|Year : 2019 | Volume
| Issue : 2 | Page : 40-42
One-week-old irreducible hallucal interphalangeal joint dorsomedial dislocation due to an incarcerated sesamoid: A case report and its review of literature
Anurag Mittal1, Deepankar Verma1, Arunim Swarup2, Rajnand Kumar1, Rajat Kapoor3, Sourabh Rai1
1 Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
2 Department of Orthopaedics, Subharti Medical College, Meerut, Uttar Pradesh, India
3 Department of Orthopaedics, S. N. Medical College, Agra, Uttar Pradesh, India
|Date of Submission||04-Sep-2019|
|Date of Decision||06-Sep-2019|
|Date of Acceptance||09-Sep-2019|
|Date of Web Publication||21-Oct-2019|
Dr. Deepankar Verma
1139/1, Sector-3, Vasundhara, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Among the dislocations around the great toe, hallucal interphalangeal (IP) dislocation is a rare entity, with the most common being metatarsophalangeal dislocation due to its greater lever arm. We present the case of a young manual labourer with a missed hallucal IP joint dislocation with an incarcerated sesamoid, initially managed by an osteopath. After a failed attempt of closed reduction in the emergency department, we performed open reduction and reposition of sesamoid using dorsal incision and stabilized the joint with a K wire which was removed after 4 weeks. The patient was gradually mobilized and returned to his work of manual labor after 3 months without any residual pain or deformity.
Keywords: Hallucal interphalangeal dislocation, Miki classification, sesamoid
|How to cite this article:|
Mittal A, Verma D, Swarup A, Kumar R, Kapoor R, Rai S. One-week-old irreducible hallucal interphalangeal joint dorsomedial dislocation due to an incarcerated sesamoid: A case report and its review of literature. J Orthop Dis Traumatol 2019;2:40-2
|How to cite this URL:|
Mittal A, Verma D, Swarup A, Kumar R, Kapoor R, Rai S. One-week-old irreducible hallucal interphalangeal joint dorsomedial dislocation due to an incarcerated sesamoid: A case report and its review of literature. J Orthop Dis Traumatol [serial online] 2019 [cited 2020 Jan 29];2:40-2. Available from: http://www.jodt.org/text.asp?2019/2/2/40/269585
| Introduction|| |
Hallucal interphalangeal (IP) dislocation is a rare type of injury, and only few cases have been described in literature with varied presentation and multiple methods for its management. These types of dislocations are difficult to diagnose and are not readily reducible. However, most of the toe dislocations are at the level of metatarsophalangeal (MTP) joint due to its longer lever arm and greater mobility. We report the case of an 1-week-old irreducible hallucal IP joint dislocation and a review of literature in relation to this condition.
| Case Report|| |
We present the case of a 35-year-old manual labourer with the complaint of left great toe swelling and pain for 1 week [Figure 1]a. The patient was initially managed by an osteopath in a village where he was being treated conservatively. However, as the pain of the patient did not subside, he sought a specialist opinion and was diagnosed with IP dislocation of the left great toe associated with a wound over its plantar aspect [Figure 1]b. Plain radiography showed overlapping of the distal phalanx on the proximal phalanx and dorsal dislocation of the IP joint on the anteroposterior view. There was also an interposed sesamoid bone on the lateral view [Figure 2]. No fracture had been identified. Initially, closed reduction was attempted in the emergency department and then again in the operating room under digital block, but despite multiple attempts, the dislocation was irreducible. Incarceration of the sesamoid became a block to manipulation and reduction at the specialist outpatient clinic 1 week later. Subsequently, we did open reduction with a dorsal incision and extension slip splitting approach [Figure 3]. Intraoperatively, there was a sesamoid incarcerated between the proximal and distal phalanges which moved dorsally due to hyperextensive force to the great toe as evidenced by the lacerated wound over its plantar aspect [Figure 3]. The sesamoid was relocated; reduction of IP joint was achieved and stabilized with K wire as the reduction was unstable [Figure 4]. The joint was immobilized for 4 weeks, and the K wire was removed after 4 weeks. The patient regained full functional status; there was no residual disability, and 3 months post reduction, the patient is performing well and is back to his work of manual labour.
