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The volar surgical approach in complex dorsal metacarpophalangeal dislocations
Injury, Int. J. Care Injured 40 (2009) 657–659
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The volar surgical approach in complex dorsal metacarpophalangeal dislocations Oguz Durakbasa *, Bulent Guneri Orthopaedics and Traumatology Department, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 21 October 2008
Objective: To describe the surgical treatment of complex dorsal metacarpophalangeal dislocations, emphasising the volar approach. Methods: Seven cases of isolated, closed, complex dorsal metacarpophalangeal dislocation, treated surgically using the volar approach, were retrospectively evaluated. The median follow-up period was 91 months. Results: Five of the injuries involved children. The thumb was involved in four cases and the index finger in three. The volar plate was found to impede reduction in all cases. The operated joint was immobilised in a functional brace for a median of 3 weeks. At final follow-up (median 91 months), the metacarpophalangeal range of motion, grip power, stability and sensation were normal. Conclusions: Using the volar surgical approach, the strangulated metacarpal head can be directly visualised and the volar plate, which is longitudinally split for reduction, can be repaired. Reduction should be performed within the first day from injury, and the joint should be immobilised in a functional position no more than 3 weeks. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Dorsal metacarpophalangeal dislocation Volar approach Functional splint
Introduction Complex metacarpophalangeal (MCP) dislocation is uncommon. ‘Complex’ suggests irreducibility of the joint by closed methods.2,8 Debate continues between the advocates of the palmar and or the volar approach in surgical treatment. The aim of this study was to describe a single clinic’s experience of the presentation, surgical treatment and outcome of complex dorsal MCP dislocations, with particular emphasis on surgery using a volar approach.
Materials and methods Records of all cases of complex MCP dislocation treated in our clinic between 1998 and 2007 were retrospectively evaluated. Of the seven patients included, all were male and five were children aged 10 years. The median age was 10 (5–36) years. The injury mechanism was axial compression leading to hyperextension of the MCP joint, caused by simple fall in four cases, sports injury in one (direct blow by a ball to the finger), and fall from stairs in two. All were closed injuries; of these four
* Corresponding author at: SOYAK Gokyuzu Konutlari, C Blok, D: 45, Barbaros Mah., Karayollari Site Sok., no: 5, 34662 Uskudar, Istanbul, Turkey. Tel.: +90 216 3860289; fax: +90 216 3697692. E-mail address: [email protected] (O. Durakbasa). 0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.10.027
involved the right thumb and three involved the left index finger. All dislocations were dorsal. The median follow-up period was 91 (5–117) months. All these patients were admitted to the emergency department on the day of injury. Closed reduction under regional anaesthesia was attempted upon admission, without success, and operative intervention was undertaken on the day of injury. The volar approach was standard, involving an S-shaped incision. The horizontal part of this incision was parallel to the distal digital palmar crease, extending from the radial to the ulnar sides of the finger (Fig. 1). After blunt dissection of the subcuticular tissue with a Pean forcep, the digital nerve and artery were located and protected. In all cases the volar plate was found to be interposed between the metacarpal head and proximal phalanx, preventing reduction, and the metacarpal head was strangulated between the volar plate, the flexor tendon and the lumbrical muscle (Fig. 2). The volar plate was bisected longitudinally, so that the joint could be reduced (Fig. 3), and was then repaired (Fig. 4) using 2/0 polyglactin with interrupted overand-over sutures. No metacarpal head fractures, loose bodies or collateral ligament tears were found. A short arm brace was applied with the MCP joint in 708 of flexion and the interphalangeal joints in full extension, for 3 weeks postoperatively, after which active and passive exercises were begun. After removal of the brace, all cases were evaluated by regular followup assessments of plain radiographs and of MCP joint range of motion, stability, grip power and sensation.
658
O. Durakbasa, B. Guneri / Injury, Int. J. Care Injured 40 (2009) 657–659
Fig. 1. The volar approach. The S-shaped incision is shown as a dotted line.
Fig. 3. The volar plate is cut longitudinally and the MCP joint is reduced. FT, flexor tendon; STL, superficial transverse ligament; LM, lumbrical muscle; RDN, radial digital nerve to the index finger; MH, metacarpal head.
