What is the appropriate management for a patient with a 4th metatarsophalangeal joint dislocation and mild osteoarthritis in the 1st metatarsophalangeal joint?

Management of 4th Metatarsophalangeal Joint Dislocation with 1st MTP Joint Osteoarthritis

For a 4th metatarsophalangeal joint dislocation, closed reduction should be attempted first, followed by immobilization and rehabilitation, with surgical intervention reserved for irreducible dislocations or failed conservative management.

Initial Management of 4th MTP Joint Dislocation

Closed Reduction

• Attempt closed reduction under appropriate analgesia/sedation
• The metatarsal head is often trapped between the plantar fibrocartilaginous plate, dorsal capsule, deep transverse metatarsal ligament, flexor tendons, and lumbrical tendons 1
• Reduction technique:
  • Apply longitudinal traction to the toe
  • Apply pressure on the base of the proximal phalanx to guide it back into position
  • Gently flex the toe while maintaining traction

Post-Reduction Care

• Confirm reduction with post-procedure radiographs
• Immobilize with buddy taping to adjacent toe for 3-4 weeks
• Provide a stiff-soled shoe or walking boot for 2-3 weeks to prevent re-dislocation
• Prescribe NSAIDs for pain and inflammation control

Surgical Management (if needed)

• Indications for surgical intervention:
  • Irreducible dislocation
  • Failed closed reduction
  • Unstable reduction
  • Associated fractures requiring fixation
• Surgical approach:
  • Open reduction with division of the fibrocartilaginous plate, deep transverse ligament, and dorsal capsule to facilitate reduction 1
  • Reconstruction of collateral ligaments may be necessary for stability 2

Management of Concurrent 1st MTP Joint Osteoarthritis

Conservative Management

• Custom orthotic devices with metatarsal pads to redistribute pressure
• Footwear modifications:
  • Wide toe box
  • Rocker-bottom soles
  • Low heels
• Physical therapy:
  • Toe and foot strengthening exercises
  • Range of motion exercises
  • Gait training

Surgical Options (if conservative measures fail)

• For mild to moderate osteoarthritis:
  • Cheilectomy (removal of bone spurs)
  • Metatarsal osteotomy to realign the joint
• For advanced osteoarthritis:
  • Metatarsophalangeal joint arthroplasty 3
  • Arthrodesis for end-stage disease

Follow-up Care and Rehabilitation

Early Phase (0-2 weeks)

• RICE protocol (Rest, Ice, Compression, Elevation)
• Protected weight-bearing with appropriate footwear
• Gentle range of motion exercises after initial pain subsides

Intermediate Phase (2-6 weeks)

• Progressive weight-bearing as tolerated
• Increase range of motion exercises
• Begin strengthening exercises for intrinsic foot muscles

Late Phase (6+ weeks)

• Return to normal footwear and activities as tolerated
• Continue strengthening and proprioceptive exercises
• Consider custom orthotics for long-term management

Common Pitfalls to Avoid

• Failing to recognize associated injuries (tarsometatarsal joint disruptions occur frequently with MTP dislocations) 4
• Neglecting to address both conditions simultaneously, as altered biomechanics from one condition can affect the other
• Inadequate immobilization after reduction, leading to recurrent dislocation
• Overlooking the need for proper footwear modifications to prevent recurrence
• Delaying surgical intervention when closed reduction fails or is unstable

Special Considerations

• Athletes may require more aggressive rehabilitation and preventive measures to allow return to sports 5
• Consider stiffening the forefoot in athletic shoes or using orthotic devices to prevent recurrence in active individuals
• Regular follow-up is essential to monitor for development of post-traumatic arthritis