Hallux, Sesamoid, and First Metatarsal Injuries

      Keywords

      Hallux, sesamoid and first metatarsal injuries are common foot injuries and have important implications in the biomechanical functionality of the first ray and foot.
      • Perlman M.D.
      Fractures of the proximal phalanx of the hallux: the use of plates with displaced multifragment fractures.
      • Mittlmeier T.
      • Haar P.
      Sesamoid and toe fractures.
      The hallux is essential for propulsion in normal gait. As part of the first ray, it is an important contributor to normal locomotion. Any structure disruption or injury can create angular changes or arthritis, which can have biomechanical implications, including pain, disability, compensation, swelling, and reduced range of motion.
      • Christensen J.C.
      • Jennings M.M.
      Normal and abnormal function of the first ray.
      In a study reviewing amputation and replantation of the hallux,
      • Ademoğlu Y.
      • Ada S.
      • Kaplan I.
      Should the amputations of the great toe be replanted?.
      the pedographic studies revealed consistent changes in weight-bearing distribution of the feet with amputated hallux, altering the load distribution of the foot.

      Anatomy

      The anatomy of the hallux is different from that of the lesser digits. Besides the consistent two phalanx composition, its anatomy at the base of the hallux, at the first metatarsophalangeal joint (MTPJ), is unique and complex.
      • Sarrafian S.K.
      Anatomy of the Foot and Ankle: descriptive, topographic, functional.
      Understanding of this anatomy is crucial in the diagnosis and treatment of hallux and sesamoids injuries.
      • Oloff L.M.
      • Schulhofer S.D.
      Sesamoid complex disorders.
      The first MTPJ inherent stability comes from the complex network of ligamentous and intrinsic muscular structures extending around the base of the proximal phalanx, the head of the metatarsal, and the sesamoids. The sesamoid complex consists of seven muscles, eight ligaments, and two sesamoid bones.
      • Alvarez R.
      • Haddad R.J.
      • Gould N.
      • et al.
      The simple bunion: anatomy at the metatarsophalangeal joint of the great toe.
      In the plantar aspect of the first MTPJ, there is a fibrocartilaginous structure, the plantar plate, which also provides stability to the MTPJ. This extends plantarly from the base of the proximal phalanx into the head of metatarsal. It encompasses the capsule and the sesamoids as well. Medially and laterally, the corresponding collateral ligaments join this network of soft tissue structures, including the abductor hallucis tendon along its medial side, adductor hallucis (transverse/longitudinal) tendons along its plantar side, and flexor hallucis brevis (medial/lateral) tendons along its plantar side. The morphology of the head of the metatarsal varies from round to square shape. A prominent cristae, ridge or crest divides the sesamoid grooves. Some may have absence of this crest.
      • Brenner E.
      • Gruber H.
      • Fritsch H.
      Fetal development of the first metatarsophalangeal joint complex with special reference to the intersesamoidal ridge.
      Both the medial and lateral sesamoids are connected via the intersesamoid ligament. In the first MTPJ radiographic study, bipartite sesamoids occurred in 13.5% of 200 feet with a 37% bilaterality.
      • Prieskorn D.
      • Graves S.C.
      • Smith R.A.
      Morphometric analysis of the plantar plate apparatus of the first metatarsophalangeal joint.
      Congenital absence of sesamoids is rare.
      • Kanatli U.
      • Ozturk A.M.
      • Ercan N.G.
      • et al.
      Absence of the medial sesamoid bone associated with metatarsophalangeal pain.
      • Le Minor J.M.
      Congenital absence of the lateral metatarso-phalangeal sesamoid bone of the human hallux: a case report.
      • Leventen E.O.
      Sesamoid disorders and treatment. An update.
      • Hubay C.A.
      Sesamoid bones of the hands and feet.
      Sesamoids usually ossify at approximately age 10 and usually the medial one is larger than the lateral. Biomechanically, both function to sustain the body’s weight/pressure,
      • Stokes I.A.
      • Hutton W.C.
      • Stott J.R.
      • et al.
      Forces under the hallux valgus foot before and after surgery.
      • Nigg B.M.
      Biomechanical aspects of running.
      to act as pulley mechanism to the MTPJ, protecting the tendon of the flexor hallucis longus.

