Floating first metatarsal: A rare injury

Floating first metatarsal: A rare injury

Case Report

Floating first metatarsal: A rare injury

Pankaj Kumar*

Consultant Orthopaedic Surgeon, Apollo Reach Hospital, Karimnagar, Andhra Pradesh 505001, India

a r t i c l e i n f o

Article history:

Received 26 September 2012

Accepted 17 May 2013

Available online xxx

Keywords:

Floating

First metatarsal

Management

a b s t r a c t

We are presenting a case of floating first metatarsal, its consequence, management

guideline and results.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

A case of concomitant Lisfranc dislocation and meta-

tarsophalangeal dislocation of the hallux is rare.1,2 This is usu-

ally associated with high velocity trauma. The compound

metatarsophalangeal dislocation with fracture of proximal

phalanx and closed dislocation of cuneometatarsal joint dislo-

cationhadnot been reported in literature.This is thefirst caseof

floatingmetatarsalwith fracture proximal phalanx described in

the literature. We report an unusual case of concomitant tar-

sometatarsal (Lisfranc) and1stmetatarsophalangeal (MTP) joint

dislocations and fracture of the base of proximal phalanx of the

great toe.

2. Case report

A40 years drunken youngmale hit by buswhilewalking on side

of road.He sustained injury to right thighand ipsilateral foot. He

reported to our emergency department within 4 h of injury.

Therewas laceratedwoundof about 0.5 cm� 0.5 cmaroundfirst

metatarsophalangeal joint on dorsal aspect and associatedwith

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

jointwith fractureof base ofproximal phalanxof great toe along

with dislocation tarsometatarsal joint (Fig.1). After wound

debridement first fixation of metatarsophalangeal joint with K-

wire and open reduction of tarsometatarsal joint and fixation of

first metatarsal with second metatarsal transversally with K-

wire (Fig.2). K-wire was removed after 6 weeks of injury. We

follow the patients for one year; there was mild pain meta-

tarsophalangeal joint while prolonged walking.

3. 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: [email protected], [email protected].

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a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1e2

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

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

augmented by the plantar accessory ligament or plantar plate

(volar plate). Anatomical variations of the great toe are un-

common.3 Simultaneous dislocation of the first cuneometa-

tarsal joint andmetatarsophalangeal joint is a rare injury.4 The

simultaneousdislocationoccurredbecause the injurywasvery

severe. The treatment by closed reduction and pinning was

very classical. Occasionally the reducibility of the meta-

tarsophalangeal 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) disloca-

tion. 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 pa-

tients 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. Occa-

sionally the reducibility of the metatarsophalangeal joint may

bemademoredifficult by the interposition of a sesamoidbone.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Cuenca Espierrez J, Martinez AA, Herrera A, Panisello JJ. Thefloating metatarsal: first metatarsophalangeal joint dislocationwith 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 FootAnkle 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. Bipolardislocation of the first metatarsal bone. Acta Orthop Belg.1995;61(3):238e241.

Fig. 1 e Fracture base of proximal phalanx with

subluxation of metatarsophalangeal and

metatarsocuneiform joint.

Fig. 2 e Fixation with K-wire with reduction both the

joints.

a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1e22

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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