Metatarsal Shaft Research Articles

A New Technique for Lesser Metatarsal Osteotomy in the Treatment of Metatarsalgia

Metatarsalgia is a commonly presenting complaint to foot and ankle surgeons and can be a very debilitating condition. It is heralded by the presence of diffuse pain in the area around the metatarsal heads, often times accompanied by intractable plantar keratosis. Causes may include (1) bony (long second metatarsal, posttraumatic deformity, prominent condyle); (2) metatarsophalangeal joint instability with resultant displacement of the plantar fat pad; (3) hypermobility of the first ray leading to lesser metatarsal overload (hallux valgus, generalized ligamentous laxity); (4) iatrogenic (hallux valgus correction, with a shortening of the first metatarsal leading to transfer metatarsalgia); or (5) systemic disease (eg, rheumatoid arthritis, seronegative arthritides). With numerous etiologies, the management of this condition has varied considerably over the years. Nonoperative management is the first line of treatment. This can be accomplished with rest, footwear modification, an orthotic with a metatarsal pad, immobilization in a cast, medication (nonsteroidal anti-inflammatory drugs), or through an intra-articular steroid injection. Only when nonsurgical measures have been exhausted should surgery be contemplated. It is important to determine the cause of pain so that operative treatment can be tailored appropriately. In this study, we will be proposing a new, less technically demanding technique for the shortening of metatarsals in the treatment of metatarsalgia. This technique can be used in isolation or in combination with other procedures depending on the cause of pain and deformity. When a metatarsal requires shortening we recommend an extra-articular metatarsal shaft osteotomy with rigid plate fixation.

Fracture-Dislocation of the Second Metatarsophalangeal Joint

Traumatic second metatarsophalangeal dislocation is extremely rare. This article reports a case of traumatic second metatarsophalangeal dislocation associated with fracture of the second metatarsal shaft. Anatomical reduction is indispensable to preserve the function of the metatarsophalangeal joint and to avoid joint ankylosis and chronic foot pain. The patient was treated with open reduction of the fracture without violating the joint to decrease postoperative stiffness. He was followed-up for 6 months. The patient resumed full activity 3 months after surgery, with his joint attaining full range of movement. He reported no pain or joint stiffness during his last visit. To our knowledge, no similar injury has been reported previously.

The microvascular anatomy of the metatarsal bones: a plastination study

The purpose of this study was to categorize and systematize the arterial supply of the metatarsal bones and furthermore the observation of arterial lesions after frequently performed forefoot surgeries. Twenty-two cadaver feet were analyzed by two plastination methods and the enzyme maceration method. Five forefoot surgeries were performed after arterial injections. The bases of the metatarsal bones were primarily supplied by dorsal and plantar arteries. The arterial supply of the metatarsal diaphysis was given by a frequently observed nutrient artery. The first plantar metatarsal artery was the main supply of the first metatarsal head. The plantar and dorsal metatarsal arteries supplied the lesser metatarsals heads. The forefoot surgeries revealed lesions of arteries in all cases. The plastination methods were excellent methods to analyze the arterial supply. In addition arterial damage after forefoot surgeries could be analyzed with these methods.

Treatment of medial condylar fractures of the third metatarsus in three horses with fibreglass casts under standing neuroleptanalgesia

Minimally displaced condylar fractures propagating into the third metatarsal diaphysis were treated conservatively in one thoroughbred and two Arabian racehorses. In each case a neuroleptanalgesic protocol provided adequate pain relief...

MRI of Metatarsal Head Subchondral Fractures in Patients with Forefoot Pain

The purpose of our study was to determine the MRI features of metatarsal head subchondral fractures in symptomatic adults. A retrospective review of foot MRI procedures was performed to detect cases of metatarsal head subchondral fractures over a 6-year period. MR images of selected cases were analyzed by two reviewers for the presence of subchondral fracture, marrow edema-like pattern, metatarsal head flattening, and subchondral sclerosis. Patients with a history of foot surgery, infection, or inflammatory arthritis were excluded. Assessment for coexisting osseous and soft-tissue abnormalities was also performed. Subchondral fractures of the metatarsal heads were seen in 14 patients. All patients were women. The metatarsal head most commonly affected was the second (71%, 10/14) and the dorsal third of the metatarsal articular surface was involved in 79% (11/14). MRI findings of subchondral fracture of the metatarsal head with severe marrow edema-like pattern were seen in 71% (10/14), suggesting early stage changes. Metatarsal head collapse with subchondral sclerosis and mild or absent marrow edema-like pattern were seen in 29% (4/14) indicating late-stage changes. Concurrent abnormalities included three patients (21%) with metatarsal shaft fractures and one patient (7%) with an interdigital neuroma. One subject was treated surgically. Subchondral fractures of the metatarsal heads can be detected on MR examinations of adults with forefoot pain. A subchondral fracture with associated marrow edema-like pattern is the most common presentation and likely reflects early stages of metatarsal head infraction.