      Hallux fractures

      Hallux fractures are common injuries of the forefoot usually caused by direct impact or crushing type of mechanism. Depending on the type of injury severity and location, an associated nail injury may occur and complicate the treatment process of the osseous injury. These are treated as open injuries and may require immediate surgical intervention via irrigation and débridement, infection control, and off-loading. In the presence of a subungual hemotoma, decompression or nail removal may be performed. Normally, nail bed injuries/lacerations can be repaired without further consequences, but if the nail matrix is damaged, an abnormal or absent nail growth can be ensured postinjury.
      Hallux fractures can occur to the distal phalanx and proximal phalanx with or without intra-articular involvement into the interphalangeal or MTPJs (Fig. 1). A direct axial injury to the tip or tuff of the great toe usually can lead to distal phalanx injury, whereas a crushing type of injury can lead to both proximal and distal phalanges injury (Fig. 2). The treatment is based on the severity, displacement, and alignment factors of the fracture. When displaced, manipulation, distraction, and reduction maneuvers under sedation or local anesthesia, with or without finger trap devices, can be performed followed by immobilization and digital splinting. Comminuted and displaced intra-articular fractures of either phalanx may require surgical fixation. Often, stiffness of the interphalangeal and/or MTPJs remains as residual consequence of the injury.
      Figure thumbnail gr1
      Fig. 1Fracture hallux. Open reduction with internal fixation hallux.
      Figure thumbnail gr2
      Fig. 2Distal phalanx fracture, multifragmented.
      Stave fractures of the first metatarsal were described by Cooperman. The are equivalent to a Bennett fracture of the thumb metacarpal. These are uncommon injuries. This fracture in the foot occurs from loading of the medial cuneiform into the base of the first metatarsal. The initial report recommended plaster immobilization. Given that this is an intra-articular fracture, however, open reduction with internal fixation is recommended to minimize the risk of post-traumatic arthritis.

