Turf Toe Injury: A Pictorial Review and a Didactic Case Report

Hyperextension of the first metatarsophalangeal joint can lead to a turf toe injury of the plantar plate complex, resulting in significant morbidity for athletes. This article reviews the anatomy, pathophysiology, classification, and imaging findings of turf toe injuries. In turf toe trauma, many different structures can be injured, with the sesamoid-phalangeal ligaments the most common. Diagnosis, classification, and treatment options rely on clinical evaluation and specific magnetic resonance imaging findings. It is vital for radiologists to understand the anatomy, pathophysiology, and imaging findings of turf toe injuries to ensure an accurate diagnosis and appropriate management.

Paediatric sand toe: radiographic, ultrasound and MRI findings of dorsomedial capsular injury

Hyperflexion injury to the metatarsophalangeal joint of the great toe, referred to as sand toe, can cause significant functional impairment. To our knowledge, there have been no radiological descriptions of this injury in the paediatric age group. Here, we report radiographic, sonographic and MRI findings in a male paediatric patient who sustained a sand toe injury, highlighting structural damage to the dorsomedial capsule and medial sagittal band, and discuss sand toe's favourable prognosis with conservative management.

Grade III Turf Toe Injury in a Cowboy

Turf toe injuries are common, particularly in athletes competing on artificial turf. This debilitating injury and its associated sequelae can affect the long-term performance of athletes and others. In this case is presented an atypical cause for development of grade III turf toe. This case presents an acute injury with significant damage to the plantar first metatarsophalangeal joint, with plantar plate rupture and tibial sesamoid retraction secondary to injury involving working calves on a ranch. The anatomy, mechanism, and associated treatments are reviewed. The anatomical and functional interplay with this injury is discussed.

First Metatarsophalangeal Joint Pain in Athletes: Diagnosis, Management, and Return to Play Considerations

ABSTRACT

The first metatarsal-phalangeal joint plays a key role for athletes of various disciplines. When an athlete presents for evaluation of pain at this joint, there are several causes that should be considered. The purpose of this article is to review common injuries including turf toe, sand toe, extensor and flexor hallucis longus tendinopathy, sesamoiditis, and metatarsalgia and provide current evidence-based recommendations for diagnosis, management, and return to play considerations. Conditions not specific to athletes like gout and hallux rigidus also are discussed. Mechanism of injury, physical examination, and imaging such as weight-bearing radiographs and point-of-care ultrasound can help with diagnosis. Treatment of many of these injuries begins with nonsurgical management strategies including footwear or activity modification, physical therapy, and select interventions.

Results of a shuttle catheter technique for surgical repair of acute extensor hallucis longus tears

Background and study aims

The proximal end of a torn Extensor hallucis longus (EHL) is usually so retracted that a proximal wound extension is always required to retrieve it; leading to more adhesions and stiffness. This study aims at assessment of a novel technique for proximal stump retrieval and repair of acute EHL injuries with no need for wound extension.

Material and methods

Thirteen patients with acute EHL tendon injuries at zones III, IV were prospectively included in our series. Patients with underlining bony injuries, chronic tendon injuries and previous nearby skin lesions were excluded. Dual Incision Shuttle Catheter (DISC) technique was applied with subsequent evaluation by the American Orthopedic Foot and Ankle Society (AOFAS) hallux scale, Lipscomb and Kelly score, range of motion and muscle power.

Results

Dorsiflexion at the metatarsophalangeal (MTP) joint significantly improved from a mean of 38.4±6.2º at one month to 58±9.6º at three months to 78.8±3.1º at one year postoperatively (P=0.0004). Plantar flexion at MTP joint significantly inclined from 16±3.8º at 3 months to 30.6±7.8º at the last follow-up (P=0.006). The big toe dorsiflexion power surged from 6.1±0.9N to 11.1±2.5N to 19.7±3.4N at 1 month, 3 months and one-year follow-up periods respectively (P=0.013). As per the AOFAS hallux scale, pain score was 40 of 40 points. The mean functional capability score was 43.7 out of 45 points. On Lipscomb and Kelly scale, all were graded "good" except for one patient who was graded "fair".

