Fracture-dislocations of the carpometacarpal joints of the ring and little finger

Isolated post-traumatic osteoarthritis of the middle carpometacarpal joint: a report of two cases

We present two cases of isolated post-traumatic osteoarthritis in the middle carpometacarpal joint.

Delayed Diagnosis of Dislocation of All Four Ulnar Carpometacarpal Joints. Surgical Treatment Strategy and Challenges

Background  Carpometacarpal dislocations are rare injuries whose diagnosis is often missed initially. These injuries can be treated conservatively, as long as an anatomical closed reduction is achieved. However, in most cases, open reduction followed by internal or external fixation is necessary to reach a stable anatomical reduction. Case Description  A 32-year-old male was referred to our institution due to excess swelling of his right hand, 2 months after a motorcycle crash he sustained. During our imaging workup, a dorsal carpometacarpal dislocation of all four ulnar metacarpals was found accompanied by a fracture of the base of the fifth metacarpal. An open reduction was achieved using Kirschner wires and a small plate for arthrodesis of the fifth carpometacarpal joint. The postoperative follow-up on the 3rd, 6th, and 12th month was uncomplicated. The range of motion and grip strength was satisfactory on the 3rd month and almost full on the 6th month compared to the unaffected side. Literature Review  Carpometacarpal dislocations are rare hand injuries. They are often the result of a high-energy injury and their diagnosis is usually delayed or missed. The main reasons are the excessive pain and swelling of the hand which make the initial clinical examination difficult and the overlapping of the metacarpals on the X-ray, which make the radiological diagnosis challenging. Case Relevance  A delayed diagnosis needs urgent open surgical treatment to achieve an anatomical reduction due to the interposition of soft tissue, bony fragments, and newly formed callus. Diagnosis and treatment of these injuries demands a high clinical suspicion from the traumatologist. The role of computed tomography scan is invaluable and open reduction is the mainstay of treatment for the cases that are diagnosed late.

The long-term curative effect analysis of trans-articular plate combined with Kirschner wires in the treatment of fracture-dislocation of the fifth carpometacarpal joint

Purpose

To evaluate the long-term curative effect analysis of trans-articular plate combined with Kirschner wires in the treatment of fracture-dislocation of the fifth carpometacarpal joint.

Methods

From July 2016 to September 2021, 21 patients with fracture-dislocation of the fifth carpometacarpal joint were treated with trans-articular plate combined with Kirschner wires internal fixation. Each patient's gender, age, dominant hand, injured hand, trauma mechanism, the time between injury and surgery, the range of motion of the bilateral wrist in flexion, extension, radial deviation and ulnar deviation, grip strength of each side, the time of return to work, and follow-up time were recorded. The QDASH score and Cooney wrist function score were used to evaluate the postoperative function. The VAS system was used to evaluate postoperative pain.

Results

The follow-up time was 37.0 ± 19.0 months and the time between injury and surgery was 1.3 ± 0.5 days. In the injured side and the contralateral side, the range of motion of the wrist flexion were 58.3 ± 4.0° and 60.5 ± 3.1°, the range of motion of the wrist radial deviation were 25.7 ± 3.3° and 26.9 ± 2.9°, the range of motion of the wrist ulnar deviation were 28.1 ± 3.7° and 29.5 ± 3.1° respectively with no significant difference. The range of motion of the wrist extension (54.0 ± 3.4°) in the injured side was smaller than that in the contralateral side (56.7 ± 3.7°) with significant difference. The grip strength of the injured side and the contralateral side were 96.1 ± 9.5 LB and 100.7 ± 9.7LB respectively with no significant difference. The QDASH score was 3.8 ± 1.8, Cooney wrist function score was 94.5 ± 4.2, VAS score was 1.0 ± 0.8 and the time of return to work was 5.1 ± 0.9 weeks. In the 21 cases, no postoperative complications such as incision infection, failure of internal fixation, fracture nonunion or fracture malunion occurred.

Conclusion

The method of trans-articular plate combined with Kirschner wires is one of the alternative treatments for the fracture-dislocation of the fifth carpometacarpal joint. The long-term follow-up results were satisfactory.