      Turf toe injuries

      Turf toe (TT) injuries are defined as plantar capsular ligament sprain or disruption of the supporting soft tissue structures of the first MTPJ.
      • Prieskorn D.
      • Graves S.C.
      • Smith R.A.
      Morphometric analysis of the plantar plate apparatus of the first metatarsophalangeal joint.
      • Bowers Jr., K.D.
      • Martin R.B.
      Turf-toe: a shoe-surface related football injury.
      • Tewes D.P.
      • Fischer D.A.
      • Fritts H.M.
      • et al.
      MRI findings of acute turf toe.
      The mechanism of injury is usually associated with hyperextension of the MTPJ but can also occur with valgus or varus stress and rarely with hyperflexion (Fig. 3).
      • Coker T.P.
      • Arnold J.A.
      • Weber D.L.
      Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes.
      • Clanton T.O.
      • Butler J.E.
      • Eggert A.
      Injuries to the metatarsophalangeal joints in athletes.
      • Watson T.S.
      • Anderson R.B.
      • Davis W.H.
      Periarticular injuries to the hallux metatarsophalangeal joint in athletes.
      • Douglas D.P.
      • Davidson D.M.
      • Robinson J.E.
      • et al.
      Rupture of the medial collateral ligament of the first metatarsophalangeal joint in a professional soccer player.
      With the advent of artificial turf and lighter shoe gear, the incidence of TT in many sports (football, soccer, and dance) and trauma has increased since the late 1960s.
      • Rodeo S.A.
      • O’Brien S.
      • Warren R.F.
      • et al.
      Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players.
      • Allen L.R.
      • Flemming D.
      • Sanders T.G.
      Turf toe: ligamentous injury of the first metatarsophalangeal joint.
      TT injuries have been reported (eg, soccer, rugby, tennis, track, basketball, wrestling, skydiving, and volleyball).
      • Coughlin M.
      Figure thumbnail gr3
      Fig. 3TT injury, hyperflexion. First MTPJ dorsal capsular tear. T2 MRI view.
      In a recent National Football League team study, the findings showed that TT injuries are associated with decreased MTPJ motion (40.6° ± 15.1° vs 48.4° ± 12.8°; P = .04), increased peak hallucal pressures (535 ± 288 kPa vs 414 ± 202 kPa; P = .05), and association of the severity of symptoms or progression to first MTPJ arthritis.
      • Brophy R.H.
      • Gamradt S.C.
      • Ellis S.J.
      • et al.
      Effect of turf toe on foot contact pressures in professional American football players.
      Patients often present with acute onset of pain at the first MTP joint. The pain may be somewhat diffuse or more localized. There may be swelling and/or ecchymosis. TT and sesamoids injuries can be unrecognized or undiagnosed. The range of injuries can span from simple sprain/strain/rupture of the plantar structures to dislocation. The more severe injuries may limit athletes’ ability to push off, run, and/or pivot. Due to its extensive soft tissue disruption and damage, both TT and sesamoids can lead to chronic disorders, persistent pain, loss of push-off strength, progressive hallux and first MTPJ valgus or varus deformity, and arthritis. The incidence can be as high as 45% of professional football players.
      • Rodeo S.A.
      • O’Brien S.
      • Warren R.F.
      • et al.
      Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players.
      Risk factors include advanced age, increased weight, longevity in professional football, pes planus, increased preinjury ankle motion, and decreased preinjury MTPJ range of motion.
      • Rodeo S.A.
      • O’Brien S.
      • Warren R.F.
      • et al.
      Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players.
      • Clanton T.O.
      • Ford J.J.
      Turf toe injury.
      The treatment options of TT injuries are based on the level of damage/injury incurred, which can range from acute to chronic conditions. A careful and thorough evaluation is essential in maximizing the treatment and successful long-term sequelae. A detailed physical examination of the anatomic structures and advanced imaging studies are essential components of this evaluation. Imaging should include weight-bearing views of the injured foot and comparison films if needed, to assess for possible sesamoid fracture, diastasis of a bipartite sesamoid, and proximal migration of the sesamoid. A lateral stress view of the first MTP joint may identify an occult fracture of the sesamoid or unstable diastasis of a bipartite sesamoid. Capsular avulsion fractures may also be seen. There may be impaction of the metatarsal head with associated intra-articular fragments. Also, when available, continuous live fluoroscopy imaging is useful in visualizing the lack of motion of the sesamoids with ranging of the MTPJ. Using contrast, arthrography can also be performed with a fluoroscopy or plain films. MRI is, however, the most used and provides the highest yield.
      • Tewes D.P.
      • Fischer D.A.
      • Fritts H.M.
      • et al.
      MRI findings of acute turf toe. A case report and review of anatomy.
      In most acute cases, capsular disruption can be observed, and in most chronic cases, the associated chronic articular damage and chondrolysis may also be observed.
      Initial treatment with anti-inflammatories, rest, ice, compression, elevation, and protection is common in grade 1 injuries with microtears/ruptures. Gentle range of motion can commence less then 1 week post injury. Immobilization and protection consists of digital spica splinting, rocker boot, Morton extension, and modified stiff forefoot sole shoes/orthotics. If the swelling and skin condition allows, taping in the direction opposite to the mechanism of injury can also be useful. Preinjury activities may be returned usually in less then 1 month. In grade 2 injuries with partial soft tissue tears/ruptures, the injury may progress further if not recognized and treated promptly. Pending the level of tear/rupture, MRI findings may or may not reveal fluid uptake or a positive finding. Most injuries can take 1 to 2 months for resuming preinjury activities and a few weeks more for athletic activities. In grade 3 injuries with full tear/ruptures, MRI findings are often positive, and prolonged immobilization and protection are necessary for 3 to 6 months. Preinjury activities are resumed slowly, pending symptoms and physical findings, but athletic activities are not resumed or are carefully performed after many months of recovery. The outcome is not predictive, however, for healing and/or success in the long term; thus, surgical intervention is required.

