Melody Stouder

Class of 2014
TUSPM
 Anatomy

 Mechanism

 Classification

 Clinically

 Diagnostictools
 Closed reduction

 Open reduction

 Cases
 Intrinsics:Abductor hallucis, adductor hallucis, FHB, EHB
 Extrinsics: FHL, EHL
 Sesamoid apparatus: embedded
within fibrous plantar plate
 Intersesamoidal
ligament(1)
 Phalangeosesamoidal ligaments(2)

 Metatarsosesamoidal ligaments(2)
 (suspensory)
 Collateral ligaments (2)
 DTML

Sarrafian, S.K. Syndesmology, ch. 4. In Anatomy of the foot and Ankle, 2nd ed. pp/211-212, edited by D. Patterson, M.E.
Dickmeyer, and E.A. Durang, J.B. Lippincot and Co., Philadelphia, 1993.
 High energy
 Forced hyperextension of 1st MPJ
 Axial loading of midfoot/rearfoot

 Met head pushes through plantar plate

 Slips between FHB heads

(Brunet 1996)
  Type I: hallux dislocates dorsally
 Sesamoid complex is intact*
 “buttonholing of the met head”

 A rare injury (0.008%)

 Usually irreducible

Jahss, MH. Classic article: foot & ankle 1: 15, 1980 traumatic dislocations of the first
metatarsophalangeal joint. Foot Ankle Int. 2006 Jun;27(6):401-6
 Theory:type 1 requires open reduction
 <20 reported in last 80 years

 According to Brunet:
 11 type 1 dislocations
 5/11 cases closed reduced effectively
 Type 2a:
 dorsal dislocation and rupture of intersesamoidal ligament
 Easier to reduce
 Type 2b:
 Dislocation of hallux with transverse fracture of a sesamoid
 (ligament intact)
 Type 2c=combo of A and B
 Disruption of intersesamoidal ligament AND fracture of a
sesamoid
 Type 3:
 Sesamoids maintain anatomical
position
 Intact plantar plate
 Complete rupture of medial +
lateral phalangeal sesamoidal
ligaments
 Hallux sits dorsally
 Dimple sign medially

 Taut skin plantarly

 Shortening of 1st ray

 Edema, ecchymosis
 Hyperextend proximal phalanx
 Distract

 Dorsiflex the met head AND plantarflex the phalanx

(Killian 1997)

http://www.youtube.com/watch?v=mTaBd_8RkGY
 According to Sikka et al: (F&A INT 2012)
 Closed reduction with splinting and immobilization 3-4 weeks
 Early, active + passive ROM after one week

 PT: stretching, active/passive ROM, ultrasound, whirlpool

Early ROM->decrease risk of arthrofibrosis!

 For athletes:
 Phase 1(days 1-3): Early Protection
 NWB crutches and CAM
 Phase 2(day 3-4 weeks): Activity progression
 PWB with CAM
 Phase 3(week 5-6): Return to sport
 Throughout: active/passive ROM, ultrasound, compression
wraps/taping, ice.

 19 y/o division 1A footballer->returned to practice at 6 weeks

 Tearing of plantar
plate
 Torn ligaments
 Collaterals,
metatarsosesamoidal, phalangeosesamoidal,
intersesamoidal
 Strain of tendons
 Abductor hallucis
 Adductor hallucis

 FHB
Allows for pre-op planning by
providing adequate
visualization of damaged
anatomical structures
 Indications:
 Failed closed reduction*
 Continued instability of 1st MPJ*
 Interpositioned soft tissue
 Ruptured plantar plate/tendons

 Overall depends on severity

 (Sikka 2012)
 Medial approach

 Dorso-lateral

 Plantar approach: only if lesion already exists!!!

 can cause damage to medial plantar digital nerve
 Increase plantar sensitivity and pain
 Reduce sesamoid apparatus
 Re-align joint

