What is the diagnosis?

Plantar dislocation of the 1st metatarsophalangeal (MTP) joint.

• Pearl: These are rare injuries that occur due to hyperflexion of the joint [1].

What additional injuries are there to consider?

Fractures and soft tissue injuries, specifically the plantar plate.

Image 2. Lateral radiograph of Left Foot, showing MTP dislocation but no concurrent fracture. Author’s own

• Pearl: The plantar plate is a soft tissue structure on the plantar surface of the 1st MTP that protects from excessive dorsiflexion. Injury to this complex is classically known as “turf toe.” It is likely torn/ruptured in these dislocations.

• Pearl: Due to their proximity to the joint, the injury to the sesamoid bones and ligamentous complexes can also cause difficulty in achieving a stable reduction [1].

What is your management in the ED?

Reduction and immobilization. Reduction is performed by applying a downward, distracting force, and then pulling away (distally) from the joint. The patient can then be placed in a post op shoe or short walking boot with weightbearing as tolerated.

• Pearl: A digital block or intra articular block can be beneficial in reducing pain but can also be painful for the patient given the tight space. Depending on how recent the dislocation is, it may be more comfortable to just perform the reduction. 

• Pearl: Carbon fiber turf toe shoe inserts can also be used to provide stiff support that will not allow for as much flexion/extension of the joint as patients progress back to normal footwear. These can be purchased online or in pharmacies.

Image 3. Lateral Radiograph of Left Foot, Post Reduction. Author’s own

When do you consult Orthopedics?

Open fractures, irreducible joints, or neurovascular compromise post reduction should receive urgent consultation with orthopedics. Patients can otherwise have outpatient follow up with orthopedics or sports medicine to insure joint stability and the surrounding structures such as the plantar plate are healing.