      Sesamoid injuries

      Hallucal sesamoid injuries have been mainly reported among ballet dancers and in various sports injuries.
      • Burton E.M.
      • Amaker B.H.
      Stress fracture of the great toe sesamoid in a ballerina: MRI appearance.
      • Lo S.L.
      • Zoga A.C.
      • Elias I.
      • et al.
      Stress fracture of the distal phalanx of the great toe in a professional ballet dancer: a case report.
      • Khan K.
      • Brown J.
      • Way S.
      • et al.
      Overuse injuries in classical ballet.
      Although the hallux interphalangeal joint may be similar in structure as the other digits, authors have reported specific injuries associated in this location (Fig. 4).
      • Gong H.S.
      • Kim Y.H.
      • Park M.S.
      Varus instability of the hallux interphalangeal joint in a taekwondo athlete.
      Sesamoid injuries of the first MTPJ
      • Vanore J.V.
      • Christensen J.C.
      • Kravitz S.R.
      • Clinical Practice Guideline First Metatarsal Joint Disorders Panel of the American College of Foot and Ankle Surgeons
      • et al.
      Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 4: sesamoid disorders.
      have been described in various forms, including traumatic dislocations,
      • Tosun B.
      • Akansel G.
      • Sarlak A.Y.
      Traumatic dislocation of the first metatarsophalangeal joint with entrapment of the flexor hallucis longus tendon.
      • Maskill M.
      • Mendicino R.
      • Saltrick K.
      • et al.
      Traumatic dislocation of the first metatarsophalangeal joint with tibial sesamoid fracture: a case report of a type III B dislocation.
      • Isefuku S.
      • Hatori M.
      • Kurata Y.
      Traumatic dislocation of the first metatarsophalangeal joint with tibial sesamoid fracture: a case report.
      • Ozkoç G.
      • Hersekli M.A.
      • Akpinar S.
      • et al.
      Iatrogenic medial dislocation of hallucal sesamoids with hallux varus in an adolescent.
      • Ando Y.
      • Yasuda M.
      • Okuda H.
      • et al.
      Irreducible dorsal subluxation of the first metatarsophalangeal joint: a case report.
      • Good J.J.
      • Weinfeld G.D.
      • Yu G.V.
      Fracture-dislocation of the first metatarsophalangeal joint: open reduction through a medial incisional approach.
      • Hussain A.
      Dislocation of the first metatarsophalangeal joint with fracture of fibular sesamoid. A case report.
      • Massari L.
      • Ventre T.
      • Iirillo A.
      Atypical medial dislocation of the first metatarsophalangeal joint.
      • lian F.J.
      • Carpenter B.B.
      • Mostone E.
      Dorsal dislocation of the first metatarsophalangeal joint.
      • Brunet J.A.
      Pathomechanics of complex dislocations of the first metatarsophalangeal joint.
      • Garcia Mata S.
      • Hidalgo A.
      • Martinez Grande M.
      Dorsal dislocation of the first metatarsophalangeal joint.
      • Jahss M.H.
      Traumatic dislocations of the first metatarsophalangeal joint.
      TT injuries,
      • Rodeo S.A.
      • Warren R.F.
      • O’Brien S.J.
      • et al.
      Diastasis of bipartite sesamoids of the first metatarsophalangeal joint.
      • Hall R.L.
      • Saxby T.
      • Vandemark R.M.
      A new type of dislocation of the first metatarsophalangeal joint: a case report.
      • Graves S.C.
      • Prieskorn D.
      • Mann R.A.
      Posttraumatic proximal migration of the first metatarsophalangeal joint sesamoids: a report of four cases.
      stress/nonunion fractures/avascular necrosis,
      • Hulkko A.
      • Orava S.
      • Pellinen P.
      • et al.
      Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes.
      • Saxena A.
      • Krisdakumtorn T.
      Return to activity after sesamoidectomy in athletically active individuals.
      • Biedert R.
      • Hintermann B.
      Stress fractures of the medial great toe sesamoids in athletes.
      • Karasick D.
      • Schweitzer M.E.
      Disorders of the hallux sesamoid complex: MR features.
      and open injuries (Figs. 5 and 6).
      • Van Pelt M.
      • Brown D.
      • Doyle J.
      • et al.
      First metatarsophalangeal joint dislocation with open fracture of tibial and fibular sesamoids.
      Additional symptoms at the first MTPJ can also result from inflammation, chondromalacia, flexor hallucis brevis tendonitis, osteochondritis dissecans, inflamed bursae, intractable keratoses, infection, sesamoiditis, gout arthropathy, and rheumatoid arthritis.
      • Richardson E.G.
      Hallucal sesamoid pain: causes and surgical treatment.
      Figure thumbnail gr5
      Fig. 5CT scan of sesamoid fracture, medial, axial and sagittal views.
      Figure thumbnail gr6
      Fig. 6Sesamoid fracture, lateral, multifragmented, chronic.
      Surgical intervention of TT and sesamoids injuries are indicated once all nonoperative options fail. Recently, the advent of bone stimulation, via pulsed electromagnetic field therapy, has given hope to many patients for salvaging sesamoids from surgical repair attempts or excisions. Most cases seldom require surgery. Medial and lateral capsule repair are common in these situations. Proper alignment at the hallux interphalangeal joint and MTPJ is crucial for optimal functionality. Articular damage repair and chondroplasty are also performed when indicated. Often, a type of bunionectomy procedure, along with above procedures, is referred. Hallucal or MTPJ sesamoids repair, partial removal, partial resection, or complete removal is also considered in the presence of sesamoids injuries (Fig. 7). Adjuctive procedures are also common: abductor/adductor tendon transfer, capsular interposition, osteotomy, and extensor/flexor tendon transfers. It is imperative to discuss the long-term sequelae of these conditions with patients, which may prompt further surgical interventions: sesamoidectomy, hallux interphalangeal joint, and/or first MTPJ arthrodesis, amputation.
      Figure thumbnail gr7
      Fig. 7Sesamoid fracture, lateral, plain films, bone scan, postoperative plain films, and clinical incisional approach.

