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CASE REPORT ARTICLE

Multiple Carpometacarpal Dislocations – A Case Report Of A Rare Injury Pattern

Mike Kent, Bob Sangar Simon Richards

Department of Trauma and Orthopaedics, Poole General Hospital, Longfleet Road, Poole, Dorset

Address for Correspondence:  

Mike Kent
Department of Trauma and Orthopaedics,
Poole General Hospital, Longfleet Road, Poole, 
Dorset, UK
E-mail: mmikekent_100@hotmail.com
 

Abstract:

Multiple carpometacarpal joint dislocations are rare, occurring most frequently in high energy trauma, especially road traffic accidents involving motor-cyclists. They are usually associated with fractures of the metacarpal or carpal bones (usually the little finger metacarpal), and usually require open reduction and internal fixation to achieve good long term function.
We report a case of a dislocation of the index, middle and ring finger carpometacarpal joints as well as a fracture dislocation of the little finger  carpometacarpal joint, following a motorcycle accident.  This was treated with prompt closed reduction under general anaesthetic (without the use of Kirschner wire fixation), and a period of close observation with specialised hand therapists. The patient went on to have a good functional outcome. 
This case shows that it is possible to manage these relatively rare injuries conservatively with prompt reduction and casting, coupled with intense physiotherapy and close clinical observation.

J.Orthopaedics 2009;6(1)e1

Keywords:

Carpometacarpal dislocation; trauma

Introduction:

Multiple carpometacarpal (CMC) joint dislocations are rare. They account for less than 1% of hand injuries, and occur most frequently associated with fractures of the metacarpal or carpal bones (usually the little finger metacarpal) (1,2,6,10). Previous reports in the literature suggest that these injuries are sustained by a variety of different mechanisms, including crush injuries and falls, but occur most commonly following motorcycle accidents, classically as a result of firmly gripping the handlebars prior to impact (7).

Case Report:

A right handed 33-year old graphics engineer presented to the Emergency Department with an injury to the left hand following a collision with a car whilst riding his motorcycle. He had stopped abruptly from a speed of thirty-five miles per hour whilst holding the handlebars. He had been wearing full protective clothing including reinforced gloves (which were mildly damaged as a result of the accident).  He had previously sustained a laceration to his hand, transecting his left extensor digiti minimi tendon, which was repaired and from which he had made a full recovery.
On arrival in the Emergency Department he was assessed according to the ATLS protocol, and a closed injury to the left hand was identified, along with some other superficial abrasions.  Further examination of the hand revealed significant swelling and deformity around the CMC area, with bony tenderness. He was unable to flex or extend his fingers, and all other movements of the hand and wrist were limited by pain. There was no neurovascular compromise. 
Posteroanterior radiographs showed shortening of the ulna metacarpals and a fracture of the proximal little finger metacarpal. Lateral radiographs showed dorsal dislocation of the CMC joints of the index, long and ring fingers, with dorsal displacement of the metacarpals, and a comminuted intrarticular fracture dislocation of the base of the little finger metacarpal, with dorsal displacement.  

Fig 1 – Initial lateral and postero-anterior radiographs

The patient was placed in a dorsal backslab and the limb was elevated in a Bradford sling before being taken to theatre. Under a general anaesthetic the CMC joints and the fracture of the little finger metacarpal were reduced by manipulation. The stability of the joints and the fracture were found to be satisfactory under clinical and fluoroscopic assessment, thus requiring no further stabilisation or fixation. He was placed in a dorsal backslab in neutral alignment and observed. He was followed up at six days and six weeks the plaster was removed revealing an acceptable range of movement, and repeat radiographs showed good position. At this point, the patient was commenced on a regime of hand physiotherapy, and was warned that there was a chance of re-dislocation and requiring subsequent re-manipulation and the possibility of internal fixation.
Specialised hand therapy continued for three months. There was a small residual rotational deformity of the little finger following the injury, but his range of movement at this stage is excellent, with an unaffected level of function.

