Dorsal Dislocation of the First

Metatarsophalangeal Joint
Traumatic dislocation of the first metatarsophalangeal joint is a rare clinical finding. Ability to reduce the
dislocation by nonoperative measures depends largely on the type of dislocation and involvement of the
sesamoid complex. A brief description of the incidence, anatomy, and pathomechanics of dorsal
dislocation of the first metatarsophalangeal joint is given. A report of a 33-year-old female with
complete dorsal dislocation of the first metatarsophalangeal joint and anatomically preserved sesamoid
complex is provided. (The Journal of Foot and Ankle Surgery 36(2):131-135, 1997)

Key words: first metatarsophalangeal joint, sesamoid complex, dislocation

Frank J. Killian, DPM 1

Brian B. Carpenter, DPM 1
Edward Mostone, DPM, FACFAS2

The incidence of first metatarsophalangeal joint involved in the dorsal dislocation of the first MPJ and
(MPJ) dislocation is rare. Jahss (1) describes two cases present a case report of a patient in whom there was
in 25,000 patients (incidence of 0.008%) and Giannikas neither involvement of the plantar intersesamoidalliga-
et al. (2) report four cases in 10,000 patients (incidence ment nor distal dorsal dislocation of the sesamoid
of 0.04%) The most common cause of this injury is a complex.
motor vehicle accident. Falls from heights and athletic
injuries are secondary causes (3). Jahss defines two basic Anatomy
types of dislocations. Type I is a dislocation in which the
The MPJ complex of the hallux differs from the
plantar capsule and sesamoid complex remain attached
articulations of the lesser toes in that it includes the
to the base of the proximal phalanx, and as such, are
phalangeal sesamoid apparatus. The two sesamoids
dislocated distally and dorsally. Type II dislocations are
are embedded in the thick fibrous plantar plate and
subdivided into IIA and lIB. Type IIA involves disrup-
are connected to the proximal phalanx. The sesamoids
tion of the plantar sesamoidal ligament and Type lIB
have been shown to move in conjunction with the
involves rupture of the intersesamoidal ligament with a
phalanx, having approximately 1 cm. excursion on the
transverse fracture of either sesamoid. The Type I
fixed first metatarsal head during normal hallux dor-
dislocation is often irreducible (2, 4, 5). However, in
siflexion and plantarflexion (1). According to Sarra-
Type II injuries, the rupture of the intersesamoidal
fian, the sesamoid complex will always follow the
ligament results in wide separation of the sesamoids on
proximal phalanx and not the metatarsal head during
the metatarsal head, which allows for easier closed
traumatic displacements (7).
reduction.
The head of the first metatarsal is much larger than
Since his original paper in 1980, Jahss reported one
those of the lesser metatarsals. Plantarly, it has two grooves
case of complete dorsal dislocation of the hallux with the
oriented in an anterior-posterior direction. The medial
sesamoids remaining in their anatomic position under
groove is wider and deeper to accommodate the medial
the metatarsal. Upon exploration, complete rupture of
sesamoid, which is almost always larger than the lateral.
the conjoined tendons with intact sesamoids and volar
The dorsal surfaces of the sesamoids articulate with the
plate were found. This was classified as a Type III dorsal
plantar grooves of the first metatarsal. The articular facet
dislocation (6) (Fig. 1). Currently, there is little mention
of the proximal phalanx is concave and has a smaller
in the literature of Type III dorsal dislocations. This
surface area than does the metatarsal head. The first MPJ
paper will review the anatomy and pathomechanics
sesamoid complex has a fibrous capsule that completely
surrounds the joint. Plantarly, its attachment is several
From the Division of Podiatry, The Cambridge Hospital, Cam-
bridge, Massachusetts.
millimeters from the articular surface,"
1 Submitted while resident. Address correspondence to: Depart-
ment of Podiatry, The Cambridge Hospital, 1493 Cambridge Street, 3 From: Lower Extremity Anatomy, unpublished class notes, B. E.
Cambridge, Massachusetts 02143. Hirsch (ed.), Pennsylvania College of Podiatric Medicine, pp. 369 -373,
2 Chief attending, Department of Podiatry. 1991.

VOLUME 36, NUMBER 2, 1997 131

 Heads of
NORMAL adductor
halluc is

Intersesamoid Abductor ha ll uc is
_a,..r
____ Ii
g \
Med ial
sesamoid
TYPE I

TYPE IIA

M irror im age \
FIGURE 1 The classification of first MPJ dislocations. Normal first MPJ posit ion. Type I: the hallux dislocates and locks dorsally with the
sesamoids. This usually requires open reduction. Type IIA: dorsal dislocation with split intersesamoid ligament. Type liB : dorsal dislocation
with fracture of one sesamoid . Type II is more amenable to closed reduction . Type 11/: dorsal dislocation with rupture of both conjoined
tendons, the sesamoids remaining plantarward with the volar plate. (Reprinted with permission . Jahss , M. H. Disorders of the Foot and Ankle.
Edited by E. H. Wickland, W. B. Saunders Co.)

