Boxer knuckle (injury of the extensor hood with extensor tendon subluxation): diagnosis with dynamic US--report of three cases

The use of dynamic ultrasonography (US) in diagnosing traumatic and nontraumatic extensor tendon dislocations in fingers of three subjects is reported. Dynamic US of the clenched fist in two patients with traumatic injury revealed dislocated but grossly intact tendons surrounded by soft-tissue edema; magnetic resonance (MR) imaging in one patient indicated similar findings. Rupture in the sagittal band of the extensor hood mechanism in the two patients was confirmed at surgery. The third subject, an asymptomatic volunteer, had a congenital tendency toward dislocation. Dynamic US of the clenched fist is useful in diagnosing injuries of the extensor hood mechanism.

The floating metatarsal: first metatarsophalangeal joint dislocation with associated Lisfranc dislocation

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.

Traumatic dislocation of the fourth metatarsophalangeal joint

A32-year-old man presented to the accident and emergency department 2 hours after twisting his ankle. He had been running down stairs, barefoot, and missed a step, inverting his left ankle and landing on the lateral aspect of his left foot before falling to the ground. He was weight-bearing on his left heel, but complaining of intense pain over the lateral aspect of his forefoot. He mentioned that his wife had noticed a dimple on the sole of his foot. Besides the dimple on the plantar aspect of the left foot, about 2 cm proximal to the base of the fourth toe, no other deformity, swelling or bruising was evident. The patient was markedly tender over the dorsum of the foot over the area of the fourth metatarsophalangeal joint and over the dimple, which marked the same place on the plantar surface. Distal sensation and capillary refill were normal.

A combined proximal and distal dislocation of two adjacent metatarsals: double floating metatarsal bones (second-third)

A rare foot injury consisting of an irreducible, closed combined distal and proximal articulation dislocation of two adjacent metatarsals (second and third), called a "double floating metatarsal," was encountered in a 29-year-old man. The anatomy, mechanism of injury, and sequence of the surgical procedure are presented and discussed.

Athletic injuries of the first metatarsophalangeal joint

Turf-toe injuries can occur in many athletic endeavors. This article describes the different injuries that occur to the first metatarsophalangeal joint that may be termed "turf toe." These injuries may result in significant morbidity. Thus proper diagnosis is paramount for instituting appropriate treatment to facilitate an athlete's prompt return to the playing field. Two case studies are presented to illustrate injuries of the first metatarsophalangeal joint in the athletic population.

The floating metatarsal. A rare traumatic injury

The authors report a case of concomitant plantar Lisfranc dislocation and plantar metatarsophalangeal dislocation of the hallux. This is the second case of floating metatarsal described in the literature. When examining patients with Lisfranc joint injuries, one should explore carefully the metatarsophalangeal joints. It is also imperative to adapt the order of reductions to the presumed tension on the plantar fascia. Open reduction on the proximal side and closed reduction on the distal side, in addition to internal fixation proximally and distally, gave good results in this case.

Concomitant plantar tarsometatarsal (Lisfranc) and metatarsophalangeal joint dislocations

We report an unusual case of concomitant plantar tarsometatarsal (Lisfranc) and 1st and 2nd metatarsophalangeal (MTP) joint dislocations and fracture of the neck of the third metatarsal bone which has never been reported before. The plantar dislocation of the Lisfranc joint was treated by open reduction and fixation with K-wires; the dislocations of the MTP joints and neck fracture of the third metatarsal bone were treated by closed reduction and percutaneous fixation with K-wires and immobilized with a plaster cast. At the 5 year follow-up examination, our patient had no complaints, but the radiograph showed degenerative changes of the Lisfranc and the 1st MTP joint.

Management of Lisfranc's fracture-dislocation

Lisfranc's joint injuries are rare and complex. A car driver who sustained a traffic accident, was admitted because of partial dorsolateral fracture-dislocation of the Lisfranc's joint. The diagnosis was made by physical examination and radiographs. Reduction and pin fixation were performed under general anesthesia. At the end of the ninth month, range of motion of the foot and ankle was full, with no pain on daily activities.

[Stress fracture of the fifth metatarsophalangeal sesamoid bone: a case report]

There is a paucity of published literature on the injuries of the lesser toe sesamoids of the foot. A fifty-six-year-old male patient without a major trauma history was diagnosed as having a stress fracture of the fifth metatarsophalangeal joint medial sesamoid bone. Conservative treatment was employed and the patient was followed-up for 25 months without any complaints. The sesamoid bone injury of the fifth toe should be included in the differential diagnosis of lateral forefoot pain.

Floating lesser metatarsals associated with Lisfranc type C--total displacement injury

We present a 30-year-old woman with a complex foot injury including floating lesser metatarsals, an intact base of second metatarsal and an irreducible fifth metatarsophalangeal joint. The recognition of potential associated injuries together with a Lisfranc fracture-dislocation must not be overlooked.

The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study

he anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Student's two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury.

Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint

Progressive subluxation/dislocation of the lesser toes resulting from idiopathic inflammation about one or more of the lesser metatarsophalangeal joints is a common cause of metatarsalgia that is frequently unrecognized or misdiagnosed. The disorder results from a failure of the plantar plate and collateral ligaments that stabilize the metatarsophalangeal joints and is typically associated with abnormal forefoot loading patterns. The authors refer to this condition as predislocation syndrome and have devised a clinical staging system that is based on the clinical signs and symptoms present during examination. A thorough review of predislocation syndrome and an overview of the conservative and surgical treatment options available for this disorder are presented.

