Pertinent Pearls On Treating First MPJ Injuries In Athletes

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A Brief Overview Of First MPJ Structures

Capsule
Collateral ligaments
Flexor hallucis brevis muscle and tendon
Adductor hallucis muscle and tendon
Abductor hallucis muscle and tendon
Flexor hallucis longus insertion
Extensor hallucis longus insertion
Extensor hallucis brevis insertion
Intersesamoid ligament
Sesamoids

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Author(s): 
A. Douglas Spitalny, DPM, FACFAS

   Acute treatment for turf toe injuries always entails ice and time off from the sport. The degree of edema and ecchymosis that develops will be the clue of a more significant injury. When the athlete has significant pain with first MPJ range of motion, then MRI is necessary. Further treatment will be based solely on the MRI findings. Simple strains may only require taping and stiffer shoes while tears will benefit from plantarflexed splinting of the first MPJ and four to six weeks on crutches.

What You Should Know About Hallux Fractures

Fractures of the hallux do not pose diagnostic challenges but there is significant debate on how to treat them. Fractures of the hallux may be either extra-articular or intra-articular. Obviously, intra-articular fractures of the first IPJ or first MPJ are far more concerning because of the risk of future post-traumatic arthritis.

   Fractures may involve the distal phalanx or proximal phalanx. Anatomically, fractures can involve the head, base or shaft of the proximal phalanx, and the distal tuft and base of the distal phalanx. Other than shaft fractures, the majority are avulsion-type fractures. There are tendon, ligament and capsular structures that insert on the distal and proximal phalanx. We can see avulsion fractures at any one of those attachments. The larger the fracture piece, the greater the likelihood that surgical intervention will be necessary.3,10

   Personally, I have been very aggressive in fixing intra-articular fractures of the hallux. Of course, any displaced fractures will automatically be dealt with surgically. Recovery often takes three to four months regardless of the treatment but one must caution athletes in regard to chronic hallux swelling. Ultimately, the chronic swelling associated with hallux fractures will always delay an athlete’s ability to wear shoes, let alone compete.

Salient Insights On Managing Sesamoid Fractures

Sesamoid fractures are more often associated with hyperdorsiflexion injuries often leading to splitting of the sesamoid in either half, thirds or tiny avulsions. Crush injuries can occur but are not related to hyperflexion injuries. Sesamoid injuries can also lead to bipartite and tripartite disruptions, which can be just as devastating as a fracture. In my experience, fractures tend to heal better than fibrous disruptions. The position of the foot will determine which of the two sesamoids are injured. Every surgeon prays that the tibial sesamoid is the one injured simply because it is so much easier to deal with surgically if it fails to heal.11-12

   Surgeons need to thoroughly understand the mechanism of injury because sesamoid fractures are often associated with significant soft tissue injury. Frequently, it is the soft tissue component that will determine the outcome. Do not forget to assess the soft tissue structures via MRI. Although treatment may remain the same, the recovery will always be longer for the soft tissue component of these injuries: six to eight months versus three to four months for a simple sesamoid fracture.

   More importantly, how do we deal with sesamoid fractures acutely? There are several reports of open reduction internal fixation (ORIF) for sesamoid fractures and there are numerous reports of how to fixate a sesamoid.13,14 I think the jury is still out on the success of sesamoid ORIFs. During my career, I have seen over 300 sesamoid fractures and I have not needed to fixate one acutely.

   How should we treat sesamoid fractures non-surgically? The only method I have had success with is splinting the first MPJ into a plantarflexed position and casting for six weeks. Additionally, I do not clear patients to run for four to six months.

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