MCP joint dislocation is uncommon.5 In complex dorsal MCP dislocations, the structure most likely to hinder reduction of the joint is the interposed volar plate;4 the metacarpal head is thus strangulated between volar plate, flexor tendon and the lumbrical muscle.12 The border digits (index and little fingers) are most frequently involved because of their increased vulnerability to trauma and lack of stabilisation by two adjacent deep transverse metacarpal ligaments.8 In this study, the thumb was the most commonly injured, followed by the index finger. It was interesting
(and unexplained) that all our cases of complex dorsal MCP dislocation of the thumb were paediatric, although dislocation of the MCP joint of the thumb is rare among children.7 There is ongoing debate regarding the surgical approach to complex dorsal MCP dislocation.3–5 The dorsal approach was first described by Farabeuf in 1876, and the volar approach by Kaplan in 1957.4 The advantages of the dorsal approach include excellent exposure of the volar plate, no risk of damage to the digital nerves or vessels, and accessibility to osteochondral fragments of the metacarpal head. The main disadvantage is that the volar plate, which is longitudinally split to reduce the MCP joint, cannot be repaired when using this technique. On the other hand, the volar approach allows direct access to the lesion, anatomical restoration of the joint and repair of the volar plate, decreasing the risk of late instability.2,3 The reported disadvantages include difficulty in accessing the volar plate, which is tented over the metacarpal head, and danger of inadvertent damage to neurovascular structures.3 In a cadaveric and clinical study, Barry et al. showed that both volar and
Fig. 2. The strangulated metacarpal head. VP, volar plate; FT, flexor tendon; STL, superficial transverse ligament; LM, lumbrical muscle; RDN, radial digital nerve to the index finger; MH, metacarpal head.
Fig. 4. The split volar plate is prepared for repair. VP (s), volar plate split.
Results In all cases, the final MCP range of motion, stability, grip power and sensation were normal and on plain radiography the MCP joint was congruent. No sign of subluxation or degenerative arthritis was detected. Discussion
O. Durakbasa, B. Guneri / Injury, Int. J. Care Injured 40 (2009) 657–659
dorsal approaches were successful in repairing such injuries.3 Their study found that the dorsal approach was simple and safe but, because the volar plate was longitudinally split, it was theoretically liable to late instability. They also indicated that the palmar approach was more suitable for restoring normal anatomy, but was risky with regard to damage to the digital nerves and vessels. In the present series, the volar approach was preferred because it enabled the operating surgeon to directly visualise the strangulated metacarpal head. The potential disadvantage of iatrogenic neurovascular damage can be prevented by meticulous dissection, carefully protecting the digital nerve and vessels. It is important to know that the stretched, palmarly displaced neurovascular structures comprise the radial digital nerve and artery in injury to the second and third digits, and the ulnar digital nerve and artery in injury to the fourth and the fifth digits.1 A volar plate which is split longitudinally to reduce the MCP joint can be repaired by the volar approach, and therefore the risk of instability is removed. It has been shown that results are satisfactory if operation is performed within the first day from injury, and motion initiated within 3 days.5 Both delayed surgery and prolonged postoperative immobilisation are cited as contributing to failure. Light and Ogden recommended early protected mobilisation of the joint, with a dorsal splint preventing full extension, and suggested that the reduction would be stable as long as hyperextension was avoided during the first few weeks after surgery.6 The cases in the present series also were operated on within the first day of injury, but a longer duration of postoperative immobilisation was applied, with no resultant restriction in range of motion. Thus we propose bracing in a functional position a period of 3 weeks, to enable softtissue and volar-plate healing. This method has yielded encouragingly good results. Digital nerve damage, reduced range of movement of the affected digit and degenerative arthritis have been identified as complications following surgery for MCP dislocations.9,10 Digital nerve damage can result from using a volar approach, whereas reduced range of motion of the affected digit and degenerative arthritis are related to repeated attempts at closed reduction, prolonged reduction time, prolonged immobilisation, fracturedislocation and open dislocation.6,9–11 None of these complications were encountered in the present series within the long-term follow-up period, probably because all the cases were isolated closed dislocations that were promptly reduced within the first day from injury. Gentle reduction of the MCP joint was made by using a direct volar approach and incising longitudinally the volar plate (which is the main structure hindering reduction), and functional bracing was applied. Fracture-dislocations and open dislocations seem to have poorer outcomes. Conclusions The number of cases in the present study was limited, but enabled strict comparison between volar and dorsal surgical
659
approaches. The volar approach was found to be a reliable alternative for treating dorsal MCP dislocations; it not only has the advantage of direct visualisation of the anatomy of complex dorsal MCP dislocation, but also allows repair to the split volar plate, thus avoiding possible joint instability. Reduction should be carried out within the first day of injury, and the joint should be immobilised in a functional position for no more than 3 weeks. Longer periods of immobilisation may lead to reduced range of motion of the affected digit and degenerative arthritis. The limitations of the technique that should be kept in mind are difficulty in visualisation of the volar plate lying dorsal to the metacarpal head, vulnerability of the radial or ulnar digital nerve and artery of the digit to iatrogenic injury, and unsuitability for treating fracture-dislocations.
