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Floating first metatarsal: A rare injury

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A case of concomitant Lisfranc dislocation and metatarsophalangeal dislocation of the hallux is rare. This is usually associated with high velocity trauma. The compound metatarsophalangeal dislocation …

A case of concomitant Lisfranc dislocation and metatarsophalangeal dislocation of the hallux is rare. This is usually associated with high velocity trauma. The compound metatarsophalangeal dislocation with fracture of proximal phalanx and closed dislocation of cuneometatarsal joint dislocation had not been reported in literature. This is the first case of floating metatarsal with fracture proximal phalanx described in the literature. We report an unusual case of concomitant tarsometatarsal (Lisfranc) and 1st metatarsophalangeal (MTP) joint dislocations and fracture of the base of proximal phalanx of the great toe.

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  • 1. Floating first metatarsal: A rare injury
  • 2. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e2 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Case Report Floating first metatarsal: A rare injury Pankaj Kumar* Consultant Orthopaedic Surgeon, Apollo Reach Hospital, Karimnagar, Andhra Pradesh 505001, India article info abstract Article history: We are presenting a case of floating first metatarsal, its consequence, management Received 26 September 2012 guideline and results. Accepted 17 May 2013 Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. Available online xxx Keywords: Floating First metatarsal Management 1. Introduction A case of concomitant Lisfranc dislocation and metatarsophalangeal dislocation of the hallux is rare.1,2 This is usually associated with high velocity trauma. The compound metatarsophalangeal dislocation with fracture of proximal phalanx and closed dislocation of cuneometatarsal joint dislocation had not been reported in literature. This is the first case of floating metatarsal with fracture proximal phalanx described in the literature. We report an unusual case of concomitant tarsometatarsal (Lisfranc) and 1st metatarsophalangeal (MTP) joint dislocations and fracture of the base of proximal phalanx of the great toe. multiple stone chips were attached with clotted blood and multiple abrasions on ipsilateral thigh. On X-ray examination there was compound dislocation of first metatarsophalangeal joint with fracture of base of proximal phalanx of great toe along with dislocation tarsometatarsal joint (Fig.1). After wound debridement first fixation of metatarsophalangeal joint with Kwire and open reduction of tarsometatarsal joint and fixation of first metatarsal with second metatarsal transversally with Kwire (Fig.2). K-wire was removed after 6 weeks of injury. We follow the patients for one year; there was mild pain metatarsophalangeal joint while prolonged walking. 3. 2. Case report A 40 years drunken young male hit by bus while walking on side of road. He sustained injury to right thigh and ipsilateral foot. He reported to our emergency department within 4 h of injury. There was lacerated wound of about 0.5 cm  0.5 cm around first metatarsophalangeal joint on dorsal aspect and associated with Discussion The anatomy of the IP joint of the great toe is not complex. At the dorsal aspect, the tendon of extensor hallucis longus crosses the joint and inserts into the distal phalanx. There are two strong collateral ligaments on either side to provide mediolateral stability. The tendon of flexor hallucis longus runs over the joint on the plantar surface and inserts into the distal phalanx. The stability of the plantar surface is * Tel.: þ91 9618123678. E-mail addresses: drpankaj06@yahoo.co.in, drpankaj06@gmail.com. 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.05.018 Please cite this article in press as: Kumar P, Floating first metatarsal: A rare injury, Apollo Medicine (2013), http://dx.doi.org/ 10.1016/j.apme.2013.05.018
  • 3. 2 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e2 Fig. 1 e Fracture base of proximal phalanx with subluxation of metatarsophalangeal and metatarsocuneiform joint. very classical. Occasionally the reducibility of the metatarsophalangeal joint may be made more difficult by the interposition of a sesamoid bone.2 It is also imperative to adapt the order of reductions to the presumed tension on the plantar fascia. Open reduction on the proximal side and closed reduction on the distal side, in addition to internal fixation proximally and distally, gave good results. The reduction and stabilization of a “floating” first metatarsal should begin at the distal (metatarsophalangeal) end. The reduction of the distal dislocation will release tension on the plantar fascia, enabling the subsequent reduction of the proximal (Lisfranc) dislocation. A medial approach is convenient, affords easy access to the plantar and dorsal aspects of the joint, and repair of the medial joint structures when damaged. When examining patients with Lisfranc joint injuries, one should explore carefully the metatarsophalangeal joints. 4. Conclusion When examining patients with Lisfranc joint injuries, one must keep in mind that the axial compression forces causing the injury may also damage the metatarsophalangeal joints, and direct attention to these structures. Open reduction proximal and distally, gave good results in this case. Occasionally the reducibility of the metatarsophalangeal joint may be made more difficult by the interposition of a sesamoid bone. Conflicts of interest The author has none to declare. references Fig. 2 e Fixation with K-wire with reduction both the joints. augmented by the plantar accessory ligament or plantar plate (volar plate). Anatomical variations of the great toe are uncommon.3 Simultaneous dislocation of the first cuneometatarsal joint and metatarsophalangeal joint is a rare injury.4 The simultaneous dislocation occurred because the injury was very severe. The treatment by closed reduction and pinning was 1. Cuenca Espierrez J, Martinez AA, Herrera A, Panisello JJ. The floating metatarsal: first metatarsophalangeal joint dislocation with associated Lisfranc dislocation. SepeOct. J Foot Ankle Surg. 2003;42(5):309e311. 2. Jain R, Jain S. The floating first metatarsal: a case report. J Foot Ankle Surg. 2006 JaneFeb;45(1):34e37. 3. Jahss MH. The sesamoid of the hallux. Clin Orthop. 1981;157:110e112. 4. Trinquier JL, Filloux JF, Paul H, Jarde O, Vives P. Bipolar dislocation of the first metatarsal bone. Acta Orthop Belg. 1995;61(3):238e241. Please cite this article in press as: Kumar P, Floating first metatarsal: A rare injury, Apollo Medicine (2013), http://dx.doi.org/ 10.1016/j.apme.2013.05.018
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