|Figure 1: (a) Clinical presentation. (b) Wound at plantar aspect (arrow)Figure 4: Postoperative radiographsFigure 3: (a) Dorsal incision. (b) Sesamoid interposed between proximal and distal phalanges (arrow). (c) Closure of wound|
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|Figure 3: (a) Dorsal incision. (b) Sesamoid interposed between proximal and distal phalanges (arrow). (c) Closure of wound|
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| Discussion|| |
Sesamoid is the term derived from sesame seeds (Sesamum indicum). The term was given by Galen in AD 180. The size of sesamoid can vary from 0.5 to 1 cm. There is still a controversy, whether it is a rudimentary structure, accessory ossicle, pressure-induced reactive bone formation or a true sesamoid. Sesamoids are generally present within the tendons, but it is unclear whether they are present in flexor halluces longus tendon. One theory suggests that sesamoid is a rudiment of “lost” middle phalanx of the great toe. It is rare to find, present in only 56% of population. Radiographic interpretation of sesamoid is difficult as its radiological appearance varies from 4.3% to 93% according to literature. The sesamoid is bilateral in around 94% of population as seen in cadaveric studies. It has two surfaces. The dorsal surface is articular having two facets and articulating with proximal phalanx. The plantar surface is nonarticular and is firmly embedded in the plantar capsule of IP joint, commonly known as volar plate. It can range from mild hyperkeratotic plantar lesions to irreducible dislocation of IP joint of the great toe.
Most of the dislocations around the great toe commonly occur at MTP joint as it has greater mobility and a longer lever arm. Hallucal IP dislocation is a very rare injury as IP joint is firmly stabilized by volar plate, collateral ligaments, and flexor and extensor tendons. These structures limit passive hyperextension beyond 20° at the great toe IP joint, as demonstrated by Miki et al.
Mechanism of injury
Sesamoid occurs commonly in sportspersons or military trainees who train on mats and whose foot gets stuck in between the mats. Jones et al. reported two cases of open dorsomedial hallucal IP joint dislocation in military personnel during combat training on mats. The most common mechanism of injury is hyperextensive force and axial loading on the great toe. Due to hyperextensive injury, there can be laceration in the plantar aspect of the great toe as seen in our case [Figure 1]b. The injury can be open or closed and can be reducible or irreducible. Irreducibility is due to accessory sesamoid or due to volar plate incarceration. Intact collateral ligaments help keep the distal phalanx locked in the dislocated position. Dislocation can be pure dorsal, dorsomedial, or dorsolateral.
Based on radiographic and clinical findings, Miki described two types of irreducible hallucal IP dislocation. In Miki type 1, the volar plate is ruptured and displaced into the IP joint space. In this, the toe is slightly elongated, but the deformity of the toe is not so marked. In Miki type 2, where the volar plate is completely displaced over the proximal phalangeal neck, the deformity of the toe is extreme as the IP joint is locked in hyperextension due to an interposed sesamoid that tightens the collateral ligament. In the former type, the dislocation is often misinterpreted to have been repositioned manually because of relatively slight deformity. In either type of dislocation, the volar plate is detached from both the distal and proximal phalanges, and so displaced into the joint, so as to form a barrier to manual repositioning. Tight collateral ligament and swelling makes closed reduction difficult. However, an attempt of closed reduction should be made prior to operative intervention. If pain persists and the movements are restricted after an attempt of closed reduction, then it indicates the possibility of sesamoid bone interposition and unreduced IP joint. Open reduction may be required if there is presence of sesamoid on the dorsum of proximal phalanx.
Closed manipulation can reduce such dislocations satisfactorily, although reported only in few cases. Therefore, frequently, open reduction is needed. The recommended treatment for sesamoid interposition is a trial of closed manipulation and reduction. Open reduction is performed for failure of closed reduction.
Different approaches have been described in literature by different authors according to the dislocation type and surgeon's preference. Dorsal,, medial,, plantar and dorsal, and dorsolateral with division of extensor tendon are the approaches that can be used. Crosby et al. used medial approach for a dorsomedial IP dislocation. None of the approaches described is superior to other. Extensor tendon division provides a better exposure but it needs to be repaired after reduction. The offending volar plate can be removed or its origin and insertion can be repaired. However, an additional plantar incision (which can lead to painful hyperkeratotic scar over weight-bearing area) would be required for repairing the volar plate and moreover, it is technically demanding. Hence, most of the authors avoid repairing it as the joint is stabilized by collateral ligaments after reduction. Reduction can be further stabilized by the use of buddy strapping, bulky dressing,, K wires, short leg cast,, or a combination of these. 3–4 weeks of immobilization is recommended.,, In most of the literatures, there is no significant morbidity with the open reduction. Hatori et al. reported a case of neglected great toe IP joint dislocation which was managed with arthrodesis after 4 years of injury.
| Conclusion|| |
Dislocation of IP joint of the great toe is an uncommon entity due to its inherent stability. There should be a high index of suspicion for its diagnosis due to its subtle clinical signs. Close reduction is often difficult due to incarcerated sesamoid or ruptured volar plate but is possible in acute settings. Open reduction and fixation with K wire is commonly required, but neglected dislocation may have to be treated with open reduction and arthrodesis of IP joint for painless great toe.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]