Turf Toe Injury: A Pictorial Review and a Didactic Case Report.

Hyperextension of the first metatarsophalangeal joint can lead to a turf toe injury of the plantar plate complex, resulting in significant morbidity for athletes. This article reviews the anatomy, pathophysiology, classification, and imaging findings of turf toe injuries. In turf toe trauma, many different structures can be injured, with the sesamoid-phalangeal ligaments the most common. Diagnosis, classification, and treatment options rely on clinical evaluation and specific magnetic resonance imaging findings. It is vital for radiologists to understand the anatomy, pathophysiology, and imaging findings of turf toe injuries to ensure an accurate diagnosis and appropriate management.

[Case report: Great toe dorsal defect reconstruction by cross-toe flap]. / Cas clinique : reconstruction d'une perte de substance de la face dorsale de l'hallux par lambeau cross-toe.

Reconstruction of hallux soft-tissue defects is essential for the locomotor function. Some regional flaps are available and have to be preferred in case of small defect. Here, we present the case of a patient treated by a cross-toe flap in order to cover an exposed hallux proximal interphalangeal joint, after an open fracture. The functional outcome of this reliable and easy flap was very satisfying, with quick wound healing and resumption walk.

The reconstruction of fingertip injury by mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique based on the equivalent design theory.

INTRODUCTION: How to reconstruct the damaged fingertip is a clinical problem. Our team propose the theory of equivalent design and use the mini toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique to reconstruct Allen's type II fingertip injury. Thus, we perform the retrospective study to evaluate the effects of this technique on fingertip injury. MATERIALS AND METHODS: A retrospective analysis was performed on 56 patients admitted to our hospital from January 2015 to January 2020 who used equivalently designed miniature hallux toenail flaps for the plastic repair of fingertip damage. We recorded the size of the miniature hallux toenail flap, operation time, intraoperative blood loss, and complications and calculated the survival rate of the transplanted miniature hallux toenail flap. During routine follow-up after surgery, we recorded nail growth time and observed finger appearance. At the last time of follow-up, we recorded Semmes-Weinstein evaluating tactile sensation and Two-point discrimination testing (TPD). The efficacy was evaluated by Zook score evaluation. RESULTS: The size of the mini hallux toenail flap was 0.71 cm × 1.22 cm to 0.88 cm × 1.71 cm. The operation time was (3.54 ± 0.58) hours, the intraoperative blood loss was (20.66 ± 4.87) ml, and the survival rate of mini hallux toenail flaps was 100%. The postoperative follow-up time was (30.82 ± 11.21) months, and the total nail growth time was (9.68 ± 2.11) months. The average tactile sensation evaluated by the Semmes-Weinstein test was (0.32 ± 0.14) g, and the average TPD was (7.33 ± 1.02) mm. According to Zook score, the curative effect of fifty-six cases were all excellent or good with 100% excellent and good rate, and all patients had beautiful appearances and good function of damaged fingertips. CONCLUSIONS: Based on the equivalent design theory, the mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique is an effective method to reconstruct Allen's type II fingertip injury with a beautiful appearance and good function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Lateral Toe Pulp Flap Used in Reconstruction of Distal Dorsal Toe Defect: Case Report and Review of the Literature.

BACKGROUND: When the distal dorsal part of the great toe is injured, especially with exposure of a tendon, bone, or joint, applying a free or local flap is difficult because of the lack of locally available tissue for reconstruction. Management of the distal dorsal part of a great toe soft tissue defect can be challenging for plastic surgeons. PATIENT AND METHOD: An 18-year-old woman presented with an injury to the dorsal aspect of her right great toe caused by a cobra bite. After fasciotomy, the wound showed exposure of the extensor hallucis longus tendon. After demarcation and infection control, the wound was reconstructed using a lateral toe pulp flap of approximately 3.5 × 1.0 cm. The flap was transposed to the defect, and the donor site was closed primarily. Toe pulp flaps are mainly used to reconstruct finger pulp defects and are useful because they provide a glabrous skin flap suitable for resurfacing fingertip injuries. A lateral toe pulp flap uses a homodigital adjacent skin flap, which is transposed to cover the soft tissue defect. Using a quick and straightforward procedure, we designed this flap to reconstruct a distal dorsal defect of the great toe, with minimal morbidity at the donor site. RESULTS: The flap initially showed mild congestion but survived completely. CONCLUSIONS: Applying a lateral toe pulp flap is a quick, simple, and reliable 1-stage procedure. It may be an effective option in reconstructing distal dorsal defects of the great toe.