Surgical Management of Ulnar Metacarpal Base Fracture-Dislocations: A Systematic Review

BACKGROUND

Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, prompting surgical stabilization. Studies investigating this injury are limited by small case volumes. Our purpose is to review the surgical techniques, outcomes, and complications of ulnar CMC joint stabilization.

METHODS

A literature search was performed of all articles published on the surgical treatment and outcomes of ulnar CMC fracture dislocations using PubMed and Google Scholar databases between the years 2014 and 2019. Data were pooled and analyzed, assessing surgical techniques and hand outcome measures: union, recurrent dislocations, range of motion, grip strength, and complications.

RESULTS

Six studies met inclusion criteria. All surgical patients, regardless of technique, went on to union with no incidents of recurrent instability. Grip strength was significantly decreased postoperatively (82.7% of uninjured side). Patients with CMC dislocations of both the fourth and fifth ray had similar postoperative outcomes to those with CMC dislocations of the fifth ray alone. One third of plate and screw constructs required plate removal, due to breakage (2) or implant-related pain (4). Plate-related symptoms resolved after removal in all cases. Delayed treatment decreased the effectiveness of nonoperative treatment, and increased the likelihood of postoperative pain, chronic deformity, malunion, and CMC osteoarthritis.

CONCLUSIONS

Closed reduction percutaneous pinning, open reduction percutaneous pinning, and open reduction internal fixation with CMC joint bridging or dorsal buttress plating are all well described, safe techniques with low complication rates. Early, accurate diagnosis of fourth and fifth CMC joint fracture-dislocations is crucial for optimizing hand function and postoperative outcomes.

Ulnar-sided carpometacarpal fractures and fractures-dislocations. A systematic review and publication guidelines

BACKGROUND

Intra-articular fractures and fracture-dislocations of the ulnar-sided carpometacarpal joints (US-CMC) are common and under-reported. Their diagnosis is often delayed or incomplete, and there is no consensus as to the best treatment. The aim of this systematic literature review was to focus on the quality of existing data and to describe in detail the available evidence on the diagnosis and treatment of these lesions. Based on our findings, we will propose guidelines for improving the design of future studies on these lesions.

METHODS

This systematic literature review looked at all articles published between 1918 and 2019 on US-CMC fractures and fracture-dislocations. The quality of the articles was evaluated using the Quality Appraisal Tool devised by Moga et al. Information on the diagnostic and therapeutic methods were extracted along with epidemiological data, classifications, and clinical and radiological outcomes.

RESULTS

Of the 500 articles identified, 13 were included. According to the Quality Appraisal Tool, three of these articles had acceptable quality. While either radiographs or CT scans were used for the diagnosis, the radiographs were insufficient to precisely describe the lesions and guide the treatment. Conservative treatment or percutaneous surgical treatment was preferred for acute stable lesions without extensive fractures or comminution, while open surgical treatment was used most often in cases of unstable or sub-acute fractures and fracture-dislocations.

DISCUSSION

The current literature on this topic is made up of case series with a low level of evidence. CT is needed to assess and classify these lesions and select between conservative and surgical treatment. Unstable cases or those with delayed presentation should be treated with an open surgical approach. Based on our findings, we propose reporting guidelines for future studies on the treatment of US-CMC fractures and fracture-dislocations.

LEVEL OF EVIDENCE

III.

Metacarpal Arc Motion: Comparison of Different Measurement Methods

Introduction The range of motion of the carpometacarpal (CMC) joints is difficult to assess in clinical practice.

Materials and Methods The purpose of this study was to measure a precise range of motion measurement of the metacarpal arc during maximum palmar flexion of the fifth CMC joint in healthy persons with three different methods: optical, electrogoniometrical, and sonographical.

Results The metacarpal arc motion measured with the optical technique was 24.9 degrees (standard deviation [SD]: 6.2 degrees), with the electrogoniometric technique was 24.3 degrees (SD: 3.6 degrees) and with sonography was 25.1 degrees (SD: 3.5 degrees), with no differences between left and right hand for all methods.

Conclusion This study shows that different techniques can be used for the measurement of the metacarpal arc motion. With these techniques, it is possible to assess the metacarpal arc in patients with fractures to the CMC joints to evaluate posttraumatic function und rehabilitation progress. This study shows level of evidence as III.

