Complex hallucal interphalangeal joint dislocation with incarcerated sesamoid: percutaneous reduction with K-wire and literature review

INTRODUCTION

The hallucal interphalangeal joint is stabilized on the plantar aspect by a thickened plantar plate and the flexor hallucis longus tendon. The hallucal interphalangeal sesamoids are accessory ossicles of the interphalangeal joint of the hallux. Although termed sesamoids, they are classified as accessory ossicles, as they are located outside the flexor hallucis longus tendon.¹ True sesamoid bones are within the substance of the tendons. Dyre Trolle remarked upon the ubiquity of this sesamoid, present in the 56% of the sectioned embryonic feet. Bizarro demonstrated with x-rays the prevalence to be within the range of 5 to 13%.^2,3 These small, pyramidal-shaped osseous structures are characteristically found in pairs, situated beneath the proximal phalanx of the hallux. They are fully enveloped by articular cartilage and articulate with the interphalangeal joint.

Their dimensions exhibit variability, ranging from 0.5 to 10 mm², and although typically situated in the midline, they may also be in medial or lateral positions. Their oval-shaped, osseous bases are embedded within the dorsal surface of the plantar plate, positioned outside the flexor hallucis longus tendon.⁴ Dislocation of the hallucal IP joint is rare and often results from an axial force on an extended toe. Miki et al described two patterns: type 1, where the sesamoid and plantar plate become interposed within the joint; and type 2, where the sesamoid lies dorsal to the proximal phalanx (Table 1).⁸

When interposed, the sesamoid functions as a rigid mechanical wedge preventing reduction (type 2), and repeated closed man oeuvres risk converting the injury into a more complex pattern, producing the characteristic elongated toe (type 1).

CASE REPORT

We present a case of a 22-year-old man who sustained an injury while playing badminton barefoot. He landed awkwardly on the tip of his hallux and presented to the emergency department with a deformed toe. Initial x-rays revealed a type 2 dislocation, which was manipulated under sedation. The technique involved holding the ankle in plantar flexion to relax the flexor hallucis longus (FHL), gently hyperextending the interphalangeal joint, and applying traction. This inadvertently converted the dislocation into a type 1 injury, resulting in an elongated, stiff toe.

Subsequently, the decision was made to reduce the joint surgically under general anesthesia. The sharp end of a 2 mm K-wire was gently inserted into the interphalangeal joint from the medial paraxial border of the toe at the junction of the glabrous and non-glabrous skin. Then, the blunt end of the K-wire was used to avoid injuring the articular cartilage. The K-wire was placed dorsal to the sesamoid and pushed in a plantar direction to reduce the sesamoid, which was accompanied by an audible click. The joint was noted to be stable to 30 degrees of passive dorsiflexion, and a thermoplastic extension blocking splint was applied for 3 weeks. The patient returned to sports activities two months post-injury and has no symptoms at 1 year.

DISCUSSION

Interphalangeal joint (IPJ) dislocations of the hallux remain rare injuries, with approximately 30-35 cases reported in the literature, including the present report. Most injuries occur following hyper dorsiflexion or axial loading mechanisms and may present either as simple dorsal dislocations or as irreducible injuries with incarceration of the sesamoid–plantar plate complex, classically described as Miki type 2 dislocations. This distinction is clinically important because type 2 injuries are consistently resistant to closed reduction due to soft-tissue interposition, most commonly involving the plantar plate and sesamoid apparatus. Our findings are concordant with previous reports demonstrating that failure of closed reduction is a hallmark feature of sesamoid-entrapped dislocations and should prompt early consideration of minimally invasive or open techniques.^5-7

Earlier case series predominantly described open dorsal, medial, or plantar approaches to achieve reduction, often accompanied by partial or complete sesamoid excision.^5-7 While these methods reliably restore alignment, they are associated with increased soft-tissue access trauma and longer recovery. More recent literature reflects a shift toward minimally invasive strategies, including percutaneous sesamoid manipulation, ultrasound-guided reduction, and temporary Kirschner wire stabilization.^15-17 The present case supports this and demonstrates that percutaneous sesamoid reduction under fluoroscopic guidance can achieve stable reduction while preserving surrounding soft tissues.

(A and B) type II dislocation: clinical photograph and radiographs demonstrating dorsal skin puckering and hyperextension deformity, with sesamoid positioned dorsal to the proximal phalangeal head, (C and D) type I dislocation following attempted closed reduction: clinical photographs and radiographs showing characteristic elongated toe appearance with sesamoid interposed within the widened joint space, (E-G) percutaneous reduction technique: stepwise demonstration of 2-mm Kirschner wire introduction through the medial mid-axial border at the junction of glabrous and non-glabrous skin, with subsequent manipulation using the blunt end to displace the interposed sesamoid in a plantar direction and (H and I) post-reduction verification: image intensifier views in anteroposterior and lateral projections demonstrating successful congruent reduction of the interphalangeal joint.