Fig 2 – Post rehabilitation photographs showing excellent range of movement and grip

Discussion :

A significant force is required to achieve dislocation of the CMC joints (4,9). Several cases are described in the literature following motorcycle accidents. We concur with Shih et al (12) that the most likely cause of the injury is a large deceleration force communicating longitudinally and dorsally through the metacarpals via the motorcycle handlebars, resulting in dislocation of the CMC joints. Dorsal dislocation is more common than volar dislocation, with the direction of dislocation following the direction of the force applied (11).
The management of CMC dislocations remains controversial, although it is well accepted that the initial treatment involves closed reduction and application of plaster cast (13), however some cases require reduction and internal fixation (8).  Prokuski et al, 2001 (14) have published the largest series of this injury complex, supporting prompt open reduction and internal fixation, as there is often difficulty achieving a stable closed reduction due to oedema, interposed soft tissue and bone fragments (from fractures of the metacarpal or carpal bones) or ligament damage. Open Reduction and Internal Fixation is best achieved via a dorsal approach, with good fixation of the middle finger metacarpal base being crucial to the all round stability of the reduction (5,9).
Close observation is essential after reduction has been achieved, to ensure that anatomical reduction is maintained, thus reducing the incidence of functional complications such as grasp weakness, muscle imbalance and arthritis (3).
This case confirms that CMC joint dislocations are high energy injuries strongly associated with motorcycle accidents (7). It is possible to achieve stability with early reduction and without the need for open reduction and internal fixation, nor the need for Kirschner wire fixation, and that function is optimised with intensive physiotherapy under close clinical supervision.
CMC joint dislocations are often difficult to detect clinically. However, marked pain and swelling in this area should give a high index of suspicion. This coupled with their high energy nature and subsequent association with other more life-threatening injuries makes a thorough secondary survey crucial, and reinforces the importance of true lateral radiographs in diagnosis.

Reference :

  1.       Bergfield TG, Dupuy TE, Aulicino PL (1985) Fracture dislocations of all five carpometacarpal joints – a case report. J Hand Surg 10A: 76-78

  2.       Dobyns JH, Linscheid RL, Cooney WP (1983) Fractures and dislocations of the wrist and hand, then and now. J Hand Surg 8A:687-690

  3.       Glickel SZ, Barron OA, Eaton RG (1998) Dislocations and ligament injuries in the digits In: Green DP (ed) Operative hand surgery, 4th edn. Churchill Livingstone, New York, pp772-808

  4.       Gunther SF (1984) The carpometacarpal joints. Orthop Clin North Am. 15:259-277

  5.       Hartwig RH, Louis DS (1979) Multiple carpometacarpal dislocations: a review of four cases. J Bone and Joint Surg 61A 906-908

  6.       Hsu JD, Curtis RM (1970) Carpometacarpal dislocations on the ulnar side of the hand. J Bone Joint Surg 52A:927-930

  7.       Kneife F (2002) Simultaneous dislocations of the five carpometacarpal joints Injury Nov;33(9):846

  8.       Kumar R, Malhortra R (2001) Divergent fracture dislocation of the second carpometacarpal joint and the three ulnar carpometacarpal joints. J Hand Surg 26A: 123-129

  9.       Lawlis JF, Gunther SF (1991) Carpometacarpal dislocations: Long term follow up. J Bone Joint Surg 73A: 52-58

  10.       Mueller JJ (1986) Carpometacarpal dislocation: report of five cases and review of the literature. J Hand Surg (Am) 11:184-8

  11.       Pankaj A, Malhotra R, Bhan S (2005) Isolated dislocation of the four ulnar carpometacarpal joints. Arch Orthop Trauma Surg 125: 541 – 544

  12.       Shih KS, Tsai WF, Wu CJ, Mudgal C (2006) Simultaneous dislocation of the Carpometacarpal and Metacaprophalageal joints of the thumb in a motorcyclist. J Formos Med Assoc Vol 105, No8

  13.       Watt N, Hooper G. Dislocation of the trapezio-metacarpal joint. (1987) J Hand Surg 12B 242-5

  14.        Prokuski LJ, Eglseder WA Jr. Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints. J Orthop Trauma. (2001) Nov;15(8):549-54.


 

This is a peer reviewed paper 

Please cite as : Mike Kent: Multiple Carpometacarpal Dislocations – A Case Report Of A Rare Injury Pattern

J.Orthopaedics 2009;6(1)e1

URL: http://www.jortho.org/2009/6/1/e1

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