An analysis of pathomorphic forms and diagnostic difficulties in tarso-metatarsal joint injuries

Tarso-metatarsal injuries are rare but frequently missed. Due to the large variation in pathomorphic forms of these injuries, great precision is required when carrying out clinical and X-ray diagnostic procedures. The aim of the study was to describe the different forms of Lisfranc joint injuries and analyse the causes of delayed treatment. The treatment results of acute and chronic injuries were compared in 41 patients, with an average follow-up period of 16 years. Statistically significant poorer results were obtained in the group of chronic cases, based on two functional scores - the AOFAS evaluation questionnaire and the Lublin functional questionnaire. The main factor delaying the start of the proper treatment was diagnostic error during initial admission. The best results were achieved after closed reduction and percutaneous Kirschner wire fixation in acute cases.

Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique

BACKGROUND

Open reduction and internal fixation is currently the accepted treatment for displaced Lisfranc joint injuries. However, even with anatomic reduction and stable internal fixation, treatment of these injuries does not have uniformly excellent outcomes. The objective of this study was to compare primary arthrodesis with open reduction and internal fixation for the treatment of primarily ligamentous Lisfranc joint injuries.

METHODS

Forty-one patients with an isolated acute or subacute primarily ligamentous Lisfranc joint injury were enrolled in a prospective, randomized clinical trial comparing primary arthrodesis with traditional open reduction and internal fixation. The patients were followed for an average of 42.5 months. Evaluation was performed with clinical examination, radiography, the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, a visual analog pain scale, and a clinical questionnaire.

RESULTS

Twenty patients were treated with open reduction and screw fixation, and twenty-one patients were treated with primary arthrodesis of the medial two or three rays. Anatomic initial reduction was obtained in eighteen of the twenty patients in the open-reduction group and twenty of the twenty-one in the arthrodesis group. At two years postoperatively, the mean AOFAS Midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005). Five patients in the open-reduction group had persistent pain with the development of deformity or osteoarthrosis, and they were eventually treated with arthrodesis. The patients who had been treated with a primary arthrodesis estimated that their postoperative level of activities was 92% of their preinjury level, whereas the open-reduction group estimated that their postoperative level was only 65% of their preoperative level (p < 0.005).

CONCLUSIONS

A primary stable arthrodesis of the medial two or three rays appears to have a better short and medium-term outcome than open reduction and internal fixation of ligamentous Lisfranc joint injuries.

First metatarsophalangeal joint dislocation with open fracture of tibial and fibular sesamoids

Traumatic dislocations of the first metatarsophalangeal joint were first described by Mouchet in 1931. The anatomical complexity of the first metatarsophalangeal joint makes this injury one of a kind. There have been only been a limited number of case reports of this injury, but none in combination with open fractures of both sesamoids. We would like to report 1 case of an open traumatic dislocation of the first metatarsophalangeal joint with open fracture of the fibular and tibial sesamoid. Open reduction and internal fixation of the injury led to a successful outcome.

Subchondral bone failure in overload arthrosis: a scanning electron microscopic study in horses

Mechanical overload leads to a common arthrosis in the metacarpal condyle of the fetlock joint of racehorses. This is usually asymptomatic but severe forms can cause lameness. Subchondral bone failure is often present and the predictability of the site provided an opportunity to study of the progression of bone failure from microcracks to actual collapse of subchondral bone. Twenty-five fetlock condyles from racehorses with various stages of disease were selected. Stages ranged from mild through severe subchondral bone sclerosis, to the collapse of bone and indentation or loss of cartilage known as 'traumatic osteochondrosis'. Parasagittal slices were radiographed and examined with scanning electron microscopy. Fine matrix cracks were seen in the subchondral bone layer above the calcified cartilage and suggested loss of water or other non-collagenous components. The earliest microcracks appeared to develop in the sclerotic bone within 1-3 mm of the calcified cartilage layer and extend parallel to it in irregular branching lines. Longer cracks or microfractures appeared to develop gaps as fragmentation occurred along the margins. Occasional osteoclastic resorption sites along the fracture lines indicated activated remodeling may have caused previous weakening. In one sample, smoothly ground fragments were found in a fracture gap. Bone collapse occurred when there was compaction of the fragmented matrix along the microfracture. Bone collapse and fracture lines through the calcified cartilage were associated with indentation of articular cartilage at the site.

The Pathogenesis and Biomechanics of Turf Toe

Sprain injury to the 1st metatarsophalangeal joint is referred to as turf toe. The incidence of this injury has increased over the years secondary to athletic fields being covered by artificial turf and also by increased flexibility of the toe box in athletic shoes. The pathogenesis of turf toe will be presented in this article.

