Traumatic Dislocation of All Four Lesser Metatarsophalangeal Joints. A Rare Case Presentation

Closed traumatic multiple dislocations of metatarsophalangeal joints (MTP) are uncommon injuries. In the majority of cases described in the literature, open reduction is the treatment for reduction of the dislocation due to the complex anatomy of MTP joints, preventing closed reduction of the affected joints. Our case report describes the dorsoradial dislocation of the second to fifth MTP joints of the left foot following a motor vehicle accident, which was treated by closed manipulation and reduction of the affected joints under anesthesia successfully without external Kirschner wire fixation. Post-reduction, the affected foot was immobilized in a below-knee posterior plaster slab with strapping of the toes for a total of four weeks. At 12 weeks follow-up, the patient had resumed pre-injury activities with a painless range of all lesser toe movements without any radiographic evidence of arthritis on subsequent follow-up at 06 months post-injury.

This case highlights that a proper closed manipulation and reduction under anaesthesia is worth trying before embarking on open reduction, as the results of closed reduction are excellent with less morbidity and risks associated with open reduction.

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Closed simultaneous dislocation of MTP joints are very unique and rare injury [1], which, if not managed in time, can have a detrimental effect on the patient’s weight bearing and gait in the future. Metatarsophalangeal joints (MTP) are synovial condyloid-type joints. They are important in the formation of the transverse arch of the foot, the terminal stance and pre-swing phase of the gait cycle and for flexion and extension of toes [2]. Anatomically, the stability of MTP joints is due to deep transverse metatarsal ligaments and the plantar plate, which is a dense fibrous thickening of the plantar capsule. The joints are relatively unprotected on the dorsal side, making dorsal dislocation more common. There are some reports of isolated dislocation of a single MTP joint described in literature [3-5] along with very few reports of all five MTP joints dislocations [6-8], all of which were treated by open reduction with Kirschner wire fixation. Only one case of traumatic dorsal dislocation of all five MTP joints to date has been described in the literature, which was treated successfully by closed reduction [9].

Our case is the second case that highlights the successful closed reduction of all four lesser dislocated MTP joints with gratifying results.

Case report

A 32-year-old male patient with no medical co-morbidity was brought to the emergency department of our hospital late at night following a motor vehicle accident with main complaints of trauma to the left foot and ankle, which was swollen with deformity of the lesser toes with associated painful attempted movements. Distal foot vascularity was intact with intact neurology. The medial aspect of the ankle was swollen with tenderness around the medial malleolus. Radiographs of the injured foot and ankle revealed dorsoradial dislocation of the lesser four toes at MTP joints with a unicortical crack seen in the ipsilateral medial malleolus (Figure 1).

Figure 1: Pre Reduction Anterio posterior and lateral views left foot showing MTP dislocations of the lesser toes.

The patient was admitted and, after a preliminary workup, was scheduled for closed / open reduction under anesthesia. He underwent closed manipulation and reduction under General anesthesia by simultaneous reverse mode of injury manipulation of all four toes to free any soft tissue impingement. The joints were stable and congruent after closed reduction without any need for K-wire stabilization (Figure 2). Post buddy toe operatively strapping with below-knee plaster of Paris posterior back slab was applied for immobilization of the foot in neutral position. Patient was kept non-weight bearing for 05 weeks, followed by progressive weight bearing as tolerated.

Figure 2: Immediate Post Closed Reduction of MTP dislocations of lesser toes, AP and lateral views of the left foot.

At 12 weeks (Figure 3), follow up patient was doing fine with full weight bearing and had returned to pre-injury level activities with good painless range of toe movements. The patient was followed for a period of 06 months post-injury without any complaints.

Figure 3: Follow-up radiographs of the left foot at 12 weeks of age.

1. De Palma L, Santucci A, Marinelli M. Traumatic dislocation of metatarsophalangeal joints: report of three different cases. Foot Ankle Surg. 2001;7:229–234. Available from: https://doi.org/10.1046/j.1460-9584.2001.00277.x
2. Raj S, Subramani S, Babar SJ, Balaji MSS, Anand V. Rare case report of closed traumatic dislocation of second to fifth metatarsophalangeal joints. Cureus. 2020;12(11):e11745. Available from: https://doi.org/10.7759/cureus.11745
3. Sharma A, Dosajh R, Bedi GS, Gupta K, Jain A. First and second metatarsophalangeal joint open dislocations: a case report. Malays Orthop J. 2017;11(1):71–73. Available from: https://doi.org/10.5704/moj.1703.010
4. Vasu P, Mitchell R, Pai V. Irreducible dislocation of the metatarsophalangeal joints of the foot: a case report. Foot Ankle Online J. 2008;1(5). Available from: https://faoj.org/2008/05/01/irreducible-dislocation-of-the-metatarsophalangeal-joints-of-the-foot-a-case-report/
5. Chou LC. Traumatic dislocations of the first and second metatarsophalangeal joints: a case report. J Med Health. 2015;4(1):127–131.
6. Concha JM, Gonzalez H, Concha C. Uncommon case of traumatic dislocation of all five metatarsophalangeal joints: results of treatment after 36 months. Foot Ankle Surg Tech Rep Cases. 2022;2:100141. Available from: https://doi.org/10.1016/j.fastrc.2021.100141
7. Masaaki M, Ken-ichi M, Shigenori T, Toshihiko Y. Dislocation of all metatarsophalangeal joints caused by horse injury. J Trauma Inj Infect Crit Care. 2007;63:938–939. Available from: https://doi.org/10.1097/01.ta.0000235280.94471.e9
8. Neogi DS, Bandekar SM, Sadekar V, Patnaik S, Bhat T, D'Mello Z. Irreducible dislocation of all the lesser metatarsophalangeal joints of the foot: a case report. Foot Ankle Spec. 2012. Available from: https://doi.org/10.1177/1938640012457940
9. Bhide PP, Anantharaman C, Mohan G, Raju K. A case of simultaneous traumatic dorsal dislocation of all five metatarsophalangeal joints treated successfully with closed reduction. J Foot Ankle Surg. 2016;55:423–426. Available from: https://doi.org/10.1053/j.jfas.2015.02.014
10. Stephenson KA, Beck TL, Richardson EG. Plantar dislocation of the metatarsophalangeal joint: case report. Foot Ankle Int. 1994;15:446–449. Available from: https://doi.org/10.1177/107110079401500809
11. Gale DW. Lateral dislocations of the first metatarsophalangeal joint: a radiographic indicator of reducibility. Injury. 1991;22:230. Available from: https://doi.org/10.1016/0020-1383(91)90048-j
12. Ito MM, Murase KI, Tanaka S, Yamashita T. Dislocation of all metatarsophalangeal joints caused by horse injury. J Trauma. 2007;63:938–939. Available from: https://doi.org/10.1097/01.ta.0000235280.94471.e9
13. Leung W, Wong S, Lam J, Ip F, Ko P. Presentation of a missed injury of a metatarsophalangeal joint dislocation in the lesser toes. J Trauma. 2001;50:1150–1152. Available from: https://doi.org/10.1097/00005373-200106000-00029