Conclusion

Dual Incision Shuttle Catheter (DISC) technique represents a reliable method for repair of acute EHL injury at zones III, IV.

Alternative treatment for varus instability of the hallux interphalangeal joint: A case report

Forefoot injuries are commonly caused by sport-related activities and are often around the metatarsophalangeal joints. The hallux interphalangeal (IP) joint is anatomically stable; therefore, injuries to this joint are considered to be rare compared with those to the metatarsophalangeal joint. Instability of the hallux IP joint has rarely been reported in barefoot contact sports, and its treatment has not been sufficiently explored.This study investigated chronic varus instability of the hallux IP joint. We performed a surgical reconstruction owing to conservative treatment failure. A good surgical outcome was achieved by reconstruction of the collateral ligament using the 4th extensor tendon-a promising alternative treatment option for this type of injury. This method indicated no morbidity outside the site of surgery and was more cost-effective than reconstruction using an allograft.

A Viable Osteochondral Allograft for Articular Cartilage Replacement of the First Metatarsal Head — A Case Series

Few reports in the literature have described the use of an osteochondral allograft for the treatment of articular cartilage damage of the 1st metatarsal phalangeal joint. We present here the clinical outcomes and detailed surgical technique of four cases in which we used a cryopreserved, viable, osteochondral allograft (CVOCA) for full cartilage replacement of the first metatarsal head to address degenerative articular cartilage damage. At 10-22 months of follow-up, patients reported clinical improvement, with VAS pain-scale scores decreasing from an average of 8.0 to 0 post-operatively, and range-of-motion improvement from an average of 4.3 degrees to 58.3 degrees dorsiflexion. Radiographic improvement was also seen, with an increase in average joint space from 1.1mm, 1.5mm, and 2.2mm from medial to lateral on dorsoplantar views pre-operatively, to 3.1mm, 2.8mm, and 3.1mm 15 months post-operatively, respectively. These results suggest that CVOCA is a desirable treatment option for end-stage degenerative joint disease of the first metatarsal phalangeal joint.

[Treatment of the injury of the plantar plate on the second metatarsophalangeal joint with dorsal approach and Weil osteotomy]

OBJECTIVE

To evaluate the clinical results of dorsal approach and Weil osteotomy in treating the injury of the plantar plate in second metatarsophalangeal joint.

METHODS

Eight feet with plantar plate tear in five cases were treated by plantar plate repairment through dorsal approach and Weil osteotomy from June 2012 to December 2013. The mean age of the patients was 52 years old. All the patients were followed up for 6 to 12 months. American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) were used to evaluate the clinical effect.

RESULTS

The second metatarsophalangeal joint stability recovered and the pain released in all patients. Postoperative VAS was lower and AOFAS was higher than preoperative.

CONCLUSION

Combined dorsal approach and Weil osteotomy can effectively release the pian of plantar plate, stabilize the metatarsophalangeal joint, decrease the incidence rate of postoperative subluxation and anchylosis in treating plantar plate tears in the second metatarsophalangeal joint.

A variant neglected Type IIIA dorsal dislocation of first metatarsophalangeal joint. A case report

We present a rare injury consisting of a neglected, irreducible, dislocation of the first metatarsophalangeal joint that was diagnosed 4 months after the injury. An open reduction was necessary from the beginning. Patient returned to full activity without pain or disability, so a good prognosis despite the delayed diagnosis was achieved. We are unaware of previous reports in the literature describing this unusual variant.

Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables

Although metatarsophalangeal (MTP) plantar plate tears are common, they are still often missed. The purpose of this study is to find the best clinical variables to define and grade the plantar plate injuries. Sixty-eight patients (100 MTP joints) were graded arthroscopically and divided into five groups (0 to IV) according to the anatomical classification. Their medical records were reviewed to establish correlations of clinical findings with the anatomical lesions. The positive correlations found were acute pain, widening of the interdigital space, loss of ground touch, positivity of the MTP joint drawer test, reduction of the toe purchase, and toe supination. The drawer test is the most reliable and accurate tool to classify and grade the plantar plate lesion, followed by ground touch and rotational deformities. It is possible to improve the accuracy of diagnosis of plantar plate tears by means of the combination of both clinical history and physical examination data.

[Surgical repair of chronic tears of the second plantar plate]

OBJECTIVE

To explore the operative methods and the short-term effectiveness to repair chronic tears of the 2nd plantar plate.

METHODS

Between June 2012 and June 2013, 14 patients with chronic tears of the 2nd plantar plate were treated. There were 4 males and 10 females with an average age of 65.9 years (range, 51-82 years) and with an average disease duration of 6.2 years (range, 5-9 years). The left side was involved in 5 cases and the right side in 9 cases. One patient had simple hammer toe; 2 patients had hallux valgus and claw toe; and 11 patients had hallux valgus and hammer toes. All of them had unstable the 2nd metatarsophalangeal joints. The results of modified Lachman test and drawer test were positive. The surgical treatment included a Weil osteotomy and plantar plate repair operation for rupture via dorsal incision after correcting hallux valgus.

RESULTS

Primary healing of incision was obtained in all patients. Twelve patients were followed up 6-12 months (mean, 8.2 months). Hallux valgus, claw toe, and hammer toe were all corrected. The results of modified Lachman test and drawer test were negative at 3 months after operation. Mild pain of the 2nd metatarsophalangeal joint occurred, but no stiff was observed in 2 cases at 6 months after operation. The midfoot and forefoot score of American Orthopedic Foot and Ankle Society (AOFAS) was 90.50 +/- 3.73 at last follow-up, which was significantly higher (t=21.724, P=0.000) than preoperative score (57.33 +/- 4.99).

CONCLUSION

The plantar plate is the key to maintain the stability of the metatarsophalangeal joints, and surgical repair can achieve good short-term effectiveness in treating chronic tears of the 2nd plantar plate.

[Dislocation and necrosis of the first, second and third wedges. Management with the Masquelet technique. A case report]

The induced membrane technique was first described by Masquelet in 1986. It was initially used for the reconstruction of long bone shaft defects, particularly of the femur and tibia. The technique consists of two stages. During the first stage a membrane is induced to provide support to the grafts and supply growth factors that contribute to provide a favorable receiving bed for the future graft. During the second stage the poly-methyl-methacrylate spacer is removed and replaced with bone grafts, usually harvested from the iliac crest. Given that this technique has proven good results, it started to be used at other bone sites. We present herein the case of a patient with a large bone defect in the midfoot in whom the Masquelet technique was used with iliac crest grafts. Arthrodesis with a distal radius plate was performed to improve medial column stability, with favorable clinical and functional results.

Pull-out technique for plantar plate repair of the metatarsophalangeal joint

Plantar plate rupture is a common cause of forefoot pain, multiplanar malalignment, subluxation, or dislocation of the metatarsophalangeal joint (MTPJ). The treatments that have been described for MTPJ instability of lesser toes include amputation, lengthening and/or tendon transfer, periarticular soft-tissue release (capsule, collateral ligaments, and plantar plate), colateral ligament reconstruction, metatarsal shortening osteotomy, and suture of plantar plate lesion. This article outlines the anatomy, pathogenesis, and diagnosis of plantar plate rupture, and describes a new technique that combines joint decompression by Weil osteotomy with a plantar plate repair using a pull-out technique.

Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes

Sprains of the first metatarsophalangeal (MTP) joint, referred to colloquially as "turf toe," are a debilitating sports injury because the hallux is pivotal to an athletes' ability to accelerate and cut. Severe sprains may require weeks to full recovery, and injuries requiring surgery may prevent an athlete from full athletic participation for months. Whereas the diagnosis and treatment of turf toe are well documented in the literature, less is known about the biomechanics of this joint and the mechanical properties of the structures that compose it. Nevertheless, this information is vital to those, such as equipment designers, who attempt to develop athletic footwear and surfaces intended to reduce the likelihood of injury. To that end, this review summarizes the literature on the anatomy of the first MTP joint, on biomechanical studies of the first MTP joint, and on the incidence, mechanisms, and treatment of turf toe. Furthermore, gaps in the literature are identified and opportunities for future research are discussed. Only through a thorough synthesis of the anatomic, biomechanical, and clinical knowledge regarding first MTP joint sprains can appropriate countermeasures be designed to reduce the prevalence and severity of these injuries.

[Diagnosis and surgical treatment of tarsometatarsal joint complex injuries]

OBJECTIVE

To explore the diagnosis and surgical treatment of tarsometatarsal joint complex injuries.

METHODS

Between January 2000 and October 2009, 24 cases of tarsometatarsal joint complex injuries were treated. There were 14 males and 10 females with an average age of 38 years (range, 21-65 years). Injury was caused by a machine in 8 cases, by traffic accident in 12 cases, and by falling from height in 4 cases. All fractures were closed. The time from injury to hospitalization was 2-17 hours (5 hours on average). Open reduction and internal fixation with screw were performed.

RESULTS

Incision healed by first intention in other patients except 1 patient who had effusion at incision. Twenty-three cases were followed up 12-47 months with an average of 23 months. X-ray films showed that all fractures healed after 9-15 weeks of operation (13 weeks on average). No complication was found, such as osteofascial compartment syndrome, nonunion infection, loosening or breakage of the internal fixator. According to Maryland scoring, the results were excellent in 7 cases, good in 8 cases, fair in 5 cases, and poor in 3 cases with an excellent and good rate of 65.2%.

CONCLUSION

Anatomical reduction and stable fixation are important for satisfying results in treating tarsometatarsal joint complex injuries.

[Arthrodesis of the first metatarsophalangeal joint using a spherical reamer and titanium compression staples--preliminary report]

BACKGROUND

The role of arthrodesis of the first metatarsophalangeal joint (MTP I) for the treatment of many primary foot problems or as a salvage procedure is an well accepted procedure. In this study, authors present the results of a surgical technique using spherical reaming and compression with two titanium staples in perpendicular planes to achieve fusion. Compression across arthrodesis site is achieved by difference in width between holes in drill guide and width of titanium staple.

MATERIALS AND METHODS

27 metatarsophalangeal joint arthrodeses were performed in 24 patients with different forefoot deformities. The average age of the patients was 53 years and average followup period was 28 months.

RESULTS

The authors obtained MTP I joint fusion in 26 treated feet within 6-12 weeks. The mean AOFAS score was 49 points preoperatively and increased to 76 points at last followup.

CONCLUSION

Arthrodesis of the first metatarsophalangeal joint with spherical reaming and fixation with two titanium compression staples placed in perpendicular planes is a valuable and reproducible procedure for achieving fusion in a majority of patients.

[Arthrodesis of the lisfranc joint as salvage procedure after trauma injury]

Dislocations and fractures of the tarsometatarsal joints (Lisfranc joint) are rare, often non properly diagnosed and treated. Lack of proper diagnosis and postponed operative treatment causes painful deformity of the foot. There are presented results of operative treatment in 6 patients (6 feet) with fracture/dislocation of the Lisfranc joint. In all of them arthrodesis as salavage procedure was performed. Age at the fracture/dislocation ranged from 13 to 58 years. After trauma no one was treated operatively. Injury was overlooked in 2 patients. Indications for arthrodesis were pain causing limping as well flattening and abduction deformity fo the foot. Arthrodesis was performed from 1 to 39 years after trauma. It was closing wedge resection of the Lisfranc joint, stabilization with Kischner wires for 6 weeks and below knee plaster cast for 3 months. Follow-up ranged from 14 to 52 months. Functional results in AOFAS scale ranged from 6 do 90 points (mean 63 points) of 100. Subjective results ranged from 1 to 8 points (mean 5.6 points) of 10. Two females were not satisfied with the results of treament.