Surgical Treatment for Delayed Ulnar Carpometacarpal Fracture-Dislocations

Background  Fracture and dislocations of the carpometacarpal (CMC) joints except the thumb are relatively rare. Herein, we report the case of a delayed fracture-dislocation of fourth and fifth carpometacarpal joints. Case Description  The patient is a 41-year-old, right-handed male. To improve the complaints, such as decreased motion, reduced grip strength, and cosmetic appearance, surgical treatment surgically performed with resection of scar tissues and fixation using suture button at 11 weeks after injury. Movement began at 2 weeks after the surgery, which resulted in satisfactory appearance and good function of 92 and 101% of the motion of the unaffected side of the fifth CMC joint and grip strength, respectively. Literature Review  Missed diagnosis can cause impairment of function including grip strength and range of motion. Nevertheless, a few previous studies reported that patients with delayed diagnosis did not need further treatment because of less functional loss and less improvement. Clinical Relevance  The surgical treatment using the implant allowed early motion from 2 weeks after surgery which resulted in good motion of the ulnar CMC joints as well as increased hand grip.

Sensitivity and Specificity of Radiographs in the Diagnosis of Little and/or Ring Carpometacarpal Joint Injuries

Introduction  Little and ring finger carpometacarpal joints (CMCJs) injuries are commonly missed due to misinterpretation of radiographs. We aimed to determine the sensitivity and specificity of four different radiographic views.

Materials and Methods  Radiographs (posteroanterior [PA], lateral [LAT], pronated oblique [POL], and supinated oblique [SOL] views) showing normal findings or little/ring finger CMCJ injuries were shown to two cohorts of orthopaedic trainees and a cohort of emergency nurse practitioners.

Results  The POL view performed best in all three testing scenarios. The SOL view performed least well. The combination of a PA, true LAT, and POL identified 78% of injuries correctly. In no cases did the SOL view correctly identify an injury when the other three views had been interpreted as normal.

Conclusion  We recommend a combination of the PA, POL, and LAT views in diagnosing these injuries. Where doubt remains, cross-sectional imaging is essential.

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.

New Locked-Wire-Type External Fixator (the Ichi-Fixator) for Fourth and Fifth Carpometacarpal Joint Dislocation

We developed a new fixation method that involves the insertion of two wires and external wire fixation using a metal clamp. The aim of this technique was to increase the stability and rigidity of conventional percutaneous Kirchner wire fixation. Here, we present a patient with dislocation of the fourth and fifth carpometacarpal joints who was satisfactorily treated with closed reduction and percutaneous fixation with a linking external wire fixator (Ichi-Fixator). Operative treatment using the Ichi-Fixator system facilitates anatomical reduction and immediate full mobilization, resulting in good outcomes. The patient could perform all routine activities with normal grip strength and a full range of hand motion without pain. Such a treatment that improves comfort after the operation and may allow an immediate return to work will clearly boost patient satisfaction. Linked external wire-type fixation enables enhanced security of fixation, facilitates postoperative mobilization, and may allow an immediate return to work.

Management of fracture-dislocations of the little finger carpometacarpal joint: a systematic review

Fracture-dislocations of the carpometacarpal joint (CMCJ) of the little ray involve dorsal subluxation of the metacarpal base and they may be associated with injury of neighbouring CMCJs. Different treatment options are described, with no clear consensus on their management. This study presents a systematic review of comparative studies describing the management of these injuries. A bespoke search strategy was applied across multiple databases. Results were screened against specified stepwise inclusion criteria and data were extracted independently by two authors with discrepancy resolution by a third. Of 437 search results, six comparative studies were identified. Comparisons included non-operative or early mobilization versus fixation K-wires or open reduction and internal fixation. Conclusions were mixed; all studies had critical or significant risks of bias (using the ROBINS-I tool) and there was heterogeneity between studies.

Plate versus Kirschner wire fixation in treatment of fourth and fifth carpometacarpal fracture-dislocations: A retrospective cohort study

BACKGROUND

Fourth and fifth carpometacarpal fracture-dislocations with unsatisfactory closed reduction commonly require later open reduction and internal fixation. However, the optimal method of internal fixation for these is unknown. The purpose of this study was to determine through objective clinical measures which method is superior for fourth and fifth carpometacarpal fracture-dislocations: a K-wire or a plate.

