Multiple Volar Carpometacarpal Dislocations: Case Report/Review of the Literature

Dorsal approach for isolated volar fracture-dislocation of the base of the second metacarpal: A case report

BACKGROUND

We report a case with the displacement of an articular fracture fragment of the base of the second metacarpal from the ulnar to the volar side, treated via the dorsal approach. The dorsal approach can be a good option not only because it allows direct observation of ligament damage and fixation of bone fragments but also because the thin subcutaneous tissue makes the approach easier.

CASE SUMMARY

A 45-year-old man with a right hand injury visited the hospital. A small bone fragment was identified using plain radiography. Lateral radiography revealed the fragment as lying over the volar aspect of the carpometacarpal (CMC) joint. Computed tomography revealed that approximately one-third of the CMC joint surface of the second metacarpal was damaged. We provisionally diagnosed an intra-articular fracture with significant CMC joint instability and performed open reduction and internal fixation. We made a dorsal longitudinal incision over the CMC joint between the second and third metacarpals. The dorsal ligament of the third CMC joint was torn. We thought it had been dislocated to the volar side and spontaneously reduced to that position. There are only few reports of volar dislocation of CMC joint fractures, particularly of the second and third metacarpals; our report is unique as our patient had an intact interosseous ligament between the second and third metacarpals.

CONCLUSION

Although past reports have used a palmar approach, the dorsal approach is a good option for these cases.

Multiple carpometacarpal joint fracture-dislocation from the second to fifth: A case report

Introduction

and importance: Herein we present a rare case of multiple second to fifth carpometacarpal joint fracture-dislocations. It is important in such cases to be aware of a high-velocity impact etiology of the fractures, which will ensure proper imaging, diagnosis and treatment.

Case presentation

A 34-year-old male presented with severe pain in his left hand following a motorcycle accident. He was diagnosed as multiple second to fifth carpometacarpal joint fracture-dislocations. He was successfully treated with closed reduction with multiple Kirshner wires fixation under general anesthesia. A one-year follow up confirmed excellent clinical results.

Clinical discussion

There are various surgical options including casting, closed reduction and percutaneous pinning (CRPP), and open reduction internal fixation, however, the optimal treatment is still controversial. The closed reduction is recommended in all CMC joint dislocations. Adding a K-wire fixation can create a secure fixation and achieve an excellent outcome.

Conclusion

Multiple carpometacarpal joint fracture-dislocations is a very rare injury. Careful clinical examination is important for an accurate diagnosis and plain radiographic studies are necessary. Standard fracture dislocation treatment can be used. Simple closed reduction with the K-wires fixation technique is easy to perform and in our case achieved successful treatment in terms of clinical and radiographic outcomes.

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Multiple carpometacarpal joint fracture-dislocations is a very rare injury.

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Careful clinical examination is important for an accurate diagnosis and plain radiographic studies are necessary.

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Simple closed reduction with the K-wires fixation technique is easy to perform and achieved successful treatment.

Fracture dislocations of the carpometacarpal joints of the fingers

OBJECTIVE

Fracture dislocations of the multiple carpometacarpal joints [CMCJ] of the fingers are uncommon injuries that can significantly compromise hand function and durability if managed sub-optimally. These injuries are at risk of being missed as they are commonly a part of major high energy trauma with associated more obvious and immediately threatening injuries getting all the attention. The clinical and radiological parameters which could help a surgeon to detect and analyse these injuries well are discussed. The management of these injuries with emphasis on the pattern of K-wire fixation is presented.

METHOD

A review of multiple CMCJ dislocations at our institution found 39 hands in 38 patients (one case with bilateral injury) over a seven-year period (January 2010 to January 2017). The pattern of injury noted in these cases was assessed and categorized. Our preferred management plan for these injuries is discussed.

RESULTS

The patterns of dislocations noted in a total of 39 cases were-dorsal (25), dorsal radial (6), volar (1), volar radial (5) and divergent (2). The dorsal dislocations were the commonest (25/39) and additional 6/39 were radial-dorsal, only six displaced in a volar direction. Divergent dislocation was seen in only two cases.

CONCLUSION

The pattern of dislocations noted in 39 cases in our institute (Ganga Hospital- A tertiary level trauma center) is presented to provide an overview of the spectrum of the injuries which a surgeon could face. Early surgery is recommended and should be aimed to restore perfect anatomical alignment of the skeleton. Surgeon should have a low threshold for open reduction in case of gross swelling or inability to get an anatomical closed reduction. The method of K-wire fixation presented herein has resulted in good outcome in our practice; wherein we fix the dislocated CMCJ by inserting K-wires from the radial and ulnar borders of the hand and avoiding wires in the central part of the hand. This prevents extensor tendons tethering by the K-wires. The fixation achieved by multiple K-wires passed in this manner provides enough stability to allow for early active mobilisation of the fingers. The need for careful assessment to detect associated nerve injury and compartment syndrome; and post-operative strict hand elevation and prevention of stiffness of the MCP joints has been emphasized.The CMCJ dislocations have innumerable patterns possible; however, the management principles remain the same. In spite of the gross distortion of the anatomy seen in these injuries, anatomical reduction and adequate stabilization to allow early mobilization generally results in satisfactory outcomes.

Volar dislocation of the second and third carpometacarpal joints - the Lisfranc injury of the hand?

A case of an isolated volar dislocation of the second and third carpometacarpal (CMC) joints in an 18-year-old man is described. He presented following a game of rugby unable to move his hand or wrist. He was managed by manipulation and K-Wire fixation. Hand function was excellent following wire removal and mobilization. This is an extremely rare injury, easily missed. The mechanism of injury described leads to comparison with the Lisfranc injury of the foot.

Combined Dorsal and Ulnarward Carpometacarpal Dislocation Associated with Open Fracture of the Base of First Metacarpal and Severe Degloving Injury

We report a rare case of dislocation of second to fourth carpometacarpal (CMC) joints of the right hand with combined dorsal and ulnarward displacement of the second to fourth digits and fracture of the shaft of the first metacarpal associated with degloving injury. These injuries were diagnosed early and treated successfully with closed reduction and internal fixation using Kirschner wires. The functional outcome was good at follow-up at 5 years. A high index of suspicion is required to successfully diagnose and treat this condition.