Arthroscopic diagnosis and treatment of intra-articular insertional injuries of the suspensory ligament branches in 18 horses

REASONS FOR PERFORMING STUDY

Clinical association between the branches of insertion of the suspensory ligament (SL) and metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints has been reported. However, there has been no assessment of the lengths of the SL branches which are subsynovial with respect to the joints or reports of involvement of the MCP/MTP joints in injuries of the SL branches.

OBJECTIVES

To establish proportions of SL branches subsynovial with respect to the MCP/MTP joints and report clinical and arthroscopic findings in horses with desmitis of SL branches identified as having an articular component to the lesion.

HYPOTHESIS

Arthroscopic surgery enables identification and potential treatment of intra-articular injuries of SL branches.

METHODS

Twelve forelimbs and 13 hindlimbs were dissected and the total and subsynovial lengths of the SL branches recorded. Case records of horses with intra-articular injuries of the SL branches were reviewed and 18 animals identified. Diagnostic information and arthroscopic findings were recorded and results of treatment determined by telephone follow-up.

RESULTS

Of SL branches, 28.45% in the forelimb and 29.56% in the hindlimb were subsynovial to the MCP and MTP joints. All animals with intra-articular lesions of the SL branch were lame and had distension of the affected MCP/MTP joint. In 16 horses (17/22 branches), there was palpable thickening of the affected SL branch. Disrupted infrastructure was evident ultrasonographically in 15/17 branches and involvement of the dorsal articular surface of the ligament was predicted in 12/17 branches. Following arthroscopic intervention, 13 horses returned to work at a level equal to or greater than that achieved prior to injury and 2 returned to work at a lower level. Three horses incurred separate injuries and were retired or subjected to euthanasia.

CONCLUSIONS

Articular involvement should be considered in animals with injuries of an SL branch and concurrent distension of the MCP/MTP joint. Arthroscopy is necessary to identify such lesions confidently and to direct case management.

POTENTIAL RELEVANCE

Arthroscopy of the MCP/MTP joints can make a positive contribution to the assessment and management of some SL branch injuries.

Midfoot arthritis

Foot and ankle complaints are commonly encountered in orthopedic practice. Midfoot arthritis has the potential to cause a significant amount of pain and disability. A variety of conditions can cause or lead to midfoot arthritis. Treatment consists of either conservative management or surgical arthrodesis of the painful joints. In this article, we review the midfoot (its basic anatomy and biomechanics) and midfoot arthritis (its clinical presentation and etiology, radiographic evaluation, and treatment options).

Lisfranc injury: how frequently does it get missed? And how can we improve?

Lisfranc injuries are sometimes easily missed especially if they present in a subtle form. In this study, we have tried to measure the level of accuracy of plain radiographs in detecting this type of injury. We have selected 30 sets of foot radiographs with various diagnoses. Eighteen of them had a Lisfranc type of injury which was confirmed by operative findings or further imaging. These radiographs, together with a small diagnostic questionnaire, were presented to nine senior clinicians. We found that only 11 of the 18 cases (61%) were detected by all the readers. Eight of nine readers (90%) missed one particular case of subtle Lisfranc injury in a diabetic neuropathic foot. One case of a divergent injury was missed by five readers (56%). Another case with a coexistent Frieberg's disease was missed by three readers (33%). The mean accuracy for all injuries was 87% (95% confidence interval (CI) 84.6-89.9%). The mean accuracy level for detection of Lisfranc injury among the whole series was 92% (CI 89-95%). We think that the presence of a strong clinical index of suspicion or the presence of impaired pain sensation, further imaging is a must to avoid missing this type of injury at early presentation, and consequently the long term poor prognosis.

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.

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.