Predislocation Syndrome

Question 1

Where is the plantar plate attached to?

Answer 1

firmly attached to base of proximal phalanx

loosely attached to head of metatarsal

Question 2

what is turf toe?

Answer 2

hyperextension of 1st MPJ

Question 3

what is sand toe?

Answer 3

hyperflexion of 1st MPJ

Question 4

describe the relationship of the lumbricals and interossei to the deep transverse metatarsal ligament.

Answer 4

interossei- lie above

lumbricals- lie below

Question 5

what PE finding is positive in predislocation syndrome?

Answer 5

vertical stress test (Lachman/drawer test)

Question 6

what is the staging system for predislocation syndrome?

Answer 6

Yu and Judge

Question 7

What is Yu and Judge stage 1?

Answer 7

mild plantar/dorsal edema
extreme tenderness with palpation
no clinical malalignment

Question 8

What is Yu and Judge stage 2?

Answer 8

moderate edema
toe doesn’t purchase ground in stance
deviation of toe both clinically and radiographically

Question 9

What is Yu and Judge stage 3?

Answer 9

moderate edema; extends into toe
more pronounced deviation with possible dorsal dislocation
can proceed to crossover 2nd toe

Question 10

what additional imaging can you do if MRI/CT isn’t available?

Answer 10

arthrogram

Question 11

what stage of predislocation is it if a toe doesn’t purchase the ground during stance?

Answer 11

stage 2

Question 12

What structures attach to the plantar plate?

Answer 12

plantar fascia
collateral ligaments of MPJ
transverse metatarsal ligament
interossei 
flexor tendons

Question 13

Why is there a reported healing problem after plantar plate tears?

Answer 13

type 1 collagen is most abundant in the plantar plate (75%) and the next most common is type 2 collagen (21%). this collagenous composition may be a factor that affects poor healing capability of plantar plate. The same healing problem is reported to occur in the meniscus of the knee where there is also a high level of type 1 collagen.

Question 14

What are some DDx for pain localized to the 2nd MTPJ?

Answer 14

capsulitis
Freiberg infarction
metatarsal stress fx
neuroma

Question 15

conservative treatment options?

Answer 15

NSAIDs or steroidals (prednisone taper) 
Figure 8 taping
Budin splint
orthotics: metatarsal pad
shoe modifications- extra wide
CAM boot 
steroidal injections *may cause rupture of PP

Question 16

How can you use a flexor tendon transfer to your advantage to correct a transverse plane deformity?

Answer 16

the contracture structures on the side of the MTPJ to which the toe is deviated are released through a dorsal incision. Harvest the FDL tendon and split it longitudinally, wrapping each end of the tendon dorsally around the medial or lateral sides of the proximal phalanx.

Question 17

What distal metatarsal osteotomy can be performed to correct transverse plane deformity?

Answer 17

Weil osteotomy - allows shortening of teh metatarsal, decompression of the MTPJ, and translocation of the capital fragment in the transverse plane and sutured to the extensor hood.

Question 18

what is the recommended amount of translocation of the met head?

Answer 18

no more than 1/3 to 1/2 the met head width

Question 19

The FDL transfer (flexor-to-extensor transfer) corrective procedure for transverse plane digital deformity is aka?

Answer 19

Girdlestone-Taylor

Question 20

if the 2nd toe is deviating medially, which collateral would you cut to correct the transverse plane deformity?

Answer 20

medial collateral ligament

the medial collaterals are tight; lateral collaterals are stretched

Question 21

why is a dorsal-medial dislocation following failure of plantar plate seen more commonly?

Answer 21

(think about the anatomy!) the second toe is anatomically unique, having insertions of 2 dorsal interosseous tendons but no plantar interosseous tendon. The lumbrical tendon has a medial insertion and provides a slight medial pull in the 2nd toe. Both lumbricals and interossei provide most of the flexion that occurs at the lesser MPJs under normal circumstances, but with dorsal subluxation, they migrate dorsal to the axis of the MPJ and subsequently lose their mechanical ability to provide flexion of the joint.