Clinical outcomes across published cases are uniformly favourable, regardless of the reduction technique employed. Most patients regain full or near-full range of motion, experience minimal residual pain, and return to normal activities within weeks to months.^22,29,30 Similar to these reports, our patient achieved excellent functional recovery without stiffness or instability. These consistent outcomes suggest that timely restoration of joint congruity—rather than the specific surgical approach—is the dominant determinant of prognosis. Immobilization strategies across published cases ranged from 3 to 6 weeks, using buddy splinting, cast boots, or rigid soled footwear.^14,22,28 Our patient was immobilized with an extension-blocking thermoplastic splint for three weeks. Return to full sporting activity was achieved at two months, which compares favourably with Woon et al who reported mild interphalangeal stiffness at six months following percutaneous reduction, and with Kang et al who reported no symptoms at eight months.^22,30 The absence of residual stiffness in our patient may reflect the benefit of minimally invasive technique and the shorter immobilization period, though conclusions are limited given the single-case nature of this report.

Miki et al originally proposed a two-type classification system based on the final position of the sesamoid and plantar plate after attempted reduction.⁵ Although widely cited, subsequent authors have highlighted important limitations of this system. Several reports describe conversion of type 2 injuries into type 1 patterns following traction-based manipulation, indicating that the classification may reflect the post-reduction state rather than the initial injury morphology.^22,28 Our case similarly demonstrates dynamic migration of the sesamoid–plantar plate complex, supporting the notion that the Miki classification has limited value for guiding real-time management. Instead, a functional assessment emphasizing the presence of a mechanical block, intra-articular sesamoid position, and post-reduction stability may be more clinically meaningful. Authors advocating this approach report improved decision-making and earlier selection of percutaneous or open techniques when closed reduction is unlikely to succeed.^15,16 Diagnosis remains challenging, and delayed recognition is common. Characteristic findings include dorsal skin puckering, loss of active plantarflexion, and widening of the IPJ space on radiographs.^{5,9,14,17,18,20-22} True lateral views are essential, as sesamoid displacement may be subtle or occult on anteroposterior projections. Our experience reinforces previous recommendations that early identification prevents repeated forceful manipulations that may cause chondral injury or worsen soft-tissue interposition.

Most authors agree that gentle closed reduction may be attempted initially using ankle plantarflexion to relax the flexor hallucis longus and exaggeration of deformity to disengage the joint.⁵ However, once a mechanical block is encountered, further forceful attempts should be abandoned in favor of percutaneous or open techniques. The present case demonstrates that percutaneous Kirschner wire–assisted sesamoid reduction represents an effective intermediate strategy between closed and open methods, combining direct mechanical leverage with minimal soft-tissue disruption. The advantage of using a Kirschner wire lies in its small caliber and controlled flexibility, which provides tactile feedback and reduces the risk of sesamoid fracture compared with rigid instruments such as Freer elevators or dental probes.^28,29 This technical nuance aligns with previously described minimally invasive techniques and may contribute to the excellent outcomes reported with percutaneous approaches.

