Let’s imagine you are in this very shift in your critical care area (who knows, maybe this really happened). A 56 year old man was shot in lower abdomen in a robbery, brought in by EMS as a notification and a trauma code was called.
But this post is not about GSWs.
You examine your patient. He has a GCS of 15 and reports that he was shot by the robber from the back when he tried to escape and then fell. ABC’s are intact, with good pulses in all extremities. There is an entry wound on the left buttock with an exit wound in the left inguinal region. But while everybody is concerned about bleeding, FAST, vascular injury and, of course, the rectal exam, the patient keeps complaining only of right foot pain and asking everyone to leave the wound alone and look at his foot!
On first glance the right leg and foot look normal. There is no apparent injury, pulses and sensory exam are intact. The only abnormal finding is extreme tenderness in the distal half of the foot and the patient does not allow you to touch it, let alone move it. Initially you think about ischemia/vascular/neurologic injuries, although the presentation is unusual. The bullet is in the left buttock; why is the right foot tender?!
You order scans of abdomen, pelvis, bilateral CTAs of the extremities, a few trauma x-rays and finally add on a foot x-ray; which happens to be the only one that comes back abnormal!
What is your diagnosis?
Believe it or not, but what you thought is True.
This is a 2nd-5th metatarsophalangeal (MTP) joint dislocation. A dorsal MTP joint dislocation usually occurs when the ankle is dorsiflexed and toes are hyperextended. Looks like our patient was putting weight on his right foot when he tripped on his outstretched toes as the bullet got him in his left buttock.
Lesson relearned again: All injuries are not caused by the bullet in the case of a GSW. Perform a proper secondary survey when you are convinced that the patient is stable. If our patient were altered or distracted, this significant injury could have very easily been missed.Treatment:
Fortunately, the bullet did not cause any serious injuries in its trajectory. So our patient could potentially be discharged after a few hours if we take care of his foot properly.
You want to reduce the dislocation, but are not sure what to do for anesthesia. So you ask Dr. Google, who directs you to the wonderful resource of the New York School of Regional Anesthesia .
Remember the anatomy? I didn’t. In summary, you need to block five nerves to have a complete sensation-free foot and after which you are welcome to do whatever you want to that foot:
For the first two blocks you should use ultrasound.
- Posterior tibialis nerve block: This will block the medial plantar, lateral plantar and calcaneal branches all together!
- Deep peroneal nerve block.
For the following superficial nerve blocks you don’t need ultrasound:
- Superficial peroneal nerve
- Sural nerve
- Saphenous nerve
Hyperextension with traction and small pressure on the proximal phalanx.
You should feel a “pop” on every toe followed by a sense of pride and send the patient to get a post reduction x ray.
In our case, the patient returns from radiology and you look up the image. You unhappily find out that all of the toes are still dislocated! You figure that you either did not reduce the toes properly in the first place, or that they just re-dislocated.
What do you do now? It might be that the joint is just too unstable due to interposed soft tissue and requires open reduction. However, since all four toes were dislocated, this injury might simply be difficult to reduce.
If that is the case, what you can try doing is hanging the toes.
Simply tie the IP joints to a band and hang them from an IV stand by the patient’s bed. Leave it there for 20-30 minutes and send the patient to radiology again.
Let’s hypothetically say that this is what actually worked in our case!
This patient of our’s is discharged with a hard sole and a splint extended under his toes, so that he can not dorsiflex them. He is given appointments for orthopedics and surgery (let’s not forget his buttock).
Some more details:
Dislocation of multiple toes is rare and there are very few reports of this happening. Some have tried closed reductions successfully and some required surgery. Dislocation of the great toe MTP is more common than the other toes. The patient generally presents with pain, swelling, inability to walk and a visible deformity, unless there is no visible deformity like in our case! Why? first of all because all the toes are dislocated, which makes the shape of the foot more uniform and secondly because everybody is thinking about the GSW.
Toe dislocations can be plantar or dorsal. Dorsal dislocations are by far more common. If the dislocation is complicated (i.e. there is also a fracture/loose body/sesamoid bone in the joint) or is unstable (i.e. the tendons are ruptured and it comes out after reduction), the patient might need an immediate orthopedics consult to plan for an open reduction and fixation. Otherwise you can block the foot and get the satisfaction of reducing the joint yourself.