A Case of Simultaneous Traumatic Dorsal Dislocation of All Five Metatarsophalangeal Joints Treated Successfully With Closed Reduction.

Simultaneous dislocation of multiple metatarsophalangeal joints is a rare injury, because of the impediment presented by the anatomy of the lesser metatarsophalangeal joints. To the best of our knowledge, only 1 case of simultaneous dislocation of all 5 metatarsophalangeal joints has been previously reported in peer-reviewed studies. Owing to the same anatomic structures that obstruct relocation, closed reduction has been known to fail in a large proportion of cases. We report a case of simultaneous dorsal dislocation of all 5 metatarsophalangeal joints of the right foot after a motor vehicle accident. The highlight of our case was successful closed reduction after application of the reduction maneuver to all lesser metatarsophalangeal joints simultaneously in the second attempt with the patient under anesthesia. On confirming the stability of the reduction, the foot was immobilized in a short-leg, posterior slab cast for 3 weeks without placing Kirschner wires across the joints. At the 3-month follow-up evaluation, the patient had reacquired their preinjury level of activity with a good range of motion . At the 2-year follow-up evaluation, this range of motion was maintained with no radiologic evidence of arthrosis. We have inferred that the reduction was successful the second time because the maneuver freed the soft tissue structures from the contiguous impingement in the metatarsophalangeal joints by the exact reversal of the mode of injury using simultaneous application of the maneuver to all the lesser metatarsophalangeal joints. We encourage a trial of this modification of the closed reduction method in the emergency setting before proceeding to open reduction, because the results of closed reduction can be biologically rewarding without the risks associated with open surgical dissection.

Quantitative evaluation of balance in patients with spinocerebellar ataxia type 1: a case control study.

OBJECTIVE: Quantitative assessment of balance in spinocerebellar ataxia type 1 (SCA1). BACKGROUND: Evaluation of balance in degenerative ataxias is often clinical and subject to bias. Quantification of balance is crucial for evaluating the efficacy of therapeutic and rehabilitative interventions. METHODS: The subjects were 20 patients (males: 14, females: 6) with genetically positive SCA1 and 20 age and gender matched healthy subjects. Ataxia was rated using the International Cooperative Ataxia Rating Scale (ICARS). Balance was assessed by dynamic posturography (Biodex, USA) which included: (a) ability to control balance in all directions (overall balance index, OBI), front to back (anterior-posterior index, API) and side-to-side (medio-lateral index, MLI); and (b) the limits of stability (LOS) in all directions. Balance index was considered abnormal if the actual value exceeded the predictive value. RESULTS: Impaired balance was found in 80% of patients (all indices in 35%, OBI+API in 25%, only OBI in 15%, and OBI+MLI in 5%). Compared to controls, SCA1 patients had significantly higher balance indices and lower LOS scores. Unlike in controls, the mean value of API was significantly higher than MLI in SCA1. LOS was found to the best predictor of balance abnormality. In patients, all balance indices had significant positive correlations with ICARS, static score of ICARS, body weight, severity and duration of illness, but not with the CAG repeat length. CONCLUSIONS: Patients with SCA1 had global impairment of balance, with greater instability in anterior-posterior than medio-lateral directions. Apart from severity and duration of illness, body weight was detriment to maintenance of balance in SCA1. This information may be useful in planning balance rehabilitation in SCA.