthrosis).
either side of the metatarsal neck. This is a type I dislocation, according to Jahss classification (2), which is usually irreducible on closed manipulation. The continu-
ing force was transferred to the metatarsal, which was plantarflexed on the midfoot, causing the Lisfranc dislocation and metatarsal fractures. Dorsal (3,4), plantar (5,6), and medial approaches (7) have been used to reduce first metatarsophalangeal joint. We chose a medial approach because it allows a good visualization of all affected structures, avoiding plantar scars and damage of the neurovascular bundle. Once the first metatarsophalangeal joint has been reduced, subsequent Lisfranc dislocation management became easier. When examining patients with first metatarsophalangeal joint dislocation, the clinician must keep in mind that a tarsometatarsal injury may coexist. Careful examination of the entire foot is necessary because clinical and radiographic evidence of tarsometatarsal dislocations usually is not as evident as that of the metatarsophalangeal dislocation. Radiographs must include the whole foot. The use of 10° and 20° external oblique views, as advocated by Myerson (8), can visualize subtle widening of the first intermetatarsal interspace.
References 1. Leibner ED, Mattan Y, Shaoul J, Nyska M. Floating metatarsal: concomitant Lisfranc fracture-dislocation and complex dislocation of the first metatarsophalangeal joint. J Trauma 42:549 –552, 1997 2. Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1:15–21, 1980 3. Lewis AG, DeLee JC. Type-I complex dislocation of the first metatarsophalangeal joint. Open reduction through a dorsal approach. J Bone Joint Surg 66A:1120 –1123, 1984 4. Yu EC, Garfin SR. Closed dorsal dislocation of the metatarsophalangeal joint of the great toe. A surgical approach and case report. Clin Orthop 185:237–240, 1984 5. Giannikas AC, Papachristou G, Papavasiliou N, Nikiforidis P, Hartofilakidis-Garofalidis G. Dorsal dislocation of the first metatarso-phalangeal joint. Report of four cases. J Bone Joint Surg 57B:384 –386, 1975 6. Salamon PB, Gelberman RH, Huffer JM. Dorsal dislocation of the metatarsophalangeal joint of the great toe. J Bone Joint Surg 56A:1073– 1075, 1974 7. DeCasas R, Mesa F. Irreducible dorsal dislocation of the metatarsophalangeal joint of the hallux. Arch Orthop Trauma Surg 109:173–174, 1990 8. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am 20:655– 664, 1989
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