The Lindgren and Chevron Osteotomies Were Not Different in Repair of Hallux Valgus

Question: In patients with hallux valgus, how does the Lindgren osteotomy compare with the distal chevron osteotomy? Design: Randomized (allocation concealed), blinded (outcome assessor), controlled trial with mean 4.7-year follow-up. Setting: A hospital in Stockholm, Sweden. Patients: 100 patients, 16 to 80 years of age (mean age 48 y, 94% women), with a hallux valgus angle (HVA) of 20° to 44°, a first-second intermetatarsal angle (IMA) of up to 20°, a distal metatarsal articular angle of up to 25°, no radiographic evidence of degenerative metatarsophalangeal (MTP) arthritis, and persistent symptoms. Exclusion criteria were a previous operation on the affected foot or a history of diabetes, peripheral vascular disease, peripheral neuropathy, rheumatoid arthritis, or other inflammatory diseases. Ninety percent of patients were available for a mean 4.7-year follow-up. Intervention: Patients were allocated to receive an osteotomy according to the Lindgren method (n= 50) or the chevron method (n = 50). The Lindgren osteotomy was subcapital and extra-articular. The straight skin incision was done medial to the extensor hallucis longus tendon. The dissection was to the bone with the saw blade aligned halfway between the perpendicular long axis of the first metatarsal and the plantar aspect of the foot. A transverse osteotomy was made at a 30° angle from the long axis of the metatarsal shaft. The distal fragment was displaced laterally, up to 8 to 10 mm. Pronation of the hallux was corrected as needed. The distal fragment was fixed with a 2.7-mm lag screw. The chevron osteotomy involved an incision over the MTP joint, placed straight medially without a tenotomy. The distal fragment was displaced laterally about 4 to 6 mm, and the osteotomy site was impacted on itself. The plantar and dorsal aspects of the flap were tightly closed before the capsular flap was reattached. No fixation was used. Main outcome measures: Functional outcome was graded with the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating system (pain [40 points], function [45 points], and alignment [15 points]); degree of pronation of the great toe (0 [no rotation] to 3 [>45° rotation]); pain on the 100-mm visual analog scale (VAS) (0 [no pain] to 100 [worst pain imaginable]); health-related quality of life in 5 dimensions (EuroQol-5D [EQ-5D]): mobility, self care, usual activities, pain or discomfort, and anxiety or depression; and radiographic parameters (HVA, IMA, and intermetatarsal distance [IMD]). Main results: At 1 year, both the Lindgren and chevron groups improved significantly in AOFAS scores (Table), VAS scores, and degree of great toe pronation, showing no difference between groups. Patients who were not satisfied with the cosmetic result (5 patients in each group) and those who had trouble wearing shoes at the time of follow-up (4 patients in each group) had lower EQ-5D scores. The HVA, IMA, and IMD decreased significantly in both groups but to a greater extent in the Lindgren group (Table). At 4.7 years, both groups showed partial loss of correction. Conclusion: In patients with hallux valgus, no significant differences in clinical improvement were seen between osteotomy performed with the Lindgren procedure or the distal chevron procedure, although a better radiographic correction was obtained with the Lindgren method.