Traumatic hallux valgus following rupture of the medial collateral ligament of the first metatarsophalangeal joint: a case report

Metatarsophalangealjoint injuries of the great toe are receiving increasing attention in athletes. Significant disability and long-term morbidity can result from these focal injuries. The entity known as turf-toe is widely recognized. Rupture of the medial collateral ligament of the first metatarsophalangeal joint is less common. A case of traumatic rupture of the medial collateral ligament in the great toe of a soccer player, which progressed to hallux valgus deformity, is presented.

Irreducible dorsal subluxation of the first metatarsophalangeal joint: a case report

We report a case of dorsal subluxation of the first metatarsophalangeal joint without dislocation of the sesamoids or destruction of the sesamoid complex. Closed reduction was unsuccessful. At surgery, the subluxation was found to be associated with locking of the abductor hallucis tendon onto the medial condyle of the metatarsal. After restoration of the tendon to its normal anatomic alignment, the joint was successfully reduced. One year after the injury, the patient was asymptomatic and had full range of motion of the metatarsophalangeal joint.

Digital foot trauma: emergency diagnosis and treatment

Trauma to the foot is commonly seen in the emergency setting. An accurate diagnosis and step-wise management is appropriate. Although most injuries respond to aggressive non-surgical treatment, surgical intervention may be required for an unstable or a displaced fracture, particularly of the first metatarsophalangeal joint.

Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management

Metatarsalgia is a common presenting symptom with an established list of differential diagnoses. The authors present a classification system and surgical treatment algorithm for chronic metatarsophalangeal pain due to metatarsophalangeal joint capsule tear. A series of 58 metatarsophalangeal joints with partial tear diagnosed by arthrogram and treated by surgical repair are reviewed. The authors propose a classification system based on preoperative arthrography and a surgical repair procedure for each type of three distinct patterns. A study was developed and funded to perform postoperative arthrograms on 15 patients who had undergone surgical repair using the procedures presented. The purpose of the study was to validate the utility of the arthrogram in the diagnosis and clarification of the nature of the capsular tear. The authors were also able to demonstrate that the arthrographic findings became normal postoperatively, and that surgical repair of a seemingly innocuous capsule tear relieves pain. Fifty-six patients in the series reported relief of their preoperative symptoms. Postoperative arthrograms in 15 patients demonstrated a normal pattern in 73%, 20% had decreased extravasation, and 7% were unchanged.

Complications of lesser toe surgery

Surgical procedures for lesser toe problems are among the most common surgeries done on the foot. In a shoe wearing population, the incidence of lesser toe pathologic disorders is high. The complications associated with lesser toe surgery can be troublesome for patients and physicians. Understanding the possible common complications and how to avoid them is essential to maximizing satisfactory clinical results.

Fracture-dislocation of the first metatarsophalangeal joint: open reduction through a medial incisional approach

A case of traumatic fracture-dislocation of the first metatarsophalangeal joint is reported. This type of injury is extremely rare. The injury was associated with complete disruption of the following anatomic structures: conjoined tendon of abductor hallucis and medial head of flexor hallucis brevis, plantar plate, and the intersesamoid ligament. Additionally, there was a transverse fracture of the tibial sesamoid. Excision of the fractured tibial sesamoid trapped within the joint and primary repair was achieved through a medial incisional approach. A complete description of the repair and rationale for the surgical procedure is discussed.

Complete dorsal tarsometatarsal dislocation of the first metatarsal

The authors describe a rare case of Lisfranc's dislocation that occurred after a 13-year-old boy kicked the ground while playing soccer. He presented with complete pure dorsal tarsometatarsal dislocation of the first metatarsal. He was treated succesfully by closed reduction and percutaneous K-wire fixation. No complication was found and he returned to his preinjury lifestyle at 3 months. No sequelae are found 3.5 years later.

[New varieties of lateral metatarsophalangeal dislocations of the great toe]

PURPOSE OF THE STUDY

We report seven cases of traumatic dislocation of the great toe, detailing the anatomy, the mechanism of injury and the radiographic diagnosis. We propose an additional classification based on three hereto unreported cases.

MATERIAL AND METHODS

Between october 1994 and october 1997, we treated seven patients with traumatic dislocation of the first metatarso-phalangeal joint of the great toe. There were six men and one woman, mean age 35 years (range 24 - 44 years). Dislocation was caused by motor vehicle accidents in four cases and by falls in three. Diagnosis was made on anteroposterior, lateral and medial oblique radiographs. According to Jahss' classification, there was one type I and three type IIB dislocations. There was also one open lateral dislocation and two dorsomedial dislocations. Only these dorsomedial dislocations required open reduction, done via a dorsal approach. Mean follow-up was 17.5 months (range 9 - 24 months) in six cases. One patient was lost to follow-up. The outcome was good in six cases and poor in one (dorsomedial dislocation).

DISCUSSION

Dislocation of the first metatarso-phalangeal joint of the great toe is an uncommon injury. In 1980, Jahss reported two cases and reviewed three others described in the literature. He proposed three types of dislocation based on the feasibility of closed reduction (type I, II and IIB). In 1991, Copeland and Kanat reported a unique case in which there was an association of IIA and IIB lesions. They proposed an addition to the classification (type IIC). In 1994, Garcia Mata et al. reported another case which had not been described by Jahss and proposed another addition. All dislocations reported to date have been sagittal dislocations. Pathological alteration of the collateral ligaments has not been previously reported. In our experience, we have seen one case of open lateral dislocation due, at surgical exploration, to medial ligament rupture and two cases of dorsomedial dislocation due, at surgical exploration, to lateral ligament rupture.

CONCLUSION

We propose another additional classification with pure lateral dislocation (type III) and dorso-lateral dislocation (type IL or IIL+), which are related to the formerly described variants.