Conflict of interest statement This paper has not been published previously, is not under consideration for publication elsewhere, and if accepted, will not be published elsewhere in the same form, in English or in any other language, without the written consent of the publishers. The authors have no financial or personal relationships with other people or organisations that could inappropriately influence (bias) their work.
References 1. Al-Qattan MM, Murray K. An isolated complex dorsal dislocation of the MP joint of the ring finger. J Hand Surg [Br] 1994;19:171–3. 2. Andersen JA, Gjerloff CC. Complex dislocation of the metacarpophalangeal joint of the little finger. J Hand Surg [Br] 1987;12:264–6. 3. Barry K, McGee H, Curtin J. Complex dislocation of the metacarpophalangeal joint of the index finger: a comparison of the surgical approaches. J Hand Surg [Br] 1998;13:466–8. 4. Bohart PG, Gelberman RH, Vandell RF, Salamon PB. Complex dislocations of the metacarpophalangeal joint. Operative reduction by Farabeuf’s dorsal incision. Clin Orthop 1982;164:208–10. 5. Dutton RO, Meals RA. Complex dorsal dislocation of the thumb metacarpophalangeal joint. Clin Orthop 1982;164:160–4. 6. Light TR, Ogden JA. Complex dislocation of the index metacarpophalangeal joint in children. J Pediatr Orthop 1988;8:300–5. 7. Maheshwari R, Sharma H, Duncan RD. Metacarpophalangeal joint dislocation of the thumb in children. J Bone Joint Surg [Br] 2007;89:227–9. 8. May Jr JW, Rochrich RJ, Sheppard J. Closed complex dorsal dislocation of the middle finger metacarpophalangeal joint: anatomic considerations and treatment. Plast Reconstr Surg 1988;82:690–3. 9. Mudgal CS, Mudgal S. Volar open reduction of complex metacarpophalangeal dislocation of the index finger: a pictorial essay. Tech Hand Up Extrem Surg 2006;10:31–6. 10. Stiles BM, Drake DB, Gear AJ, et al. Metacarpophalangeal joint dislocation: indications for open surgical reduction. J Emerg Med 1997;15:669–71. 11. Stowell JF, Rennie WP. Simultaneous open and closed dislocations of adjacent metacarpophalangeal joints: a case report. J Emerg Med 2002;23:355– 8. 12. Viegas SF, Heare TC, Calhoun JH. Complex fracture-dislocation of a fifth metacarpophalangeal joint: case report and literature review. J Trauma 1989;29: 521–4.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The volar surgical approach in complex dorsal metacarpophalangeal dislocations Oguz Durakbasa *, Bulent Guneri Orthopaedics and Traumatology Department, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 21 October 2008
Objective: To describe the surgical treatment of complex dorsal metacarpophalangeal dislocations, emphasising the volar approach. Methods: Seven cases of isolated, closed, complex dorsal metacarpophalangeal dislocation, treated surgically using the volar approach, were retrospectively evaluated. The median follow-up period was 91 months. Results: Five of the injuries involved children. The thumb was involved in four cases and the index finger in three. The volar plate was found to impede reduction in all cases. The operated joint was immobilised in a functional brace for a median of 3 weeks. At final follow-up (median 91 months), the metacarpophalangeal range of motion, grip power, stability and sensation were normal. Conclusions: Using the volar surgical approach, the strangulated metacarpal head can be directly visualised and the volar plate, which is longitudinally split for reduction, can be repaired. Reduction should be performed within the first day from injury, and the joint should be immobilised in a functional position no more than 3 weeks. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Dorsal metacarpophalangeal dislocation Volar approach Functional splint
Introduction Complex metacarpophalangeal (MCP) dislocation is uncommon. ‘Complex’ suggests irreducibility of the joint by closed methods.2,8 Debate continues between the advocates of the palmar and or the volar approach in surgical treatment. The aim of this study was to describe a single clinic’s experience of the presentation, surgical treatment and outcome of complex dorsal MCP dislocations, with particular emphasis on surgery using a volar approach.