Stress Reaction of the Fifth Metatarsal Head in a College Basketball Player

Stress Reaction of the Fifth Metatarsal Head in a College Basketball Player

Osteoid Osteoma

An osteoid osteoma located in the forefoot can be difficult to diagnose, and the diagnosis is frequently delayed. We present a clinical case of a patient with pain, erythema, and swelling of the left forefoot with no history of trauma. Although rarely seen in the metatarsal, osteoid osteoma should be included in the differential diagnosis of foot pain. Findings from radiographs, magnetic resonance images, and a detailed clinical history led to the diagnosis of osteoid osteoma of the left second metatarsal. The lesion was surgically excised using curettage. This process significantly weakened the lateral cortex of the metatarsal shaft. To correct this surgically induced stress riser, an external fixator was applied to provide stability, allow for callus distraction, and allow the patient to walk as early as possible. We review osteoid osteoma, including the classic clinical presentation and treatment associated with this benign bone tumor.

Modified Crescentic Proximal Metatarsal Osteotomy and Distal Soft Tissue Procedures in Hallux Valgus

The results of a modified crescentic proximal metatarsal osteotomy and distal soft tissue procedures for patients with symptomatic, incongruent, metatarsophalangeal joint, hallux valgus deformity were reviewed. Forty-nine feet of 41 patients were evaluated. All of the patients were male military personnel of different ranks, and their mean age was 23 years (range, 20-43 years). The mean follow-up period was 25 months (range, 10-60 months). The patients were evaluated according to the American Orthopedic Foot and Ankle Society forefoot scoring system. The mean preoperative score was 54.4, and the mean postoperative score was 95.4. The mean hallux valgus angle was 39.4 degrees before surgery and 12.8 degrees after surgery (26.6 degrees correction); the mean intermetatarsal angle was 15.9 degrees before surgery and 7.1 after surgery (8.8 degrees correction). A total of 93.8% of the patients were satisfied with the results of the procedure. Complications included delayed union in one case and superficial wound infections in two cases. We also emphasize small modifications performed while shifting the metatarsal shaft laterally and compare the results of our study with those of similar studies.

Isolated lower extremity metastases, 9 years after initial diagnosis of retinoblastoma

We report the development of isolated lower extremity metastases, in a child, 9 years after her initial diagnosis and treatment of bilateral infantile retinoblastomas. The radiographic, scintigraphic, computed tomographic, and magnetic resonance imaging findings are discussed. The dominant metastatic focus was blastic, involving the medial cuneiform. Additional occult lesions were found in the base of the second metatarsal, middle cuneiform, navicular and tibial diaphysis. An open biopsy confirmed the diagnosis. The occurrence of late distant metastases is rare in the USA.

Efficacy and Mechanism of Orthotic Devices to Unload Metatarsal Heads in People With Diabetes and a History of Plantar Ulcers

Total-contact inserts (TCIs) and metatarsal pads (MPs) frequently are prescribed to reduce excessive plantar stresses to help prevent skin breakdown in people with diabetes mellitus (DM) and peripheral neuropathy. The first purpose of this study was to determine the effect of a TCI and an MP on metatarsal head peak plantar pressures (PPP) and pressure-time integrals (PTI). The second purpose of this study was to determine a possible mechanism of pressure reduction by measuring contact area and loaded soft-tissue thickness (STT) under the metatarsal heads and second metatarsal shaft. Twenty subjects (12 men and 8 women; age [mean+/-SD]=57+/-9 years) with DM (duration [mean+/-SD]=16+/-11 years), peripheral neuropathy, and a history of plantar ulcers participated. A repeated-measures research design was used, and outcome measures are reported for 3 footwear conditions: shoe, shoe with TCI, and shoe with TCI and MP. In-shoe plantar pressures were collected during walking and during spiral x-ray computed tomography (SXCT). The STT and identification of the pressure sensor and location of the MP in relationship to the metatarsal heads were determined by use of SXCT. The PPP and the PTI were 16% to 24% lower at the metatarsal heads in the TCI condition than in the shoe condition. The PPP and the PTI decreased an additional 15% to 28% (for a total reduction of 29% to 47%) with the addition of the MP. The contact area increased 27% with the TCI but not with the MP. The STT did not increase under the metatarsal heads in the TCI condition (compared with the shoe condition) but did increase 8% to 22% at metatarsal heads 2 to 5 with the addition of the MP. The PPP increased substantially (308%) and the STT decreased 14% under the shaft of the second metatarsal with the addition of the MP to the TCI-plus-shoe condition. The TCI and the MP caused substantial and additive reductions of pressures under the metatarsal heads. The TCI reduces excessive pressures at the metatarsal heads by increasing the contact area of weight-bearing forces. Conversely, the MP acts by compressing the soft tissues proximal to the metatarsal heads and relieving compression at the metatarsal heads. These findings can assist in the design of effective orthotic devices to relieve excessive plantar stresses that contribute to skin breakdown and subsequent amputation in people with DM and peripheral neuropathy.