      Metatarsal fractures

      Because of the importance of the first metatarsal in the biomechanics of gait and foot function, malreductions of this bone are generally tolerated less than other metatarsals. The first metatarsal is wider, shorter, stronger, and more mobile than the remaining metatarsals. Most of these fractures are due to a direct blow, crush, axial load, or, less often, a twisting mechanism. Due to the frequent direct injury mechanism, it is important to rule out open fractures. Patients present with pain, dorsal swelling, ecchymosis, and, most often, inability to walk. The skin should be carefully evaluated to rule out an open fracture. There is point tenderness over the fracture. Alignment may be abnormal in terms of length and rotation. Initial radiographs should include anteroposterior, oblique, and lateral views of the foot. In cases of suspicion of more severe injuries, for instance, a Lisfranc injury, stress views or weight-bearing views are helpful. CT scan is not often indicated, except for possible intra-articular fracture assessment, including those with impaction. Nonoperative treatment with a short leg cast or removable boot is indicated for nondisplaced, simple fracture patterns without associated injury. Frequent radiographs should be obtained in the first several weeks to ensure no displacement occurs. Operative treatment is indicated for open fractures, fractures associated with skin tenting, shortened fractures, unstable fracture patterns, intra-articular fractures, or fractures with greater than 10° of plantar angulation.
      • Greene W.B.
      Essentials of musculoskeletal care.
      Operative treatment consists of open reduction and stable internal fixation, most often with minifragmentary or small fragmentary screws and/or plates. Low profile plates are helpful to avoid tendon irritation (Fig. 8, Fig. 9, Fig. 10).
      Figure thumbnail gr8
      Fig. 8Metatarsal fracture: isolated base fracture, preop and postoperative views.
      Figure thumbnail gr9
      Fig. 9Metatarsal fracture: multifragmented, preop and postoperative views.
      Figure thumbnail gr10
      Fig. 10Tarsometatarsal fracture/dislocation: preoperative, intraoperative, and postoperative views.
      Stress fractures of the first metatarsal have been reported. The second and third metatarsals are the most common sites of metatarsal stress fractures, but the first metatarsal accounts for approximately 7% to 8% of metatarsal stress fractures.
      • Levy J.M.
      Stress fractures of the first metatarsal.
      These are injuries as a result of overuse and repetitive injury. They are commonly seen in military recruits, dancers, and runners. Excessive pronation, lower-extremity malalignment, and leg length discrepancy may predispose to first metatarsal stress fractures. Pain occurs with weight bearing and subsides with rest. Initial radiographs may be negative. After 2 to 3 weeks, there may be radiographic evidence of healing and callus formation. An MRI or bone scan is the definitive study if initial radiographs are normal and there is a high suspicion. Treatment is immobilization and nonweightbearing for 6 to 8 weeks. Patients may then begin low-impact activity but should refrain from any sports until they have has regained pain-free ambulation and full range of motion, strength, and proprioception.

