878 Banerjee et al. d LOCKED GREAT TOE

Clinical Pearls: Locked Great Toe

Rahul Banerjee, MD, Michael P. Bradley, MD, Eric M. Bluman, MD, PhD,Christopher W. DiGiovanni, MD

Chief Complaint. Pain and inability to flex the greattoe.

History of Present Illness. A previously healthy 28-year-old man presented to the emergency departmentafter he tripped and struck his right great toe againsta table. After the injury, he was unable to move the toeand was unable to ambulate secondary to pain.

Physical Examination. On presentation, the patient’sright great toe was mildly swollen with no obviousdeformity compared with the contralateral side. Thegreat toe was warm and well perfused, and therewere no open wounds. Sensation to the distal phalanxwas intact to light touch, and there was no evidence ofa subungual hematoma. The patient’s great toe waslocked in extension. The interphalangeal joint of thegreat toe could not be actively or passively flexed.

Radiographic Examination. Anteroposterior andlateral radiographs of the right great toe showeddistraction of the interphalangeal joint of the patient’sright great toe (Figure 1). An accessory sesamoid bonewas noted to be incarcerated within the interphalan-geal joint. Contralateral radiographs showed normalalignment of the first ray with an accessory sesamoidlocated plantar to the interphalangeal joint.

Diagnosis. Acute great toe interphalangeal jointdislocation with sesamoid interposition.

Treatment. A digital block of the right great toe wasperformed using 2% lidocaine. A reduction maneuverwas performed as follows. Gentle longitudinal tractionwas applied to the great toe. This was followed byexaggeration of the extension deformity at the in-terphalangeal joint to unlock the incarcerated bone

and soft tissue. Subsequent flexion of the interphalan-geal joint facilitated immediate joint reduction. Afterthis maneuver, full active and passive motion of thejoint was restored, and the joint was stable. Post-reduction radiographs were obtained showing normalalignment of the interphalangeal joint (Figure 2). Theaccessory sesamoid was noted to be in a reducedposition compared with the contralateral side.

Discussion

History. Sesamoid bones originally were named afterthe seeds of the plant sesamum indicum by thephysician Galen.1 The term sesamoid refers to anybone that is embedded within a tendon and serves tomodify pressure and alter the direction of muscleforces. Common sesamoid bones include the patella,the sesamoids of the palmar surface of the thumbmetacarpophalangeal joint, and the sesamoids be-neath the head of the first metatarsal.

The sesamoid bone located at the great toe in-terphalangeal joint (subhallucal sesamoid), whenpresent, is rare and found in approximately 13% ofthe population.2 Subhallucal sesamoids are oftenbilateral and are embedded within the tendon of theflexor hallucis longus.3 Several authors have reportedcases of interphalangeal joint dislocation with sub-hallucal sesamoid interposition.4–15 With the excep-tion of two previous reports,9,13 however, all of thesecases required operative reduction with removal ofthe incarcerated intra-articular sesamoid bone.

Clinical Features. Patients with sesamoid interposi-tion of the great toe interphalangeal joint present withpain and inability to flex or extend the great toe. Inmost cases, the toe is fixed in an extended orhyperextended position. The interphalangeal jointmay be grossly dislocated. Although most reportsindicate that the sesamoid interposition occurs at thetime of injury, it is possible that reduction maneuversmay force the subhallucal sesamoid into the in-terphalangeal joint.12

Treatment. Although sesamoid interposition mayresult in an irreducible interphalangeal joint, closedreduction always should be attempted on initial di-agnosis. Anesthesia can be achieved easily usinga digital block. As described earlier, reduction shouldconsist of gentle longitudinal traction along the axis of

From the Department of Orthopaedic Surgery, Rhode IslandHospital, Brown University School of Medicine, Providence, RI.Received March 8, 2003; accepted April 1, 2003.Section editor: Michelle H. Biros, MS, MD, Department ofEmergency Medicine, Hennepin County Medical Center, Minneap-olis, MN.Address for correspondence and reprints: Christopher W.DiGiovanni, MD, Department of Orthopaedic Surgery, Rhode IslandHospital, 2 Dudley Street, COOP 1st Floor, Providence, RI 02905.Fax: 401-444-6243; e-mail: yodigi@aol.com.

Figure 1. Injury radiographs.

Figure 2. Postreduction radiographs.

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the great toe, exaggeration of the extension deformityto unlock it, followed by rapid flexion to enactrelocation. If a successful, stable closed reduction isobtained, splinting can be achieved by buddy-tapingthe great toe to the second toe or using an aluminumsplint over the dorsum of the great toe. Althoughsuccessful closed reductions are typically stable, anygross instability, persistent bony or soft tissue in-carceration, or residual incongruity of the joint afterthis attempt necessitates operative intervention.

Clinical Pearls

1. Interphalangeal joint dislocation with sesamoid in-terposition is a rare condition after blunt trauma to thegreat toe.

2. Patients typically present with a swollen, painful greattoe fixed in an extended or hyperextended position.

3. Closed reduction should be attempted using a digitalblock and gentle longitudinal traction, followed bya maneuver of extension and rapid toe flexion.

4. Inability to reduce the interphalangeal joint, failure toextract the intra-articular sesamoid, and instability ofthe interphalangeal joint after reduction all areindications for surgical treatment of this problem.

References

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2. Burman MS, Lapidus PW. The functional disturbances causedby the inconstant bones and sesamoids of the foot. Arch Surg.1931; 22:9–36.

3. Jahss MD. The sesamoids of the hallux. Clin Orthop 1981;157:88–97.

4. Muller GM. Dislocation of sesamoid hallux. Lancet. 1944;1:789 (abstract).

5. Eibel P. Dislocation of the interphalangeal joint of the big toewith interposition of the sesamoid bone. J Bone Joint Surg Am.1954; 36:880–2.

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9. Szucs R, Hurwitz J. Traumatic subluxation of theinterphalangeal joint of the hallux with interposition ofthe sesamoid bone. AJR Am J Roentgenol. 1989;152:652–3.

10. Wolfe J, Goodhart C. Irreducible dislocation of the great toefollowing a sports injury: a case report. Am J Sports Med.1989; 17:695–6.

11. Yasuda T, Fujio K, Tamura K. Irreducible dorsal dislocation ofthe interphalangeal joint of the great toe: report of two cases.Foot Ankle. 1990; 10:331–6.

12. Weiss AP, Yates AJ. Irreducible dorsal interphalangeal greattoe dislocation. Orthopedics. 1992; 15:480–2.

13. Dave D, Jayaraj VP, James SE. Intra-articular sesamoiddislocation of the interphalangeal joint of the great toe.Injury. 1993; 24:198–9.

14. Ward SJ, Sheridan RP, Kendall IG. Sesamoid bone interpositioncomplicating reduction of a hallux joint dislocation. J AccidEmerg Med. 1996; 13:297–8.

15. Berger JL, LeGeyt MT, Ghobadi R. Incarcerated subhallucalsesamoid of the great toe: irreducible dislocation of theinterphalangeal joint of the great toe by an accessory sesamoidbone. Am J Orthop. 1997; 26:226–8.

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