Plantar Forefoot Pressure Changes After Second Metatarsal Neck Osteotomy

The aim of this study was to evaluate plantar pressure changes after second metatarsal neck osteotomy using the Weil technique. Six below-knee cadaver specimens were used. Each specimen was held in a custom-built apparatus and loaded to 500 N for a period of 3 seconds. Using a computerized Musgrave pedobarograph, pressure measurements were made before and after osteotomy in both neutral and 45-degree heel rise positions. All osteotomies were made at an angle of approximately 20 degrees relative to the long axis of the metatarsal shaft. The metatarsal heads were displaced proximally by 5 mm and fixed with a single Kirschner wire. After osteotomy there was an average decrease in pressure beneath the second metatarsal from 70.6 to 45.1 kPa in neutral and from 813.0 to 281.4 kPa in heel rise, representing statistically significant (p < or = 0.05) decreases of 36% and 65%, respectively. There also were significant decreases beneath the third metatarsal in both neutral (39%) and heel rise (37%), and beneath the fourth metatarsal in neutral position (28%). A significant pressure increase occurred beneath the first metatarsal in neutral (23%). No significant pressure changes occurred under the fifth metatarsal in either position. Overall, our results indicated that the Weil metatarsal neck osteotomy is effective at offloading the second metatarsal head at neutral and heel rise positions.

Cross-sectional geometry of the human forefoot

The human forefoot presents an interesting biomechanical problem of clinical importance because loads are distributed unequally across multiple bones. The fact that long bones typically have a several-fold safety factor relative to peak loads suggests that metatarsal strengths should be related to their peak loads. This study is the first to systematically examine the cross-sectional geometric properties of the human forefoot and their relationship to external loads during walking and running. We report midlength cross-sectional geometric properties ( CA, Ix, Iy, Imax, Imin, J, Zx, and Zy) of metatarsals (1–5) and the hallucial proximal phalanx of a shod industrial population ( n = 40) obtained using computed tomography. We then examine the relationship between these measures of shaft strength and published plantar pressure data sets recorded during the following functional activities: standing, at the push-off stage of the walking cycle, the full walking cycle, and running. Cross-sectional geometric properties of the first ray are greater than those of other rays, even when scaled to bone length. This pattern corresponds to the high pressures recorded for the first ray during most activities. The relationships between cross-sectional geometric properties of the lateral metatarsals and peak plantar pressure data are more complex. Metatarsals 2–4 are weakest in most cross-sectional geometric properties. However, metatarsal 2, and to a lesser extent metatarsal 3, experience relatively high peak pressures. On average, geometric measures of axial and bending strengths (adjusted relative to body size) are lower in females than males, and in European Americans than in African Americans, which corresponds to the respective rates of general metatarsal stress fracture in these groups. The discrepancy between strength and plantar pressure values in metatarsals 2 and 3 is consistent with the high incidence of stress fractures in these bones and underscores the importance of soft tissues, such as the plantar fascia and flexor musculature, in moderating metatarsal shaft strain.

Transfer metatarsalgia after hallux valgus correction alleviated by ‘auto-Helal’ osteotomy of the second metatarsal

There have been many procedures described for the treatment of hallux valgus deformity of the forefoot. Distal first metatarsal osteotomies remain a popular option. Transfer metatarsalgia following correction of the first ray can be an occasional complication of this type of surgery [Laughlin TJ. Complications of distal first metatarsal osteotomies. J Foot Ankle Surg 1995;34:524–31; Kinnard P, Gordon D. A comparison between chevron and Mitchell osteotomies for hallux valgus. Foot Ankle 1984;4:241–3] and the subsequent treatment of these patients can be difficult [Feibel JB, Tisdel CL, Donley BG. Lesser metatarsal osteotomies. A biomechanical approach to metatarsalgia. Foot Ankle Clin 2001;6:473–89]. Helal described an oblique osteotomy of the distal metatarsal shaft [Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg [Br] 1975;57:187–92] and this has been used with varying degrees of success in the past [Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg [Br] 1975;57:187–92; Trinka HJ, Kabon B, Zettl R, Salzer M, Ritschl P, Helal B. Metatarsal osteotomy for the treatment of metatarsalgia: a critical analysis of results. Orthopaedics 1996;19:457–61]. We describe the unusual course of a patient who developed metatarsalgia after a chevron osteotomy for hallux valgus.