      Wounds and lacerations

      One of the most common sites of ulceration and laceration on the foot is the hallux. As the largest and perhaps the most biomechanically important of the digits of the foot, the hallux is subject to varying injuries, including ulceration from pressure, lacerations from trauma, and nail-related injuries and/or complications.
      Loss of the hallux at the level of the MTPJ may affect propulsion, balance, and weight redistribution, thereby contributing to transfer and other lesions of the foot. A variety of deformities result in the digit becoming more susceptible to tissue breakdown. Ambulation on a severely plantarflexed hallux may result in a distal tip or distal plantar lesion. Shoe modification or specialized walkers provide minimal pressure relief, particularly when a rigid deformity is present. Off-loading through the use of crutches or a wheelchair is impractical. Contact casting may have little to no effect on such a deformity. These types of wounds are best addressed through surgical selection with flexible deformities corrected through tendon releases and rigid deformities modified through bone excision or positional modification. Once the pressure has been relieved, wounds respond, in the absence of infection, to most topical dressings without the need for advanced therapies. Even after addressing the underlying anatomy and physiology, selection of appropriate shoegear is imperative.
      Hallux deviation, when present with hallux valgus or other MTPJ anomalies, is a significant contributor to medial and distal hallux ulcer development. In scenarios where the metatarsal is involved, the clinician must determine the relevant biomechanical forces and type of anatomic abnormality before attempting to correct the problem. Surgical intervention, when not contraindicated, provides the most rapid means of correcting and permanently addressing the problem. Splints and positional devices are only temporary measures and may be rendered ineffective unless a patient is wearing the device at all times. Wounds occurring at the medial MTPJ are commonly found in the presence of hallux valgus deformities. Determining the depth of the wound and involvement of underlying structures assists with dressing selection. When tendon or bone involvement is present, osteomyelitis must be ruled out. Amputation of the hallux may be necessary yet may not significantly affect gate if the metatarsal head is left intact.
      The nail and nail bed may become ingrown and infected as a result of poor nail care and/or poorly fitted shoes. When ingrown, the nail border should be excised down to the level of the matrix. A matrixectomy may be considered for recurrent ingrowth of the nail. Determining adequate vascular flow to the digit as well as a patient’s medical status and ability to heal must be established before nail removal. Patients should be forewarned of the high risk of amputation in cases where re-establishing the blood flow is not an option. Amputation should be limited to the hallux whenever the metatarsal is not involved.
      Trauma to the hallux may result in deep tissue damage, infection, and fractures. Standard radiographs are recommended during the initial examination with possible MRI or labeled white blood cell scan radiography when osteomyelitis is suspected. Fractures of the hallux, when nondisplaced, heal well with splinting. Major displacement may require surgical intervention. When the joint capsule has been compromised, surgical intervention is usually the only treatment option.

      Summary

      In summary, the hallux is a source of many injuries. Hallux fractures, TT injuries, and sesamoid injuries are common yet challenging because of the myriad possible etiologies and complex anatomy. Unstable, displaced, open, and intra-articular fractures of the first metatarsal should be treated operatively, most often with open reduction and internal fixation to restore proper anatomy and function. A high suspicion should be had for athletes with first metatarsal pain to rule out stress fracture. An MRI or bone scan is diagnostic if plain radiographs are negative. A few of the causes of wounds and lacerations have been discussed; however, clinicians must develop a comprehensive differential diagnosis that may include other lesions, including, but not limited to, melanoma of the skin (and occasionally below the nail bed), tinea, skin carcinomas, hyperkeratosis diseases, and other dermatologic conditions. Biopsies should also be considered when lesions do not respond to traditional approaches to care, in the presence of abnormal tissue, or when wounds have been open for greater than 3 months without response to appropriate care. As discussed previously, a thorough examination and evaluation and advanced imaging techniques are essential. When nonoperative measures fail, surgical interventions are indicated. When addressing athletes, the return to nonathletic and athletic activities needs to be discussed and custom tailored based on the sports and/or condition of the athlete, due to the possible long-term sequelae associated with these conditions.

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