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What is the diagnosis?

Dislocation of the distal phalanx of the left great toe at the interphalangeal joint 

What is the mechanism of injury?

Two major mechanisms: 

• Direct trauma and blow or “jamming” of the digit

• Hyperextension injury 

What physical exam findings are expected?

Pain, swelling, bruising with obvious deformity of the affected toe. 

Which imaging modalities can be used?

Plain radiograph is the initial modality of choice. 

Image 3 & 4. Plain radiographs of the dislocation. Arrow indicating where the dislocation is. Second image post-reduction showing realignment. Author’s own images and annotations.

Ultrasound can be utilized as seen in this case at the bedside for confirmation of realignment especially in the setting of significant swelling and repeated reduction attempts. 

• Pearl: Ultrasound gel makes reduction maneuvers difficult due to decreased ability to grip the distal portion of the dislocated joint, so make sure to wipe off with towels before attempting reduction. 

 Image 5 & 6. Ultrasound point of care screenshot of pre and post reduction of the dislocation. In the first image the hyperechoic horizontal lines are aligned but in the second image post reduction the hyperechoic line is contiguous in realignment. Author’s own images and annotations.

What is the management in the ED?

Pain control, imaging, reduction. As this dislocation had been present for almost 24 hours significant swelling had accumulated. The patient had significant needle phobia and did not want a digit block initially but after multiple unsuccessful reduction attempts at the bedside a digit block was placed allowing for successful reduction. Irreducible dorsal dislocation of the interphalangeal joint is rare but has been documented, notably secondary to incarceration of the sesamoid blocking manipulation and reduction [1]. Patient should be placed in a post op shoe with weight bearing as tolerated.  

When do you consult Orthopedics?

In general, orthopedics consultation is not required. Follow up with primary care is likely sufficient, though this may be system dependent.