Figure 1. Front view image of the toes.
Figure 2. Side view image of the toes.
Figure 3. Lateral radiograph of the toes.
A 56-year-old woman presents to the emergency department with pain and deformity of her right third toe after striking her foot against a corner wall. Inspection of the toes reveals bruising; the overlying skin is intact (Figures 1 and 2). Lateral radiograph of the foot (Figure 3) is obtained.
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Dislocation of the toe is a relatively rare diagnosis and can present with subtle physical findings that can often be missed during examination. The patient’s third toe shows loss of normal proximal interphalangeal joint flexion and dorsal translation of the joint. Lateral radiograph of the toe shows a dorsal dislocation of the proximal phalanx.
Management of a simple dislocation requires straight traction that is often sufficient to release the toe joint. Closed reduction (popping the joint into proper position) and splinting is typically adequate to maintain joint stability until the soft tissues heal.
However, up to 40% of toe dislocations may not be amenable to closed reduction.1 In these cases, the plantar plate can fold into the interphalangeal joint and block reduction.
A reduction maneuver that helps with an unstable joint involves dorsal flexing of the toe to exaggerate the deformity. Dorsal traction is then placed on the toe followed by plantar flexion until a palpable click is felt.
Redislocation and instability is common with toe fractures, and Kirschner wire fixation to hold the reduction in place may be required. The Kirschner wire is often removed 3 to 4 weeks after placement, allowing enough time for soft tissue healing for joint stability. Closed reduction should always be attempted prior to Kirschner wire fixation.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants.
1. Yang IB, Sun KK, Sha WL, Yu KS, Chow YY. Interphalangeal dislocation of toes: a retrospective case series and review of the literature. J Foot Ankle Surg. 2011;50(5):580-584.
2. Weinstein RN, Insler HP. Irreducible proximal interphalangeal dislocation of the fourth toe: a case report. Foot Ankle Int. 1994;15(11):627-629.