The floating first metatarsal: a case report

Complete dislocation of the first metatarsal represents an infrequent injury. The authors present the case of a 48-year-old man who sustained dislocation of the first metatarsal from both the metatarsophalangeal and tarsometatarsal joints in a motor vehicle accident. After open reduction, the first metatarsophalangeal joint was temporarily fixated with a Kirschner wire to maintain reduction, while the first metatarso-cuneiform joint was fixated with two cannulated screws. A discussion of the pertinent literature regarding this rare injury is also included.

Deep digital flexor tendon shortening as a treatment for distal interphalangeal joint hyperextension in a 2-year-old mare

Shortening of the deep digital flexor tendon was performed by tenotomy, overlapping and anastomosis. The procedure was performed on a two-year-old Quarter Horse Mare with distal interphalangeal joint hyperextension with subluxation and metatarsophalangeal joint hyperextension. These problems originated from damage to the digital flexor tendons, presumably due to previous distal limb trauma. The procedure markedly improved the mare's level of comfort, degree of ambulation and limb conformation. Two years following surgery the mare was comfortable at pasture.

The Weil osteotomy

We prospectively evaluated the one- and seven-year results of the Weil osteotomy for the treatment of metatarsalgia with subluxed or dislocated metatarsophalangeal joints in 25 feet of 24 patients. Good to excellent results were achieved in 21 feet (84%) after one year and in 22 (88%) after seven years. The American Orthopaedic Foot and Ankle Society score significantly improved from 48 (sd 15) points before surgery to 75 (sd 24) at one year, and 83 (sd 18) at seven years. The procedure significantly reduced pain, diminished isolated plantar callus formation and increased the patient’s capacity for walking. Redislocation of the metatarsophalangeal joint was seen in two feet (8%) after one year and in three (12%) after seven years. Although floating toes and restricted movement of the metatarsophalangeal joint may occur, the Weil osteotomy is safe and effective.

[Stress fracture of the internal sesamoid bone of the first metatarsophalangeal joint. Case report]

We present the case of a fourty-two year old truck driver without a major trauma history who was diagnosed in our unit as having a stress fracture of the first metatarsophalangeal joint medial sesamoid bone. Conservative treatment consisting of 30 day immobilisation was our treatment choice. The result was very good and at six month follow-up the patient had no complains. We have searched for other opinions but there is a paucity of published literature on the injuries of the lesser toe sesamoids of the foot. The literature review revealed different types of treatment such as: conservative treatment, internal fixation of the sesamoid fracture (screw fixation), reduction of weight-bearing pressure on the affected sesamoid, ice massage or sesamoidectomy. Due to the fact that the different conclusions are based on very few cases, it is no possible to conclude about optimal treatment.

Skimboarder's Toe: Findings on High-Field MRI

OBJECTIVE

Our purpose is to report hyperdorsiflexion injuries of the metatarsophalangeal joints associated with the sport of skimboarding and to describe the MRI appearance of these injuries.

CONCLUSION

Skimboarding can be associated with hyperdorsiflexion injuries of the metatarsophalangeal joint. MRI shows that such injuries are associated with hyperdorsiflexion of the extensor hallucis longus or extensor digitorum longus tendon, causing tear of the extensor expansion. Unlike turf toe, in which the plantar plate is involved, skimboarder's toe involves structures dorsal to the metatarsophalangeal joint.

Radiologic case study. First metarsophalangeal plantar plate injury (turf toe)

Turf toe and related injuries to the first metatarsophalangeal joint are common injuries that occur in several sports. Although often a clinical diagnosis, advanced imaging can help grade severity of sprain and evaluate for associated or unsuspected injuries. Without proper rest and conservative management, a treatable injury can have chronic sequelae and morbidity. Operative management is uncommon, but successful in returning high-level competitive athletes to their sport.

Turf toe: ligamentous injury of the first metatarsophalangeal joint

Injuries to the metatarsophalangeal (MTP) joint of the great toe have increased in incidence over the past thirty years following the introduction of artificial playing surfaces and the accompanying use of lighter footwear. Although most common in American football players, similar injuries can also occur in other sporting activities including soccer and dance, or following trauma to the great toe. The mechanism of injury is typically hyperextension of the MTP joint, but injuries have also been reported secondary to valgus or varus stress, or rarely as a result of hyperflexion injury. The abnormal forces applied to the first MTP joint at the time of injury, result in varying degrees of sprain or disruption of the supporting soft tissue structures, leading to the injury commonly referred to as turf toe. The extent of soft tissue disruption is influential in treatment planning and can be used to determine the prognosis for recovery. This report will review the anatomy of the first MTP join, followed by a discussion of the mechanism of injury and the typical clinical presentation of an individual with turf toe. Finally, the role of imaging including radiography and magnetic resonance imaging, and standard treatment options for turf toe will be discussed.