The sesamoids are attached to each other by a thick Pathomechanics

intersesamoidalligament. A less-defined pair of short
sesamoidal phalangeal ligaments attach them to the
base of the proximal phalanx. On the intra-articular
surface of the plantar plate a transverse band joins
one short sesamoidal phalangeal ligament to the
other. Metatarso-sesamoidal suspensory ligaments are
also present, inserting into adjacent sides of the
plantar plate (7) . The central segment of the plate
serves as an attachment to two vertical septa of the
plantar aponeurosis and the proximal segment of the
fibrous tunnel of the flexor hallucis longus. The lateral
and medial aspects provide insertion to the lateral and
medial heads of the flexor hallucis brevis. The remain-
der of the flexor hallucis brevis inserts into the
sesamoids, which also serve as a point of insertion for
the deep transverse metatarsal ligament, th e con-
joined tendons of the adductor hallucis laterally, and
the abductor tendon medially (7).
The mechanism of injury that causes dorsal disloca-
tion of the proximal phalanx on the first metatarsal is
forced hyperextension (3). The dorsal excursion of the
proximal phalanx results in reciprocal plantarflexion of
the metatarsal (8). These forces cause plantar stretching
of the capsule, which ruptures at its attachment under
the metatarsal neck. As the hallux extends dorsally over
the articular surface of the first metatarsal head, the
plantar capsule and sesamoid apparatus remain attached
and proceed distally and dorsally. This locks the meta-
tarsal plantarly. The adjacent medial and lateral tendi-
nous and ligamentous structures are pulled taut, which
holds the dislocated position firmly and may prevent
closed reduction (1). If closed reduction fails, open
reduction will be required. This can be achieved through
either a transverse plantar incision or through a dorsal
incision (9). This scenario defines the Jahss Type I
dorsal dislocation.

132 THE JOURNAL OF FOOT AND ANKLE SURGERY

 Continuation of the dorsal forces will lead to rupture
of the intersesamoidalligament, which will result in a wide
separation of the sesamoids on the metatarsal head (Jahss
Type ITA). Transverse fracture of one of the sesamoids also
may occur with rupture of the intersesamoidal ligament
(Jahss Type lID) (1). An injury caused by pure hyperex-
tension will result in an avulsion fracture of the sesamoid.
If the injury results from a fall from a height, then it is more
likely that the sesamoid fracture will be a crush fracture
because of the ground reactive forces being absorbed by
the sesamoid. In either case, the more proximal fragment
of the fractured sesamoid remains in a normal position in
relation to the adjacent sesamoid via the remaining intact
intersesamoidalligament (10).
The mechanism of the Jahss Type III dislocation, in FIGURE 2 Medial view of the patient's left foot at initial presenta-
which the plantar plate and sesamoids remain in their tion. Note the dorsiflexed position of the hallux on the metatarsal
anatomic position and the conjoined tendons rupture, head, the redundant skin lines dorsally, the taught skin plantarly,
and the plantarllexion of the interphalangeal joint.
has not been described in the literature. The authors
speculate that in this type of injury the dorsal dislocating
force which occurs at the first MPJ is distal to the
sesamoid complex, thereby leading to rupture of the
conjoined tendons and allowing the sesamoid complex
to remain in anatomic position. In this injury pattern
the sesamoids do not fracture, and the attachment of the
sesamoid complex at the neck of the metatarsal and the
intersesamoidal ligament remain intact.