CONCLUSION

Irreducible hallux IPJ dislocations with sesamoid incarceration require a high index of suspicion and careful radiographic evaluation. Reliance solely on the Miki classification may be misleading; instead, a functional assessment based on mechanical blockage and joint stability is more useful for guiding treatment. Percutaneous lateral-view–guided sesamoid reduction offers a minimally invasive, tissue-preserving solution with reliable outcomes. Early recognition and technique-appropriate intervention remain the cornerstones of successful management.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Suwannahoy P, Srisuwan T, Pattamapaspong N, Mahakkanukrauh P. Intra-Articular Ossicle in Interphalangeal Joint of the Great Toe and Clinical Implication. Surg Radiol Anat. 2012;34(1):39-42.
2. 2. Trolle D. Accessory Bones of The Human Foot. Copenhagen: Einar Munksgaard. 1948;1-272.
3. 3. Bizarro AH. On Sesamoid and Supernumerary Bones of the Limbs. J Anat. 1921;55(4):256-68.
4. 4. Roukis T, Hurless J. The Hallucal Interphalangeal Sesamoid. J Foot Ankle Surg. 1996;35(4):303-8.
5. 5. Eibel P. Dislocation of the interphalangeal joint of the big toe with interposition of a sesamoid bone. J Bone Joint Surg Am. 1954;36(4):880-2.
6. 6. Nelson TL, Uggen W. Irreducible dorsal dislocation of the interphalangeal joint of the great toe. Clin Orthop Relat Res. 1981;(157):110-2.
7. 7. Kursunoglu S, Resnick D, Goergen T. Traumatic dislocation with sesamoid entrapment in the interphalangeal joint of the great toe. J Trauma. 1987;27(8):959-61.
8. 8. Miki T, Yamamuro T, Kitai T. An irreducible dislocation of the great toe: report of two cases and review of the literature. Clin Orthop Relat Res. 1988;(230):200-6.
9. 9. Szucs R, Hurwitz J. Traumatic subluxation of the interphalangeal joint of the hallux with interposition of the sesamoid bone. AJR Am J Roentgenol. 1989;152(3):652-3.
10. 10. Wolfe J, Goodhart C. Irreducible dislocation of the great toe following a sports injury. A case report. Am J Sports Med. 1989;17(5):695-6.
11. 11. Crosby LA, McClellan JW, Prochaska VJ. Irreducible dorsal dislocation of the great toe interphalangeal joint: case report and literature review. Foot Ankle Int. 1995;16(9):559-61.
12. 12. Weiss AP, Yates AJ. Irreducible dorsal interphalangeal great toe dislocation. Orthopedics. 1992;15(4):480-2.
13. 13. Dave D, Jayaraj VP, James SE. Intra-articular sesamoid dislocation of the interphalangeal joint of the great toe. Injury. 1993;24(3):198-9.
14. 14. Sorene ED, Regev G. Complex dislocation with double sesamoid entrapment of the interphalangeal joint of the hallux. J Foot Ankle Surg. 2006;45(6):413-6.
15. 15. Ward SJ, Sheridan RP, Kendall IG. Sesamoid bone interposition complicating reduction of a hallux joint dislocation. J Accid Emerg Med. 1996;13(4):297-8.
16. 16. Berger JL, LeGeyt MT, Ghobadi R. Incarcerated subhallucal sesamoid of the great toe: irreducible dislocation of the interphalangeal joint of the great toe by an accessory sesamoid bone. Am J Orthop (Belle Mead NJ). 1997;26(3):226-8.
17. 17. Leung HB, Wong WC. Irreducible dislocation of the hallucal interphalangeal joint. Hong Kong Med J. 2002;8(4):295-9.
18. 18. Davies MB, Abdlslam K, Gibson RJ. Interphalangeal sesamoid bones of the great toe: an anatomic variant demanding careful scrutiny of radiographs. Clin Anat. 2003;16(6):520-1.
19. 19. Banerjee R, Bradley MP, Bluman EM, DiGiovanni CW. Clinical pearls: locked great toe. Acad Emerg Med. 2003;10(8):878-80.
20. 20. Hatori M, Goto M, Tanaka K, Smith RA, Kokubun S. Neglected irreducible dislocation of the interphalangeal joint of the great toe. J Foot Ankle Surg. 2006;45(4):271-4.
21. 21. Woon CY. Dislocation of the interphalangeal joint of the great toe: is percutaneous reduction of an incarcerated sesamoid an option? Surgical technique. J Bone Joint Surg Am. 2011;93(1):109-12.
22. 22. Özdemir E, Evren AT, Özer M, Altay M. Percutaneous reduction of irreducible dislocation of the interphalangeal joint of the hallux: a simple technique for a rare injury. Jt Dis Relat Surg. 2020;31(3):610-3.
23. 23. Paulus MC, Neufeld SK. Irreducible longitudinal distraction-dislocation of the hallux interphalangeal joint. Am J Orthop (Belle Mead NJ). 2013;42(7):329-30.
24. 24. Bin Abd Razak HR, Chia ZY, Tan HC. Irreducible dislocation of the great toe interphalangeal joint secondary to an incarcerated sesamoid. Case Rep Orthop. 2015;2015:231685.
25. 25. Silvampatti S, Rajasekaran S. Irreducible dislocation of great toe interphalangeal joint by an accessory sesamoid bone: a case report and review of literature. J Foot Ankle Surg (Asia-Pacific). 2016;3(1):56-8.
26. 26. Ab-Rahman S, Sulaiman AR, Muzaffar T. Irreducible dorsal dislocation of the interphalangeal joint of the big toe: a case report. Trauma Case Rep. 2016;3:32-5.
27. 27. Imao K, Miwa H, Watanabe K, Imai N, Endo N. Dorsal-approach open reduction for irreducible dislocation of the hallux interphalangeal joint: a case series. Int J Surg Case Rep. 2018;53:316-21.
28. 28. Özdemir E, Evren AT, Özer M, Altay M. Percutaneous reduction of irreducible dislocation of the interphalangeal joint of the hallux: a simple technique for a rare injury. Jt Dis Relat Surg. 2020;31(3):610-3.
29. 29. Takeda S, Nishimura A, Yamaji S, Tabuchi A, Sudo A, Hirata H. Percutaneous Reduction of a Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report. J Foot Ankle Surg. 2020;59(5):1072-5.
30. 30. Kang J, Lee G. Irreducible great toe dislocation with an incarcerated interphalangeal sesamoid: a case report and literature review. AOSM. 2023;10:40-3.
31. 31. Sajeev S, Bharadwaj A. Complex hallucal interphalangeal joint dislocation with incarcerated sesamoid: percutaneous reduction with K-wire and literature review. Int J Res Orthop. 2026;12(3).