Copyright 2011 by The Journal of Bone and Joint Surgery, Incorporated

Dislocation of the Interphalangeal Joint of the Great Toe: Is Percutaneous Reduction of an Incarcerated Sesamoid an Option?
Surgical Technique
By Colin Yi-Loong Woon, MBBS, MRCS(Edin), MMed(Surg), MMed(Ortho)
Investigation performed at the Department of Orthopaedic Surgery, Singapore General Hospital, Singapore The original case report in which the surgical technique was presented was published in JBJS Vol. 92-A, pp. 1257-60, May 2010

CASE REPORT An eighteen-year-old male student fell from a height onto the left foot, hyperextending the great toe. There was swelling and tenderness with hyperextension of the distal phalanx and dimpling of the skin over the interphalangeal joint. Radiographs revealed a Miki1 type-II dislocation of the interphalangeal joint (Fig. 1-A) and an entrapped sesamoid. Closed reduction, done with the patient under general anesthesia and with fluoroscopic guidance, was unsuccessful (Fig. 1-B), and percutaneous reduction of the incarcerated sesamoid was performed (Fig.

1-C). In view of perceived joint laxity, the joint was opened dorsally and the interphalangeal joint space was examined to confirm that no residual tissue was interposed between the phalanges. The incision was closed, and the joint was immobilized with a 1.25-mm Kirschner wire, which was removed at four weeks. At six months, the patient reported mild interphalangeal joint stiffness but had returned to playing basketball. The range of motion of the interphalangeal joint was reduced to 40, while the range of motion of the metatarsophalangeal joint

was normal. Radiographs revealed normal interphalangeal joint anatomy and alignment (Fig. 1-D). INTRODUCTION Percutaneous reduction of an incarcerated interphalangeal joint sesamoid is an alternative to open surgery when closed reduction of the dislocation fails. The procedure is based on the anatomical understanding that the sesamoid-plantar plate complex displaces and reduces together as a unit. Percutaneous reduction is only possible in patients with radiographically apparent sesamoids, as intraoperative fluoroscopy is neces-

Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2011;93 Suppl 1:109-112 doi:10.2106/JBJS.J.01062


The Journal of Bone & Joint Surgery Surgical Techniques March 2011 Volume 93-A Supplement 1 jbjs.org

FIg. 1-A

FIg. 1-B

Fig. 1-A Preoperative anteroposterior (left), lateral (middle), and oblique (right) radiographs showing a Miki type-II interphalangeal joint dislocation of the great toe. Fig. 1-B Intraoperative fluoroscopic image made before reduction. A Kirschner wire was inserted dorsally and directed at the sesamoid. The arrow indicates the direction of the Kirschner wire.

FIg. 1-C

FIg. 1-D

Fig. 1-C Reduction is confirmed fluoroscopically. Fig. 1-D Anteroposterior (left), lateral (middle), and oblique (right) radiographs made six months postoperatively with the sesamoid in the anatomical position.


The Journal of Bone & Joint Surgery Surgical Techniques March 2011 Volume 93-A Supplement 1 jbjs.org

sary to visualize engagement of the sesamoid by the reduction implement and confirm a satisfactory reduction after the maneuver. SURgICAL TECHNIQUE With the patient under local, regional, or general anesthesia, a small stab incision is made over the extensor hallucis longus tendon. Under fluoroscopic guidance, a 1.0-mm Kirschner wire is introduced through the extensor tendon and the dorsal aspect of the capsule toward the invaginated sesamoid while traction is applied to the distal phalanx. The Kirschner wire is used as a joystick to lever the sesamoid away from the head of the proximal phalanx and into the joint and then to push it plantarward (for Miki type-II injuries) (Fig. 2-A)1. To avoid fracturing the sesamoid, the Kirschner wire is not drilled into it but is manipulated by hand. Adequate reduction is confirmed by noting that the distal phalanx is clinically unstable, and the sesamoid is restored to its original location plantar to the interphalangeal joint. Obstructed interphalangeal joint flexion and extension suggest reduction of the sesamoid into the joint space and conversion of a type-II dislocation to a type-I dislocation (Fig. 2-B)1. The procedure should then be repeated until the sesamoid is reduced to the plantar surface (Fig. 2-C). Miki type-I dislocations can be addressed in a similar manner.

FIg. 2-A

FIg. 2-B

FIg. 2-C Percutaneous reduction of a Miki type-II dislocation (Fig. 2-A) with use of a Kirschner wire (K-wire). The sesamoid (S) is first pushed into the joint, creating a Miki type-I dislocation (Fig. 2-B), and finally it is pushed plantarward (Fig. 2-C). Following successful reduction, joint laxity and a widened interphalangeal joint space are noted. DP = distal phalanx, VP = volar (plantar) plate, and PP = proximal phalanx.


The Journal of Bone & Joint Surgery Surgical Techniques March 2011 Volume 93-A Supplement 1 jbjs.org

CRITICAL CONCEPTS
INDICATIONS: Failed closed reduction of Miki type-I and II dislocations of the great toe interphalangeal joint CONTRAINDICATIONS: The sesamoid not visible radiographically (in up to 44% of ambulatory patients)1 Chronic dislocations when it is no longer possible to distract the joint space enough to allow passage of the sesamoid through it Open dislocations Multiple trauma PITFALLS: Laceration of the extensor hallucis longus tendon Sesamoid fracture AUTHOR UPDATE: The procedure remains the same as first described.

colin Yi-loong Woon, MBBs, Mrcs(edin), MMed(surg), MMed(ortho) Department of orthopaedic surgery, singapore General Hospital, 169608 singapore.

e-mail address: [email protected]

REFERENCE

1. Miki T, Yamamuro T, Kitai T. An irreducible

dislocation of the great toe. Report of two cases and review of the literature. Clin Orthop Relat Res. 1988;230: 200-6.