Materials and methods Records of all cases of complex MCP dislocation treated in our clinic between 1998 and 2007 were retrospectively evaluated. Of the seven patients included, all were male and five were children aged 10 years. The median age was 10 (5–36) years. The injury mechanism was axial compression leading to hyperextension of the MCP joint, caused by simple fall in four cases, sports injury in one (direct blow by a ball to the finger), and fall from stairs in two. All were closed injuries; of these four
* Corresponding author at: SOYAK Gokyuzu Konutlari, C Blok, D: 45, Barbaros Mah., Karayollari Site Sok., no: 5, 34662 Uskudar, Istanbul, Turkey. Tel.: +90 216 3860289; fax: +90 216 3697692. E-mail address: [email protected] (O. Durakbasa). 0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.10.027
involved the right thumb and three involved the left index finger. All dislocations were dorsal. The median follow-up period was 91 (5–117) months. All these patients were admitted to the emergency department on the day of injury. Closed reduction under regional anaesthesia was attempted upon admission, without success, and operative intervention was undertaken on the day of injury. The volar approach was standard, involving an S-shaped incision. The horizontal part of this incision was parallel to the distal digital palmar crease, extending from the radial to the ulnar sides of the finger (Fig. 1). After blunt dissection of the subcuticular tissue with a Pean forcep, the digital nerve and artery were located and protected. In all cases the volar plate was found to be interposed between the metacarpal head and proximal phalanx, preventing reduction, and the metacarpal head was strangulated between the volar plate, the flexor tendon and the lumbrical muscle (Fig. 2). The volar plate was bisected longitudinally, so that the joint could be reduced (Fig. 3), and was then repaired (Fig. 4) using 2/0 polyglactin with interrupted overand-over sutures. No metacarpal head fractures, loose bodies or collateral ligament tears were found. A short arm brace was applied with the MCP joint in 708 of flexion and the interphalangeal joints in full extension, for 3 weeks postoperatively, after which active and passive exercises were begun. After removal of the brace, all cases were evaluated by regular followup assessments of plain radiographs and of MCP joint range of motion, stability, grip power and sensation.
658
O. Durakbasa, B. Guneri / Injury, Int. J. Care Injured 40 (2009) 657–659
Fig. 1. The volar approach. The S-shaped incision is shown as a dotted line.
Fig. 3. The volar plate is cut longitudinally and the MCP joint is reduced. FT, flexor tendon; STL, superficial transverse ligament; LM, lumbrical muscle; RDN, radial digital nerve to the index finger; MH, metacarpal head.
MCP joint dislocation is uncommon.5 In complex dorsal MCP dislocations, the structure most likely to hinder reduction of the joint is the interposed volar plate;4 the metacarpal head is thus strangulated between volar plate, flexor tendon and the lumbrical muscle.12 The border digits (index and little fingers) are most frequently involved because of their increased vulnerability to trauma and lack of stabilisation by two adjacent deep transverse metacarpal ligaments.8 In this study, the thumb was the most commonly injured, followed by the index finger. It was interesting
(and unexplained) that all our cases of complex dorsal MCP dislocation of the thumb were paediatric, although dislocation of the MCP joint of the thumb is rare among children.7 There is ongoing debate regarding the surgical approach to complex dorsal MCP dislocation.3–5 The dorsal approach was first described by Farabeuf in 1876, and the volar approach by Kaplan in 1957.4 The advantages of the dorsal approach include excellent exposure of the volar plate, no risk of damage to the digital nerves or vessels, and accessibility to osteochondral fragments of the metacarpal head. The main disadvantage is that the volar plate, which is longitudinally split to reduce the MCP joint, cannot be repaired when using this technique. On the other hand, the volar approach allows direct access to the lesion, anatomical restoration of the joint and repair of the volar plate, decreasing the risk of late instability.2,3 The reported disadvantages include difficulty in accessing the volar plate, which is tented over the metacarpal head, and danger of inadvertent damage to neurovascular structures.3 In a cadaveric and clinical study, Barry et al. showed that both volar and
Fig. 2. The strangulated metacarpal head. VP, volar plate; FT, flexor tendon; STL, superficial transverse ligament; LM, lumbrical muscle; RDN, radial digital nerve to the index finger; MH, metacarpal head.
