Posttraumatic proximal migration of the first metatarsophalangeal joint sesamoids: a report of four cases

Four cases are presented with plantar plate injury to the first metatarsophalangeal (MTP) joint and proximal retraction of the sesamoids by the flexor hallucis brevis. No history of dislocation occurred in any patient, although two had associated fractures of a sesamoid bone. Clinical and radiographic aids to the diagnosis are discussed. Clinical findings included diffuse pain beneath the first MTP joint and pain with extremes of joint motion in all patients. The anterior-posterior (AP) radiographic technique was the most helpful in determining the proximal migration of the sesamoids. By taking the AP view with both feet on the cassette and by centering the beam perpendicular to it, the diagnosis of plantar plate disruption can easily be made. Initial treatment of this disorder was nonoperative using a stiff soled shoe. With conservative treatment, two of the patients returned to preinjury activities. One patient required sesamoidectomy for resistant pain, and the final patient is still unable to return to his preinjury job requiring standing and heavy lifting.

Rupture of the flexor hallucis longus after hallux valgus surgery: case report and comments on technique for adductor release

A case of flexor hallucis longus (FHL) rupture following hallux valgus surgery is reported here. The authors conjecture that the FHL rupture was caused by a partial laceration of the FHL at the time of the surgical hallux valgus correction. The authors treated the painful problem by surgically debriding the distal stump of the FHL from under the first metatarsophalangeal joint (MP) and tenodesing that the proximal stump to the flexor digitorum longus (FDL). The authors describe a technique that minimizes the complications of an adductor tenotomy associated with a distal chevron type of hallux valgus correction.

A new classification for traumatic dislocations of the first metatarsophalangeal joint: type IIC

The anatomy, mechanism of injury, and radiographic diagnosis of traumatic dislocation of the first metatarsophalangeal joint are discussed. Previously, three basic types of these dislocations have been described. The authors propose an additional classification which has not been previously reported.

[The traumatized foot--clinical and radiological study]

Thorough examination of the injured foot is the basis of a complete diagnosis and the foundation for successful therapy. Anatomical and biomechanical knowledge is a necessity to achieve this goal. The radiological diagnostic procedures include plain film, digital subtraction angiography, US, CT and MRI. Only the combination of clinical and radiological assessment will lead to optimal results.

[Arthrodesis technique in post-traumatic foot disorders]

Surgical arthrodesis procedures are effective in stabilizing painful joints in the foot. Joints most suitable for arthrodesis are: the hallux joints, midfoot, and hindfoot joints. The use of internal fixation is recommended whenever possible to ensure a successful fusion. However, surgical technique is most important as is the final position of the fused joints.

Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players

Metatarsophalangeal joint injuries of the great toe (turf-toe) are receiving increasing attention in the literature because of the prevalence of synthetic surfaces and lighter, more flexible shoes. Eighty active professional football players were evaluated. The mechanism of injury was hyperextension in 85% of the players. Eighty-three percent reported their initial injury on artificial turf (P less than 0.05). Other factors significantly related to the incidence of turf-toe included player age (P less than 0.01), number of years in professional football (P less than 0.01), and range of ankle dorsiflexion (P less than 0.05). Turf-toe injury resulted in significantly decreased range of motion of the first metatarsophalangeal joint (P less than 0.01).

Irreducible dorsal dislocation of the metatarsophalangeal joint of the hallux

Irreducible dorsal dislocation of the metatarsophalangeal joint of the hallux is a rare injury. A case is presented and the literature is reviewed, with emphasis on pathomechanics and treatment alternatives.

Plantar panmetatarsophalangeal dislocation--a hyperflexion injury

A rare panmetatarsophalangeal dislocation of the foot in a young male is described. Hyperflexion was instrumental in causing this injury. The dislocation was in the plantar direction.

Leg and foot injuries in racquet sports

Injuries to the lower extremity are common in racquet sports. The acute injuries usually respond well to treatment. Chronic injuries may require more patience and sometimes a change of playing habits on the part of the player. Some chronic injuries will respond well to operative intervention but most will do well with conservative care.

Dorsal dislocation of the first metatarso-phalangeal joint. A case report

A case of dorsal dislocation of the first metatarso-phalangeal joint is reported because it is a very unusual injury, and the literature is reviewed.

Problems of the second metatarsophalangeal joint

Diagnosis and treatment of second metatarsophalangeal joint problems are discussed. A new staging for Freiberg's disease is presented with differential treatment for each stage. Subluxation of the second metatarsophalangeal joint occurs commonly but is often unrecognized. A simple test in physical examination, the "positive Lachman" of the metatarsophalangeal joint is illustrated and explained. Although controversial, the etiology of synovitis of the second metatarsophalangeal joint is probably diverse; it can occur idiopathically or because of mechanical instabilities relating to malalignment of the first ray or disproportionate length of the second ray. When conservative treatment fails, surgical debridement of the joint is indicated. The second metatarsophalangeal is the most common chronically dislocated joint in the foot. The surgical goal is a reduced metatarsophalangeal joint and a stable toe. Surgical correction detailed by the authors involves a stepwise approach depending on the severity of the contracture, bony overlap, and deformity.

A new classification of first metatarsophalangeal joint dislocations (type I B)

Dorsal dislocation of the first metatarsophalangeal joint is a rare occurrence that has been infrequently reported in the podiatric literature. Two types of dislocations have been described. The authors review the mechanisms of injury and describe a third type of dislocation not yet reported in the literature.

