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Complex dislocation of the first metatarsophalangeal joint.

A thirty-two-year old male presented himself in our emergency department with pain and swelling in the MTP region of the left foot. He had suffered a motorbike accident but had no other injuries. On examination, the head of the first metatarsal joint was prominent on the plantar aspect of the foot. The great toe appeared to be dorsally placed with apparent shortening of the first ray (Figs. 1A and 1B). There was a transverse laceration on the plantar aspect of the great toe, but no neurovascular deficit was found. Radiographs revealed dorsal dislocation of the first MTP joint. The sesamoids were displaced dorsally with plantarflexion of the first metatarsal. There was also an undisplaced fracture of the second metatarsal neck (Figs. 2A, 2B and 2C). Immediate closed reduction was attempted under local anaesthesia. Despite several attempts, reduction was not achieved. Therefore, the patient was taken up for reduction under general anaesthesia. Close reduction was again attempted, but it was still unsuccessful. An open reduction was then planned. A dorsal longitudinal incision was made in the first web space and branches of the deep peroneal nerve were carefully isolated. The two sesamoids, the intersesamoid ligament and the volar part of the capsule, were seen lying dorsally to the neck of the first metatarsal which was plantarflexed. The volar plate and the intersesamoid ligament were intact as the conjoint tendons of the various muscles were. Traction along the axis of the first ray caused further tightening of the buttonholed first metatarsal, which led to the irreducibility of the dislocation. The deep metatarsal ligament extending from the second metatarsal to the conjoint tendon was then cut and tagged. Now the sesamoid complex was lax and the metatarsal could be reflected dorsally with the sesamoid complex reverting back to its original plantar position. After reduction, the stability and the range of movement (ROM) were checked and found to be satisfactory. The length of the first ray also appeared to be restored (Fig.3). The deep transverse ligament was repaired and the wound was closed in layers. For additional stability, fixation of the MTP joint was performed with a Kirschner wire and a below knee cast was applied. The wire and the cast were removed after four weeks and weightbearing exercises started. One year after injury, the patient was asymptomatic and had full ROM of the MTP joint.