Case Report
A 33-year-old female with no significant past medical
history presented to the Emergency Department with a
chief complaint of a deformed and painful left first MPJ
and painful right ankle. The patient stated that while
walking down a series of stairs without shoe gear she
stepped on a drinking glass with her left forefoot and
fell. She was unable to move her left great toe and it was
dislocated.
Physical examination of the left foot revealed a
marked distortion of the normal appearance of the first
MPJ. The proximal phalanx of the hallux was in a dorsal
and extended position to the first metatarsal head. The
head of the first metatarsal was extremely prominent
plantarly, with a blanching of the skin in this region. The
distal phalanx rested in a flexed position in relation to
the proximal phalanx (Fig. 2). The left foot was in an
adducted, plantarflexed, and inverted position. The neu-
rovascular status to the left hallux was intact without
compromise. Upon examination of the right foot and
ankle, there was tenderness over the anterior talofibular
ligament and the calcaneofibular ligament with corre-
sponding mild edema to the same area.
Radiographs of the foot and ankle were made bilat-
erally to assess any bony abnormality. The radiographs
of both ankles and the right foot were unremarkable.
FIGURE 3 Lateral radiograph of the dislocated left first MPJ. The
proximal phalanx base is articulating with the dorsal surface of the
metatarsal head. The sesamoids are properly aligned under the
head of the first metatarsal.
The lateral view of the left foot demonstrated a dorsal
dislocation of the base of the proximal phalanx on the
first metatarsal head (Fig. 3). The proximal phalanx was
noted to lie in a dorsiflexed position with flexion at the
interphalangeal joint. The dorsoplantar view demon-
strated obliteration of the first MPJ space with approx-
imately 8 to 10 mm. of overlap of the base of the
proximal phalanx on top of the first metatarsal head
(Fig. 4). The tibial and fibular sesamoids were found in
relatively correct anatomic position to the first metatar-
sal head and to one another. There were no fractures
visualized on any of the views of the left foot.
Closed reduction of the dislocated first MPJ was
performed. Local anesthesia was administered to the
base of the first ray. Tincture of benzoin" was applied to
4 Paddock Laboratories, Inc., Minneapolis, MN 55427.

VOLUME 36, NUMBER 2, 1997 133

FIGURE 4 Anteroposterior radiograph of the dislocated left first
MPJ. Note the joint space is obliterated and the proximal phalanx is
overlapping the metatarsal head dorsally. The sesamoids are posi-
tioned at the neck of the metatarsal plantarly.
the left hallux to facilitate holding and maneuverability
during closed reduction. The proximal phalanx was
grasped and hyperextended onto the dorsal aspect of the
first met atarsal. A dorsiflexory force was applied under
the first metatarsal head, and strong distraction was
performed followed by plantarflexion of the proximal
phalanx. This resulted in a relocation of the first MPJ.
Utilizing Coban", the hallux was strapped with a plan-
tarflexory force and splinted to the adjacent toe to
prevent spontaneous recurrence of the deformity. Post-
reduction radiographs demonstrated anatomic align-
ment of the first MPJ without evidence of fracture (Figs.
5, 6). A compression dressing was applied to the right
ankle and surgical shoes were dispensed for both feet.
The patient was discharged with prescriptions for pain
medication, crutches to assist in weightbearing, and a
follow-up appointment in 4 days. The patient continued
to use partial weightbearing on the left foot with the left
hallux strapped in a neutral to slightly plantarflexed
5 3M Medical Products Division, St. Paul, MN 55144.
134 THE JOURNAL OF FOOT AND ANKLE SURGERY
FIGURE 5 Immediate postreduction anteroposterior radiograph of
the left first MPJ. The base of the prox imal phalanx is in correct
anatomic position with preservation of the joint space. The sesa-
maids are again seen in correct anatomic position.
position for the following 3 weeks. After 3 weeks the
patient had full mobility of the right foot and ankle
without pain, but limited and painful range of motion of
the left hallux. The patient was prescribed a regimen of
physical therapy that included ultrasound, whirlpool,
stretching, and strengthening exercises for the first MPJ .
Her activity status was weightbearing as tolerated, with
progression to normal shoe gear over the next 4 months.
At 4 months follow-up , the patient reported a return
to full activity without pain or disability. She had discon-
tinued her physical therapy regimen and returned to
normal shoe gear. The range of motion of her left hallux
was noted to be normal in both dorsiflexion and plan-
tarflexion with adequate muscle strength of the flexors
and extensors of the great toe. At 10 months follow-up
the patient had no complaints of pain or complications.
Discussion
Complications in closed reduction of a dislocation of
the first MPJ often arise due to the strong attachment of