METHODS

We conducted a retrospective review of hospital records of patients who had received treatment for fourth and fifth carpometacarpal fracture-dislocations at one hospital between May 2007 and May 2015. A total of 86 patients who had received open reduction either with plate or K-wire fixation were included. Demographic and clinical characteristics of the two groups of patients were collected. Patients received standardised clinical tests one year after fixation. Clinical outcomes included tests of grip strength and scores on the Michigan Hand Outcomes Questionnaire and Disabilities of Arm, Shoulder, and Hand. Student's t tests and Chi-square tests were used to statistically evaluate whether plate or K-wire fixation was superior on the clinical variables.

RESULTS

The two groups were statistically indistinguishable on their demographic and clinical characteristics. Generally, the clinical outcomes of internal fixation were satisfactory. The average DASH and MHQ scores of the K-wire group were superior to those of the plate group (DASH 2.3 versus 9.8, P = 0.01; MHQ 96.7 versus 86.6, P = 0.02). Grip strength was not significantly different between the two groups (89.5 ± 5.8% versus 90.1 ± 4.9%, P = 0.36).

CONCLUSIONS

This non-randomly controlled, retrospective study suggests that clinical outcomes after K-wire fixation is superior to plate fixation for fourth and fifth carpometacarpal fracture-dislocations. This is especially the case for hand functions related to work. The present results suggest that K-wire fixation is the gold-standard technique for the treatment of fourth and fifth CMC fracture-dislocations.

The Nonoperative Management of Hand Fractures in United Kingdom

Hand fractures (excluding small avulsion fractures and scaphoid fractures) almost always unite with bone. The role of the hand surgeon is not to achieve bone union but to achieve stability in an adequate position, often with some displacement, and maintenance of good soft tissue gliding. This article establishes that many fractures treated operatively do no better and often could not realistically do better than with good nonoperative treatment. Yet many are treated surgically to satisfy surgical egos, the desire to produce excellent radiographs, or just the mistaken belief that current surgical techniques can improve on nonoperative treatment.

Reliability of classification of ring and little finger carpometacarpal joint fracture subluxations: a comparison between two-dimensional computed tomography and three-dimensional computed tomography classifications

The aims of this study were to develop a classification for ring and little finger carpometacarpal joint fracture subluxations based on three-dimensional computed tomography images and evaluate the inter- and intraobserver reliability of the three-dimensional computed tomography classification. A retrospective review was performed of 30 cases of ring and little finger carpometacarpal joint fracture subluxations from 2005 to 2013. We classified ring and little finger carpometacarpal joint fracture subluxations into three types based on three-dimensional computed tomography images. An orthopaedic surgeon with 2 years of experience, a consultant hand surgeon with 8 years of experience, and a consultant radiologist with 9 years of experience, who were completely blind to the treatment algorithm, evaluated 30 cases twice at a 2-week interval using our new classification based on three-dimensional computed tomography images and the other classification based on two-dimensional computed tomography images. Our three-dimensional computed tomography classification showed almost perfect interobserver and intraobserver reliability and resulted in a better level of agreement than two-dimensional computed tomography classification.

Management algorithm for index through small finger carpometacarpal fracture dislocations

PURPOSE

Injuries to the carpometacarpal (CMC) joints are rare. The most common CMC fracture dislocations occur in the ring and small finger CMC joints. The aim of this study was to review the structured diagnostic procedure and different treatment options.

METHODS

We review the importance of early and correct diagnosis in CMC fracture dislocation, because it is needed to ensure pain-free hand function. Moreover, we contrast different therapeutic options, including non-operative and surgical therapy for CMC fracture dislocation.

RESULTS

If a clinical suspicion for a CMC dislocation based on patient examination or radiographic findings exists, then a thin slice CT should be considered. Non-operative treatment is rarely indicated. Surgical treatment may include closed or open reduction efforts. In the case of most fracture dislocations, open reduction is recommended. Fracture fixation may be accomplished with K-wires, mini plates or screws.

CONCLUSION

CMC fracture dislocations of the fourth and fifth CMC joints are uncommon and often overlooked. Primary goal of treatment is to restore normal function to the hand. Therefore, operative therapy might be the method of choice.