Severe Bilateral Foot Pain In A High School Football Player

HISTORY We present a high school football player with bilateral forefoot pain. During the first week of the season, he trained once a day without pain. There was no acute injury. He then began practicing three times a day and developed gradually worsening bilateral foot pain. The pain was initially present only with activity. However, after one week of the intense training schedule, it became constant. PHYSICAL EXAMINATION The patient was a well-built football player (200 lbs. 6 ft. 3 in.) with bilateral limping. He had normal hip and leg strength and range of motion. The arches were also normal. His feet had no swelling, edema, ecchymosis, or deformities. His right forefoot was diffusely tender to palpation and the pain was greatest along the first and third metatarsals. His left forefoot was also diffusely tender to palpation, with the greatest pain along the second metatarsal shaft. DIFFERENTIAL DIAGNOSIS Metatarsal fractures, metatarsalgia, Freiberg's infraction, myofascial strain of the interossei, sprain of the transverse ligament, extensor digitorum tendonitis, Lis Franc Ligament sprain, Morton's neuromas, or metatarsal stress fractures. TEST AND RESULTS To distinguish between the above etiologies of foot pain, MRI of the feet was performed. T2 weighted images demonstrated significantly increased signal within the shafts of the right first and third metatarsals, as well as the left second metatarsal. The remainder of the metatarsals also showed mild T2 signal abnormality. There were no fracture lines seen on either T1 or T2 images. FINAL WORKING DIAGNOSIS Grade II stress fractures of the right first and third metatarsals and left second metatarsal with diffuse stress reaction throughout both feet. TREATMENT AND OUTCOMES The patient was held from athletic participation and was weight bearing as tolerated for 3 weeks, but had little improvement. He was then given crutches for 2 weeks and his symptoms improved significantly. Dietary counseling was provided and he was educated on proper footwear and training regimens. Gait analysis is planned after the symptoms are fully resolved.

Torque Resistance After Fixation of Jones Fractures With Intramedullary Screws

Intramedullary screws frequently are used for fixation of Jones fractures of the fifth metarsal. While the ability of intramedullary screw fixation in fifth metatarsals to resist bending and tensile forces is well known, the ability to withstand torsion has not been studied. This paper compares the torsional stiffness of Jones fractures treated with 6.5-mm short- threaded intramedullary screws to those treated with 5.0-mm cannulated short-threaded intramedullary screws. Nine fresh-frozen, matched pairs of cadaver fifth metatarsals had an acute Jones fracture simulated with an osteotomy. They were stabilized with intramedullary screws and then loaded to failure. The torsional stiffness of the metatarsals fixed with the 6.5-mm did not differ significantly from that using 5.0-mm screws. However, to achieve stability, the 5.0-mm screw had to be long enough to reach the metatarsal head and neck. This tended to straighten the normally curved fifth metatarsal bone and caused lateral gapping at the fracture site. Both 5.0-mm or 6.5-mm screws provide equal torsional rigidity, but 5.0-mm screws may need to be longer, which could potentially straighten the fifth metatarsal shaft in patients who have a curved fifth metatarsal.

A comparison of 4 common methods of hand-measured techniques with a computerized technique to measure the first intermetatarsal angle

Measurement of the intermetatarsal (IM) angle on plain dorsoplantar radiographs is considered a standard in the surgical evaluation of hallux valgus. The angle formed in this measurement helps determine the selection of surgical procedure. A study was performed to determine the most consistent method to radiographically measure the first IM angle. The IM angle was measured manually with a tractograph by using 4 different techniques on 50 preoperative dorsoplantar radiographs. The techniques used were 1) bisecting the shaft of the first and second metatarsals, 2) bisecting the head and base of the first and second metatarsals (center-of-head method), 3) measuring the angle from the tangent of the medial aspect of the first and the second metatarsal shaft, and 4) measuring the angle formed by the tangent of the lateral aspects of the first and second metatarsal shafts. In addition, the same 50 radiographs were evaluated by a Java software program designed by 1 of the authors to specifically measure the IM angle by bisecting the areas of the first and second metatarsals. A statistical analysis was applied to determine which IM angle of the 4 methods measured by hand was most consistent with the computer-generated IM angle. The median absolute deviation error test was applied to interpret the results. The results showed that the bisection of the shaft of the first and second metatarsals had the smallest mean absolute value of 2.8 degrees (22.37% error), with the other techniques ranging from 3.0 degrees to 3.8 degrees. It appears that the method of bisection of the shafts of the first and second metatarsals provides the most accurate technique compared with the computer-determined technique.