Acute fractures of medial and lateral great toe sesamoids in an athlete

We report a case of acute fracture of both sesamoids of the great toe in an athlete. The fractures healed uneventfully after non-surgical treatment.

Sesamoid and toe fractures

Injuries of the toes and sesamoids of the first metatarsophalangeal joint comprise a wide spectrum of traumatic entities. Despite the fact that a majority of lesions may well respond to nonsurgical treatment and exhibit an excellent prognosis, appropriate clinical and imaging analysis is mandatory to select those injuries that require specific therapeutic and surgical measures to avoid long-term sequelae of functional disability.

[A long-distance runner with a painful sesamoid bone in the forefoot]

A 38-year-old long-distance runner presented with pain in the left medial forefoot. In the presence of such symptoms, consideration should be given to a disease of or injury to a sesamoid bone. Radiology revealed a fracture line through the medial sesamoid bone under the first metatarsophalangeal joint. Conservative treatment was initially ineffective. Ultimately, local injections of lidocaine-methylprednisolone at the site of the pain, in the metatarsophalangeal joint and in the fracture line brought relief. In the diagnosis of patients with pain in the medial forefoot, apart from the patient's history and a physical examination, a skyline X-ray can be helpful to reveal a fractured or bipartite sesamoid. Almost all conditions affecting the sesamoids improve in the long run with conservative treatment. Besides reduction of weight-bearing pressure on the affected sesamoid, NSAIDs and ice massage, special attention should be paid to the foot (postural deformities), the shoe (inlays, sesamoid pad, shock absorption, stiff sole) and running on a soft surface. Insufficient therapeutic results may be due to osteonecrosis or non-union. These and persistent pain may, as a last resort, require surgical intervention such as screw fixation in case of a fracture or sesamoidectomy.

Plantar dislocation of lateral tarsometatarsal joint: a case of subtle Lisfranc injury

INTRODUCTION

We present a rare case of plantar dislocation of the cuboid, fourth and fifth metatarsal joints. Fracture-dislocation in the midfoot region may be subtle and difficult to recognise at the emergency department.

CLINICAL PICTURE

A 16-year-old girl presented with lateral foot pain and swelling following a fall from a height of 3 m. Initial radiograph revealed a third metatarsal shaft fracture; however, additional views reviewed a plantar direction of fourth and fifth metatarsal dislocation from the cuboid.

TREATMENT

Open reduction and internal fixation with Kirschner wires followed by immobilisation in plaster was performed.

OUTCOME

She made an uneventful recovery and the wires had since been removed.

CONCLUSION

This case was unusual in that there was lateral tarsometatarsal disruption with neither diastasis between the first and second metatarsals nor injury to either the first or second tarsometatarsal joints. The plantar direction of dislocation was also unusual as these injuries are usually dorsal.

Die Weil-Osteotomie bei Metatarsalgie

AIM

The purpose of the prospective study is to evaluate the results of Weil osteotomy in painful overloaded central forefoot with dislocation of the MTP joint.

METHOD

19 left and 16 right feet underwent the Weil osteotomy. In 10 patients the procedure was performed on both feet. In 15 cases only one metatarsal was corrected (the 2 (nd) in 12 and the 3 (rd) in 3 cases), in 17 cases both the 2 (nd) and the 3 (rd) metatarsals and in 4 cases also with the 4 (th) one together. The simultaneous correction of hallux valgus was performed in 19 forefeet. The mean follow-up was 31 months (range, 19 to 41 months).

RESULTS

All patients were satisfied with the result of the operation. The results were excellent in 29 cases (83 %) and good in 6 cases (17 %). The plantar callus disappeared in 27 feet (77 %) and decreased in 8 feet (23 %). In one patient the new callus formed under the head of the neighbouring metatarsal bone. The sufficient MTP joint reduction was found in 31 cases (89 %).

CONCLUSION

It is possible with the Weil osteotomy to correct the metatarsal length accurately according to the preoperative planning. This results in the prevention of new callus formation under the neighbouring metatarsal head. Stable internal fixation allows the early mobilisation of the MTP joint.