Fracture of a Bipartite Medial Hallux Sesamoid Masquerading as a Tripartite Variant: A Case Report and Review of the Literature.

We report a case of a competitive athlete who complained of chronic pain over the first metatarsal head in the absence of preceding trauma that was exacerbated with forced plantar flexion of the big toe. Initial radiographic findings suggested a tripartite appearance of the medial hallux sesamoid, and the patient was treated as for sesamoiditis. However, persistent symptoms over a period of 12 months necessitated further imaging with magnetic resonance, which confirmed a fracture of the bipartite medial hallux sesamoid. Considering that it is clinically important to differentiate between a tripartite/multipartite hallux sesamoid variant and a fracture of a bipartite hallux sesamoid, an expedient diagnosis is vital to avoiding complications of stress fractures. This can be a diagnostic challenge for the radiologist, emergency physician, and orthopedic surgeon, requiring a high index of suspicion. Accurate and timely diagnosis can be achieved with a clear history, detailed physical examination, and appropriate radiological evaluation.

Modified Extension Block Technique for Bony Mallet Injury of the Hallux.

Bony mallet injury of the hallux is uncommon. In the few reports of this injury, authors have described surgical treatments such as closed reduction with percutaneous pinning and open surgical fixation with Kirschner wires or a suture anchor. However, the appropriate surgical management for this injury remains controversial. In this article, we describe a case of bony mallet injury of the hallux repaired with the modified extension block techniqueusing 3 Kirschner wires. This method is an effective and simple treatment to allow anatomic reduction of the displaced articular fracture fragment without incision, residual hardware, or the complications associated with open surgical treatment.

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction.

BACKGROUND: Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers. METHODS: We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues. RESULTS: At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported. CONCLUSIONS: Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible. LEVEL OF EVIDENCE: IV (Case Series).

Reconstruction of Neglected Flexor Hallucis Longus Tendon Rupture: A Case Report.

Isolated rupture of the flexor hallucis longus tendon is an unusual injury. We present the case of a neglected flexor hallucis longus tendon closed traumatic rupture at the plantar aspect of the first phalangeal head of the great toe in a middle-age male. The injury occurred while he was dancing. Because end-to-end tendon suture was impossible, the ensuing gap was repaired using a free plantaris tendon graft. We present the operative repair benefit of the flexor hallucis longus tendon rupture to regain the function and strength of the interphalangeal joint of the hallux, avoid extension of the distal phalanx, and maintain the longitudinal arch of the foot.

Reversed First Dorsal Metatarsal Artery Island Flap for First Ray Defects.

Reconstruction of the first ray is challenging because of poor skin laxity, bone and tendon exposure, and limited local flap options. Repair using full- or split-thickness skin grafts is generally not an option because of the bone and tendon exposure. Reconstructive options using local flaps from the distal foot area are restricted owing to insufficient soft tissue. Many reconstructive options have been described to overcome these difficult situations. We present 2 cases in which the great toe and first ray defect were repaired using a reversed first dorsal metatarsal artery island flap. The findings from these clinical cases and anatomic studies have shown that the reversed first dorsal metatarsal artery island flap is an alternative and suitable option for reconstruction of soft tissue defect of the distal foot, especially first and second ray defects, because it is thin and simple, has anatomic characteristics similar to those at the recipient site, and results in minimal donor site morbidity.

Split Peroneus Longus Free Tendon Autograft Transplantation for the Treatment of Neglected Extensor Hallucis Longus Tendon Laceration: A Case Report.

A neglected laceration of the extensor hallucis longus (EHL) tendon is rare. Retraction of the tendon ends often occurs when a laceration is neglected, leading to a substantial tendon deficit. A paucity of case reports is available describing the treatment of EHL laceration with a large area of gap secondary to retraction. Therefore, the treatment recommendations are limited. We present the case of a neglected EHL tendon laceration with a 10.5-cm gap in a healthy 22-year-old female. The EHL tendon laceration was repaired using a split peroneus longus tendon autograft that, to the best of our knowledge, has not been previously reported. At the 3-year follow-up evaluation, the patient retained full function of her hallux and was free of symptoms.

