A 46-year-old male, with no significant medical or surgical history, was ambulanced to the emergency department in King Abdulaziz Medical City (tertiary care center) in Riyadh, Saudi Arabia, as a result of a motor vehicle accident. The patient had a main complaint of a right first MTP joint that is mildly swollen and painful. Upon examining the big toe, swelling and deformity were observed accompanied by a painful range of motion. Also, the patient was unable to plantarflex or dorsiflex the right hallux. The right big toe showed dorsal displacement with shortening of the first ray. The vascular and neurological examination findings were normal; and the skin was intact.
A review of the radiographic images showed dorsal dislocation of the first MTP joint of the right big toe (Fig. 1). In addition, the fibular and tibial sesamoids were displaced dorsolaterally. At the emergency department, multiple attempts at closed reduction of the dislocation were unsuccessful. With the failure of the reduction to be obtained and because of the coronavirus outbreak at the hospital during that time, so the patient was referred to another hospital to take care of him. After six months, the patient was referred to the orthopedic department from the family medicine clinic since he neglected his injury. His x-ray at that time showed diffused regional osteopenia of the dislocated joint. Also, flattening of the head of the 2nd metatarsal bone was noted (Fig. 2).
Six months following the injury, another attempt at closed reduction in the operation room while the patient was under general anesthesia (with ankle block) was unsuccessful, after which an open reduction was carried out. In order to gain access to the dislocated first MTP joint, a dorsomedial approach was used (Fig. 3). The lateral and medial sesamophalangeal ligaments were torn or pulled off forcibly from their distal attachment to the proximal phalanx base upon further investigation of the sesamoid complex. Then the sesamoids retracted proximally. No fracture of the two sesamoids was observed. After the reduction was achieved, the level of stability and the movement range were verified and checked to be was expected. The first ray length seemed to be regained and back to its normal function. Fixation of the MTP joint was carried out with the help of provisional Kirschner wire (k-wire) for more stability (Fig. 4).
Then after eight weeks, the wire was taken off, and weight-bearing was gradually allowed for the patient. After three months of the operation, the patient gained a full normal activity with no degrees of pain or forms of disability. The patient did not suffer from range of motion restriction (plantarflexion and dorsiflexion). After twelve months of the operation, persistent disuse osteopenia was observed by the X-ray. However, other complications were neither observed nor reported by the patient either (Fig. 5).