Chronic irreducible dislocation of the proximal interphalangeal joint of the fifth toe: a case report
© Vaseenon et al.; licensee BioMed Central Ltd. 2014
Received: 1 May 2013
Accepted: 3 February 2014
Published: 4 February 2014
Traumatic dislocation of the interphalangeal of the fifth toe is an unusual foot injury.
We report the case of a 47-year-old woman who sustained a minor foot injury for more than 30 years, resulting in chronic, irreducible dislocation of the proximal interphalangeal joint of the fifth toe. The affected proximal interphalangeal joint was accessed via a dorsal incision over the unstable interphalangeal joint. It was found that the interposed interphalangeal joint capsule and attenuated lateral collateral ligament were reconstructed, and it was stabilized by temporary insertion of a Kirschner wire. The affected joint was found to be stable, well-positioned and pain-free at the 12-month post-surgical check-up.
This unusual presentation of a chronic joint dislocation responded favorably to open reduction, soft tissue reconstruction and restabilization of the affected joint. It is suggested that this approach will provide a good and functional outcome even in cases of very long-standing joint injury.
Isolated, traumatic dislocation of interphalangeal (IP) toe joint is an uncommon foot injury more usually occurring in association with other foot injuries . The great toe is the most commonly affected [1–7]. Healing by closed reduction is usually successful and there is either the hallux or lesser toes’ involvement . However, irreducible distal interphalangeal (DIP) or proximal interphalangeal (PIP) joint dislocation of the toes may require open surgical reduction in order to achieve joint stability and restore function [4, 5, 9]. Irreducible dislocation occurs when the plantar plate of the collateral joint ligament, or the flexor tendon becomes interposed between the bone ends of the involved joint [2, 3, 5, 7].
Non-resolving, chronic IP joint dislocation affecting the PIP joint of the fifth toe is an uncommon foot injury. When it occurs, it is usually the result of abductory forces causing dorsolateral displacement of the distal segment of the fifth toe . The joint dislocation seems irreducible when the associated medial collateral ligament or the flexor digitorum longus tendon is entrapped within the incongruent joint. The other reason is that the buttonhole effect between the fibers of extensor tendon and the proximal phalanx, will require surgical intervention to achieve joint stability and restore normal function .
It is shown that the case of chronic irreducible dislocation of the PIP joint of the fifth toe occurs and it can be resoluted by opening the reduction of the dislocation. The mid-term (a 12-month post surgery) results in the intervention are presented.
Dislocation of the PIP joint of the toe is an uncommon injury of the forefoot. The mechanism of injury usually occurs from hyperdorsiflexion or sudden application of a dorsolateral force causing traumatic abduction of the PIP joint of the toe. This is a common injury to both the great and lesser toes [1–7, 9, 10]. The dislocation causes instablility of the PIP joint because the soft tissues that normally ensure joint stability and congruency such as medial and lateral collateral ligaments, the fibrocartilagenous plantar plate (usually from the proximal attachment), the joint capsule and digital long and short toe extensor and flexor tendons are disrupted, compromised and injured during the forceful joint dislocation. Traumatic dislocation of the PIP joint of a toe may be successfully treated with closed reduction and adhesive neighbor strapping to adjacent toes . The complex dislocation as described in this case, involving a chronic irreducible joint subluxation, or a reducible but unstable dislocation requires the surgical intervention to correct the disrupted soft tissues stabilizers, such as the medial collateral ligament, the joint capsule or the plantar plate in order to achieve joint stability.
Closed reduction is usually successful in correction of IP joint dislocation in hallucal or lesser toes. The digital deformity is initially accentuated. The longitudinal traction, allowing the joint to resume this deformity was applied and then released, so it corrected the anatomical relationship . Stientra and Denner described a modification of this technique, where the dislocated joint was dorsiflexed to exaggerate the deformity. The dorsiflexion was maintained while the affected IP joint was further dorsiflexed and then plantarflexed to relocate in the anatomical joint position, usually with an audible ‘pop’ . All cases should be treated initially by closed reduction, but the closed maneuver failed to achieve joint correction. The open reduction was another treatment choice [1, 2, 7, 8]. In the case reported, only correction by closed reduction did not achieve a stable joint due to the displacement of the joint capsule, the laxity of the collateral ligament, and in part by the articular erosion of the lateral condyle of the proximal phalanx. Yang reported that approximately 50% of patients could be successfully treated by closed reduction .
Open reduction is best accomplished through a dorsal approach [1–7]. Temporary pin fixation is only indicated when the reduced joint is very unstable. Ultimate joint stability is improved when structures causing the buttonhole effect (i.e., the injury involving with the long extensor tendon, the distal end of the phalanx becoming “buttonholed” between the outer bands of the tendon) are removed. If the capsule, collateral ligaments, tendons or plantar plate are injured or attenuated, they should be repaired to achieve a neutral and anatomical position [1, 2, 6, 7, 9]. In our case, open reduction was performed via dorsal approach after failure of closed method. The attenuated lateral collateral ligament found to be entrapped within the joint was released. This finding was different from the previous publication in that medial collateral ligament and flexor digitorum longus tendon became entrapped in the joint. The plantar plate that contracted on the plantar lateral aspect of the joint from prolong period of subluxation and dislocation was one of the important structures causing the irreducible or reducible instability of the joint. It was released to restore joint stability. The dorsal capsule and lateral collateral ligament were repaired to achieve the stability. Temporary pin fixation was performed to enhance the joint stability during the surrounding tissue healing promoted. The pin was removed after 4 weeks to achieve stability and painless PIP joint. Radiographic examination following closed reduction is strongly recommended , as chronic irreducible dislocation of the lesser toes could result from the lack of definitive radiographic evaluation since closed reduction with inadequate immobilization was insufficient.
Traumatic dislocation of the interphalangeal joint of the fifth toe should be diagnosed at the earliest stage which was treated initially by adequate tractional reduction of the joint incongruency with relating to soft splintage immobilization in order to prevent subsequent complex chronic joint subluxation. In cases where this approach is not successful or pain persists open reduction, reposition and restabilization of the dislocated joint and its associated soft tissue structures are indicated to achieve a functional toe.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
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