Return to sport following stress fractures of the great toe sesamoids: a systematic review.

Introduction: This review aims to provide information on return rates and times to sport following stress fractures of the great toe sesamoids (SFGTSs). Sources of data: A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'stress', 'fractures', 'great', 'toe', 'sesamoid', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'. Areas of agreement: Fourteen studies were included: three studies reported on the outcome of conservatively-managed SFGTSs; thirteen studies reported on the outcome of surgically-managed SFGTSs. The management principles were to attempt conservative management for 2-6 months using activity modification, analgesia, orthotics and physiotherapy; if symptoms persisted following this, surgical management was to be recommended, either with internal fixation or sesamoidectomy. Areas of controversy: The optimal treatment modalities for SFGTSs remain to be defined. Growing points: Internal fixation shows the best return to full-level sport rates with low rates of complications. Areas timely for developing research: Future prospective studies should aim to establish the optimal treatment modalities for SFGTSs.

Open physeal fracture of the distal phalanx of the hallux.

Open physeal fractures of the distal phalanx of the hallux are the lesser described counterpart to the same fracture of the finger, known by its eponym as a "Seymour fracture". Displaced Salter-Harris phalangeal fractures present with a concomitant nailbed or soft tissue injury. Often these fractures occur in the summer months when open-toe footwear can be worn, however, they may occur indoors as well. Frequently, the injury results from direct axial load of the toe, or "stubbing", which causes the fracture and associated soft tissue injury. Prompt diagnosis and appropriate treatment is necessary to prevent negative sequelae such as osteomyelitis, malunion, nonunion, or premature growth arrest. In this article, we present a 12year-old male who sustained an open physeal fracture of the distal phalanx when he "stubbed" his great toe on a bed post. His injury was initially misdiagnosed at an urgent care facility, thereby delaying appropriate intervention and necessitating an operative surgical procedure. Additionally, we review the existing literature discussing these infrequently reported injuries, as well as present key points as they pertain to the diagnosis and management of this injury in the emergency department.

Gradual Correction of Traumatic Hallux Varus With Metatarsal Hemicallotasis.

Traumatic hallux varus associated with osseous deformity, especially in the case of a decreased distal metatarsal articular angle, is an extremely challenging, but rewarding, deformity to treat. To the best of our knowledge, no previous reports have referred to surgical correction of traumatic hallux varus using first metatarsal hemicallotasis. We report the case of a 54-year-old male with traumatic hallux varus associated with medial subluxation of the second metatarsophalangeal joint and second metatarsocuneiform joint arthrosis. The patient was successfully treated with metatarsal hemicallotasis with medial soft tissue release, a proximal second metatarsal shortening osteotomy, and second metatarsocuneiform joint arthrodesis. After 1 year and 6 months, the correction had been maintained in a suitable position, no discomfort or pain was present, and the patient was completely satisfied with the surgical results. Metatarsal hemicallotasis can safely determine the angle of correction and minimize the risk of avascular necrosis of the metatarsal head even in deformed halluces with previous traumatic injuries and/or surgical treatment. This technique should be indicated only for hallux varus with a decreased distal metatarsal articular angle, an angular-type metatarsal head, and good metatarsophalangeal joint congruence.

Displaced intra-articular fractures of the great toe in children: intervene with caution!