Postural alterations in children with mouth breathing assessed by computerized biophotogrammetry

To determine and compare the posture of children with obstructive (OMB) and functional mouth breathing (FMB) and children with nasal breathing (NB) using computerized biophotogrammetry, as well as to determine the viability and efficacy of this method. Evaluative and personalized methods were used for the capture and analysis of angle images obtained from 19 NB, 26 FMB and 17 OMB children of either gender aged 8 to 10 years on anterior, posterior and profile views. The nonparametric Kruskal-Wallis test was applied to analyze the three groups as a whole and the Mann-Whitney test was used for pairwise comparison of the groups (p = 0.05). The angle related to the lateral knee condyle, lateral ankle malleolus and 5th metatarsal diaphysis (KAM) was significantly greater in NB than in FMB children. With respect to the angle related to the nasal external acoustic meatus and pogonion (GMM), nasal external acoustic meatus and manubrium (GME), and 2nd cervical vertebra, major cervical curvature point and 7th cervical vertebra (C2C7), significantly higher values were observed for the OMB group compared to NB children. The angle formed by the 2nd thoracic vertebra, the major prominent thoracic point and the 9th thoracic vertebra (T2T9) was significantly greater in FMB than in OMB children. Computerized biophotogrammetry was found to e a safe and reliable technique, allowing comparison between the children analyzed, as well as the detection of postural alterations in mouth breathing children.

Vascular perfusion of the long dorsal arm versus chevron osteotomy: A cadaveric injection study

Iatrogenic disruption of the first metatarsal head’s blood supply after a distal osteotomy may lead to adverse events such as delayed union or avascular necrosis of the capital fragment. In this cadaveric study, 2 types of distal first metatarsal osteotomies were performed on 7 fresh-frozen specimens (long dorsal arm osteotomy, N = 4; chevron osteotomy, N = 3). For each specimen, the respective osteotomy was created. The dorsalis pedis artery was cannulated at the midfoot level and infiltrated with methylene blue dye until resistance was felt. The nutrient artery to the first metatarsal shaft was then exposed and the capital fragment was dissected free from the remaining soft tissues and visually inspected for the presence and distribution of dye. One of the chevron specimens was excluded because of technical error during the injection portion of the study. In all 4 of the long dorsal arm specimens, dye was observed in the entire dorsal cortical-cancellous wing and the cancellous metatarsal head region. In contrast, dye was completely absent in the capital fragment of the 2 chevron specimens. This cadaveric study showed that the vascular supply to the long dorsal arm osteotomy includes the nutrient artery, whereas the chevron osteotomy does not. This suggests that the long dorsal arm osteotomy may present a less risk of vascular compromise to the capital fragment.

Plantar Dislocation of Lateral Tarsometatarsal Joint: A Case of Subtle Lisfranc Injury

Introduction: We present a rare case of plantar dislocation of the cuboid, fourth and fifth metatarsal joints. Fracture-dislocation in the midfoot region may be subtle and difficult to recognise at the emergency department. Clinical Picture: A 16-year-old girl presented with lateral foot pain and swelling following a fall from a height of 3 m. Initial radiograph revealed a third metatarsal shaft fracture; however, additional views reviewed a plantar direction of fourth and fifth metatarsal dislocation from the cuboid. Treatment: Open reduction and internal fixation with Kirschner wires followed by immobilisation in plaster was performed. Outcome: She made an uneventful recovery and the wires had since been removed. Conclusion: This case was unusual in that there was lateral tarsometatarsal disruption with neither diastasis between the first and second metatarsals nor injury to either the first or second tarsometatarsal joints. The plantar direction of dislocation was also unusual as these injuries are usually dorsal.