Injuries to the metatarsophalangeal joints in athletes

Injury to the metatarsophalangeal joints in sports has become an increasing problem with the advent of more flexible shoewear and artificial playing surfaces. These injuries vary from mild sprains to severe tearing of the capsuloligamentous complex including avulsion fractures. This may include a compression fracture of the metatarsal head in the more severe cases. At the extreme, dislocation or fracture-dislocation of the metatarsophalangeal joint occurs. The findings in 62 cases of these injuries in Rice University athletes from 1971 to 1985 are presented. Treatment follows a standard regimen of ice, taping and anti-inflammatory medication with gradual return to sports activity as symptoms allow. Recommendations for preventive therapy include stiffening the forefoot in athletic shoes or the use of an orthotic device. This should reduce the incidence of long-term sequelae.

[X-ray examination of foot injuries]

Fractures and luxations of the phalanges, metatarsus, tarsus and their joints are discussed. Correct radiological projections, knowledge of their pitfalls and a systematical interpretation are necessary for correct diagnosis.

Simultaneous open dislocation of the metatarsophalangeal and interphalangeal joints of the hallux: a case report

Simultaneous open dislocations of the hallux metatarsophalangeal and interphalangeal joints is previously unreported. Reducibility of the isolated metatarsophalangeal joint dislocation is often implied by the sesamoid separation and/or the existence of a sesamoid fracture. In the open dislocations of the metatarsophalangeal and interphalangeal joints of the hallux reported in this article, the ease of reduction is related instead to the severe disruption of the capsule.

Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment

Seventy-two patients with 76 fracture-dislocations of the Lisfranc tarsometatarsal joint complex were evaluated. Fifty-eight (81%) were polytrauma patients and the remainder suffered isolated injuries. Sixty of the original 72 patients were available for long-term study. Eight of these had an amputation at or shortly after the original admission, leaving 52 patients with 55 Lisfranc injuries for analysis. The average length of follow-up was 4.2 years (range, 20 months to 11 years). According to the Painful Foot Center scoring system, 27 feet (49%) achieved an excellent or good result and 28 (51%), a fair or poor result. Direct crush injuries did poorly with only one of eight scoring good or excellent. Of the various treatment modalities, open reduction and internal fixation with Kirschner wires yielded the best results. The major determinant of unacceptable results was identified as the quality of the initial reduction. Tarsal instability and late degenerative joint disease caused most of the symptoms. Twenty-three of the 52 patients (44%) have had or should have further mid-foot surgery to improve function and comfort. Because our results were often poor, our present protocol includes closed or open reduction and Kirschner wire internal fixation. Displacement greater than 2 mm or a talometatarsal angle greater than 15 degrees on radiographs following a closed reduction mandates open reduction.

Arthroscopic surgery for osteochondral fractures of the proximal phalanx of the metacarpophalangeal and metatarsophalangeal (fetlock) joints in horses

Arthroscopic surgery for osteochondral fractures of the proximal phalanx was performed on 74 fetlock joints of 63 horses for a total of 87 fractures during a 2-year period. The medial dorsal proximal aspect of the proximal phalanx of the forelimbs was most commonly involved (59 fractures), followed by the lateral aspect (26 fractures), and 2 fractures occurred in the fetlock joint of the right hindlimb. At surgery, 82 fragments were removed and 5 fragments that had healed or were embedded in the joint capsule were not removed. Of the fragments removed, 15 were fixed firmly to the proximal phalanx, 63 were easily movable by arthroscopic instruments (but had soft tissue attachments to the proximal phalanx), and 4 were floating free within the joint. Arthroscopic surgery allowed excellent visualization and appreciation of the attachments of fragments and their stage of healing. Horses returned to full race training at an average of 11 1/2 weeks (range, 6 to 24 weeks). Thirty eight of 46 horses (82.6%) with adequate postoperative follow-up returned to athletic performance at least equal to that before fetlock injury.

Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes

Over a period of 11 years 15 cases of stress fractures of the sesamoid bones of the first metatarsophalangeal (MTP) joint were treated in athletes. The mean age of the patients was 22.3 years, and there were 9 males and 6 females in the series. All patients were athletes, who began to suffer from the symptoms during training without any trauma. Eight fractures were located in the medial, six in the lateral sesamoid bone, and in one case both sesamoids were affected. The diagnosis was performed on the basis of the history, symptoms, clinical examination, and radiological, or isotope scanning findings. Ten of the patients were treated conservatively by prescribing an avoidance of excessive physical activity and better training shoes. In five cases surgical excision of the fragmented painful sesamoid bone was performed. There were no complications in the series and the athletes could start gradually training 6-8 weeks after the operation. The histology showed fibrotic non-union at the fracture site and supported the diagnosis of stress fracture. Three of the conservatively treated athletes had mild symptoms in intensive training, others had a good end result.

Pedal dislocations. An overview

Identification of the mechanism of injury is the hallmark of dislocation management. If the mechanism can be established by history, anatomic disruptions can be logically explained and identified. Conversely, the injury pattern clinically may help deduce the mechanism. Once the mechanism is established, either historically or clinically, relocation maneuvers can be planned and executed. A review of pedal dislocations has been presented with emphasis on anatomic relationships and mechanism of injury. These principles encompass diagnosis, treatment, and management. They must be understood to manage not only the acute emergency situation but the chronic disability of post-traumatic arthritis.