FIGURE 6 Immediate postreduction lateral radiograph of the dis-
located first MPJ.
the sesamoid complex with the proximal phalanx and its
propensity to dislocate dorsally with the phalanx. Other
mitigating circumstances include the interposition of
associated soft tissue in the joint space and tautness of
the adjacent metatarsophalangeal ligaments and ten-
dons that make distraction of the hallux difficult during
attempted closed reduction. When the dislocation pat-
tern is a Jahss Type II, the ruptured intersesamoidal
ligament or fractured sesamoid allows for easier and
more successful closed reduction (9). The pattern of
dislocation described by the authors was also encoun-
tered once by Jahss and classified as a Type III disloca-
tion (6). The same pattern was described by Giannikas et
al. (2). In this pattern of dislocation the intersesamoidal
ligament is not ruptured, nor is there fracture of either
sesamoid. The sesamoids remain in their anatomic po-
sition rather than displacing dorsally with the proximal
phalanx. Jahss discovered that this pattern of dislocation
occurs when the medial and lateral conjoined phalangeal
sesamoidal tendon completely ruptures (6).
The case reported by Jahss required operative reduction
with a resection arthroplasty of the base of the proximal
phalanx performed for salvage. However, the case reported
by the authors of this paper was easily reduced by closed
means. The authors believe that because the conjoined
tendons inserting medially and laterally had ruptured ,
there was decreased resistance to distraction and plantar-
flexion of the proximal phalanx during closed reduction.
Also, the plantar plate and sesamoid complex remained in
anatomic position and were not dorsal to or interposed
between the articular surfaces of the first MPJ; therefore,
less distraction and force was necessary to relocate the
proximal phalanx on the metatarsal head. It is also impor-
tant to note that in the authors' case, the patient presented
for treatment within hours of injury, while in the case
reported by Jahss, the patient did not present until 9 weeks
after injury and therefore required operative intervention
(6). This indicates time between injury and intervention is
a factor which influences the ability to obtain closed
reduction.
Following reduction, patients should be maintained in
a neutral to slightly plantar position at the first MPJ for
three weeks, with partial weightbearing in a wooden-
soled shoe to prevent dorsiflexion of the hallux during
the propulsive phase of gait. Physical therapy, including
stretching, active and passive range of motion, ultra-
sound, and whirlpool may be required after the initial
healing phase, because scarring and contracture of the
dislocated and ruptured soft tissues will generally cause
pain and limit the range of motion of the hallux.
Conclusion
Dorsal dislocation of the first MPJ with anatomic
preservation of the sesamoid complex is a very rare
pattern of dislocation in an already infrequently re-
ported clinical entity. Further study is necessary to
evaluate the pathomechanics of this pattern of disloca-
tion. Provided the patient presents soon after injury,
closed reduction is easily performed with local anesthe-
sia by manipulating the proximal phalanx plantarly while
maintaining a retrograde dorsal force on the head of the
first metatarsal.
References
1. Jahss, M. H. Traumatic dislocations of the first metatarsophalan-
geal joint. Foot Ankle 1:15-21, 1980.
2. Giannikas, A. C., Papachristou, G., Papavasiliou , N., Nikifordis,
P., Hartofilakidis-Garofalides, G. Dorsal dislocation of the first
metatarsophalangeal joint. J. Bone Joint Surg. 57B:384-386, 1975.
3. Smith, T. F. Dislocations, ch. 60. In The Comprehensive Textbook of
Foot Surgery, 2nd ed., vol. 2, pp. 1481-1484, edited by E. D.
McGlamry, A. S. Banks, and M. S. Downey, Williams & Wilkins,
Baltimore, 1992.
4. Daniel, L., Beck, E. L., Duggar, G. E., Bennet, A. J. Traumatic
dislocation of the first metatarsophalangeal joint: a case report.
J. Am. Podiatr. Assoc. 66:97-100, 1976.
5. McKinley, L. M., Davis, G. L. Locked dislocation of the great toe.
J. La. State Med. Soc. 127:389-390, 1975.
6. Jahss, M. H. Disorders of the hallux and first ray, ch. 39. In
Disorders ofthe Foot and Ankle: Medical and Surgical Management,
2nd ed ., pp. 1125-1129, edited by E. H. Wickland, W. B. Saunders
Company, Philadelphia, 1991.
7. Sarrafian, S. K Syndesmology, ch. 4. In Anatomy of the Foot and
Ankle, 2nd ed. pp, 211-212, edited by D. Patterson, M. E. Dickmeyer ,
and E. A. Durang, J. B. Lippincot and Co., Philadelphia, 1993.
8. Sage, R., Hollowa y, P. Type I dorsal dislocation of the first
metatarsophalangeal joint: a case report. J. Am . Podiatr. Med.
Assoc . 75:215-217, 1985.
9. Schenk, R. C., Heckman, J. D. Fractures and dislocations of the
forefoot: operative and nonoperative treatment. J. Am . Acad .
Orthop. Surg. 3:70-78,1995.
10. DeLee, J. C. Fractures and dislocations of the foot . Ch . 35. In
Mann, R. A., Coughlin, M. J. Surgeryofthe Foot and Ankle, 6th ed.,
vol. 2, pp. 1696-1697, edited by James D. Ryan, Mosby Publi shing
Co., St. Louis, MO , 1993.
VOLUME 36, NUMBER 2, 1997 135