BACKGROUND: Intra-articular fractures of the proximal phalanx of the great toe in children are extremely rare and sparsely reported in the literature. We have noted a series of these fractures at our institution. The purpose of this report is to present a retrospective case series of children with intra-articular fractures managed operatively in order to highlight the inherent difficulties in managing these fractures. METHODS: Operative notes and billing records were searched from 2001 to 2011 to identify all children aged 18 years or younger who underwent surgical intervention for an intra-articular fracture of the proximal phalanx of the great toe. Charts and imaging studies were retrospectively reviewed to identify the mechanism of injury, fracture classification, operative details, clinical results, and complications. RESULTS: Seven boys and 3 girls with a mean age of 12.6 years (range, 8.7 to 15.7 y) were identified. The mechanism of injury was a direct blow from a stubbed toe (8 cases) or a dropped object onto the foot (2 cases). There were 7 intra-articular fractures of the proximal phalanx base, 4 of which occurred in the setting of an open physis. Mean fracture displacement was 4.4 mm. Open reduction was necessary in 9 cases, with K-wire fixation used in 9 cases. Median follow-up was 50.5 months (range, 11 to 123 mo). Seven fractures healed at a mean of 7.9 weeks. Nine patients returned to full activity without limitation at latest follow-up. Six patients had significant complications: 2 underwent revision open reduction internal fixation (one for postoperative redisplacement and the other for painful nonunion), 1 suffered a refracture, 1 developed posttraumatic arthritis requiring interphalangeal joint fusion, 1 developed an asymptomatic fibrous nonunion with avascular necrosis of the fragment, and 1 had K-wire migration necessitating early surgical removal. CONCLUSIONS: Intra-articular fractures of the great toe primarily occur in adolescents after direct impact injuries. The most common location was the proximal phalangeal base. There is a high complication rate after surgical intervention, although most patients were asymptomatic at latest follow-up. LEVEL OF EVIDENCE: IV (retrospective case series).

[Anatomical reconstruction of fresh, malunion and nonunion of fractures of the sesamoid bones of the hallux]. / Anatomische Rekonstruktion frischer und fehlverheilter Sesambeinfrakturen.

BACKGROUND: Multifragmentary sesamoid bones of the hallux have established the concept of sesamoidea multipartita which is explained as a congenital characteristic of these bones. Sesamoid bones although fragmented are often asymptomatic as are, for example fragmented patellae. Evidence shows, however, that fragmentation of sesamoid bones is significantly more frequent in young people active in sports (soccer). The diagnosis of traumatic fractures and subsequent pain and disability is a challenge. Patients often present to physicians relatively late and are, therefore, treated in the acute phase long after onset of pain. METHOD: Inquisitive interview of the patient and precise examination together with a detailed radiological investigation (computed tomography) are essential to be able to determine a causal relation to the fragmentation of sesamoid bones. Treatment consists of an anatomical reconstruction of vital bone fragments possibly augmented with an autologous cancellous bone graft after debridement. Surgical approaches are longitudinal medial for the medial sesamoid bone and longitudinal plantar for the lateral sesamoid bone. The means of fixation mostly involves two 1.5 mm screws for optimal mechanical stability.

Lateral collateral ligament reconstruction for chronic varus instability of the hallux interphalangeal joint.

Chronic varus instability of the hallux interphalangeal joint is a rare injury, and only a few reports of this injury have been published. In some studies, this injury has been related to taekwondo. Taekwondo is an essential martial art in the Korean military. We have described a case of varus instability of the hallux interphalangeal joint in a professional soldier who had practiced taekwondo for 5 years and the surgical outcome after reconstruction of the lateral collateral ligament with the fourth toe extensor tendon.

An atraumatic turf toe in an elite soccer player--a stress related phenomenon?

Plantar plate injuries to the hallux in elite athlete could potentially be career threatening. Reports in the literature are invariably linked to a significant traumatic episode. The occurrence of an atraumatic severe plantar plate injury in the presence of a bipartite sesamoid may suggest a stress related phenomenon. We present a case in an elite soccer player who was treated surgically and returned to top-level competition. The case is reported in detail and differences to other reports in the literature discussed.

First Metatarsal Headphones-Like Lesion: A Case of Unreducible Sesamoid Complex Dislocation.

CASE: A 34-year-old woman sustained a direct trauma to the left hallux during a fall. Radiographs showed a dorsal dislocation of the first metatarsophalangeal joint and a wide separation of sesamoid complex. Closed reduction was tried: postreduction radiographs displayed reduction of first metatarsophalangeal joint and a complete sesamoid complex dislocation. The patient was scheduled for surgery. Through a medial approach, open reduction together with plantar structures release and repair were performed. Functional and radiographic outcomes were satisfactory at the last follow-up. CONCLUSION: In case of a "headphones-like lesion" surgery is required, together with plantar structures repair.