 Restore 1st ray length

 Sesamoid fracture:
 Remove small fracture fragments
 Re-approximate tendon to sesamoid with 1.5mm
wire pass drill and suture(Good 2001)
 1.5mm cortical screw? (Isefuku, Hatori, Kurata 2007)
 Soft tissue:
 Repair plantar plate: 2-0 fiberwire in figure-eight
stitch(Sikka 2012)
 Repair collaterals
 Bone anchored sutures(Lomax 2013)
 Torn tendons: suture
 Athroplasty of proximal phalanx base (Jahss 1980)
 Fixation: 0.062” k wire (if instability remains)
 Post OP: NWB for 4 weeks
 Decreased ROM due to partial joint ankylosis**
 Denuding of articular surfaces
 Peri-articular soft tissue disruptions and scarring

 Sensitive
plantar scars
 Sesamoid tenderness

 Brunet 1996
 29y/o male dislocated hallux
during martial art of jujitsu
 Closed reduction failed

 2b Jahss

Lomax, Miller, Kumar. Isolated Plantar Dislocation of the 1st

Metatarsophalangeal Joint: a case report. Foot (2013),
http://dx Doi.org/10.1016/j.foot.2013.08.001
 EHB relocated dorsally: re-tensioned
 with suture
 LCL ruptured: re-attached with bone

 anchored sutures
 Capsule repaired with suture

 12 weeks: pain free, full ROM

 46 y/o old woman in
MVA with dorsally
dislocated right hallux
 Plantar incisional approach used
 Fibular sesamoid removed

 Capsule/Intersesamoidal ligament

repaired
NWB 3 weeks
- 0.062” k wire
Summary
Attempt closed reduction

Successful Unsuccessful

Open Reduction

NWB 3-4 weeks

PT/ROM exercises

Sesamoid Complex re-approximated

1st MPJ anatomically aligned
Pain free, full ROM
Brunet, Jacques. Pathomechanics of Complex Dislocations of the First Metatarsophalangeal Joint. CORR 332: 126-131, 1996.
Good, Weinfeld, Yu. Fracture-Dislocation of the First Metatarsophalangeal Joint: Open Reduction Through a Medial Incisional
Approach. JFAS 40(5): 311-317, 2001.
Jahss, MH. Classic article: foot & ankle 1: 15, 1980 traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle
Int. 2006 Jun;27(6):401-6
Lomax, Miller, Kumar. Isolated Plantar Dislocation of the 1st Metatarsophalangeal Joint: a case report. Foot (2013), http://dx
Doi.org/10.1016/j.foot.2013.08.001
Killian, Carpenter, Mostone. Dorsal Dislocation of the First Metatarsophalangeal Joint. JFAS 36(2): 131-135, 1997.
Maglaya, Cook, Zarazour et al. Return to Division IA Football Following a 1st Metatarsophalangeal Joint Dorsal Dislocation: a
case report. NAJSPT 5(3): 131-141, 2010.
Sarrafian, S.K. Syndesmology, ch. 4. In Anatomy of the foot and Ankle, 2nd ed. pp/211-212, edited by D. Patterson, M.E.
Dickmeyer, and E.A. Durang, J.B. Lippincot and Co., Philadelphia, 1993.
Sikka, Hunkele, Sugarman et al. Dorsal Dislocation of the Great Toe in a Professional Football Player: Case Report. FAI 33(9):
798-802, 2012.
Tosun, Akansel, Sarlak. Traumatic Dislocation of the First Metatarsophalangeal Joint with Entrapment of the
Flexor Hallucis Longus Tendon. JFAS 47(4): 357-361, 2008.
Trikha, Khatri, Singh, et al. Complex Dislocation of the First Metatarsophalangeal Joint. Chinese J of Trauma 12(5): 318-320,
2009.
Van Pelt M., Brown D., Doyle J. et al. First Metatarsophalangeal Joint Dislocation With Open Fracture of Tibial and Fibular
Sesamoids. JFAS 46(2): 124-129, 2007.