Fig. 4. The split volar plate is prepared for repair. VP (s), volar plate split.
Results In all cases, the final MCP range of motion, stability, grip power and sensation were normal and on plain radiography the MCP joint was congruent. No sign of subluxation or degenerative arthritis was detected. Discussion
O. Durakbasa, B. Guneri / Injury, Int. J. Care Injured 40 (2009) 657–659
dorsal approaches were successful in repairing such injuries.3 Their study found that the dorsal approach was simple and safe but, because the volar plate was longitudinally split, it was theoretically liable to late instability. They also indicated that the palmar approach was more suitable for restoring normal anatomy, but was risky with regard to damage to the digital nerves and vessels. In the present series, the volar approach was preferred because it enabled the operating surgeon to directly visualise the strangulated metacarpal head. The potential disadvantage of iatrogenic neurovascular damage can be prevented by meticulous dissection, carefully protecting the digital nerve and vessels. It is important to know that the stretched, palmarly displaced neurovascular structures comprise the radial digital nerve and artery in injury to the second and third digits, and the ulnar digital nerve and artery in injury to the fourth and the fifth digits.1 A volar plate which is split longitudinally to reduce the MCP joint can be repaired by the volar approach, and therefore the risk of instability is removed. It has been shown that results are satisfactory if operation is performed within the first day from injury, and motion initiated within 3 days.5 Both delayed surgery and prolonged postoperative immobilisation are cited as contributing to failure. Light and Ogden recommended early protected mobilisation of the joint, with a dorsal splint preventing full extension, and suggested that the reduction would be stable as long as hyperextension was avoided during the first few weeks after surgery.6 The cases in the present series also were operated on within the first day of injury, but a longer duration of postoperative immobilisation was applied, with no resultant restriction in range of motion. Thus we propose bracing in a functional position a period of 3 weeks, to enable softtissue and volar-plate healing. This method has yielded encouragingly good results. Digital nerve damage, reduced range of movement of the affected digit and degenerative arthritis have been identified as complications following surgery for MCP dislocations.9,10 Digital nerve damage can result from using a volar approach, whereas reduced range of motion of the affected digit and degenerative arthritis are related to repeated attempts at closed reduction, prolonged reduction time, prolonged immobilisation, fracturedislocation and open dislocation.6,9–11 None of these complications were encountered in the present series within the long-term follow-up period, probably because all the cases were isolated closed dislocations that were promptly reduced within the first day from injury. Gentle reduction of the MCP joint was made by using a direct volar approach and incising longitudinally the volar plate (which is the main structure hindering reduction), and functional bracing was applied. Fracture-dislocations and open dislocations seem to have poorer outcomes. Conclusions The number of cases in the present study was limited, but enabled strict comparison between volar and dorsal surgical
659
approaches. The volar approach was found to be a reliable alternative for treating dorsal MCP dislocations; it not only has the advantage of direct visualisation of the anatomy of complex dorsal MCP dislocation, but also allows repair to the split volar plate, thus avoiding possible joint instability. Reduction should be carried out within the first day of injury, and the joint should be immobilised in a functional position for no more than 3 weeks. Longer periods of immobilisation may lead to reduced range of motion of the affected digit and degenerative arthritis. The limitations of the technique that should be kept in mind are difficulty in visualisation of the volar plate lying dorsal to the metacarpal head, vulnerability of the radial or ulnar digital nerve and artery of the digit to iatrogenic injury, and unsuitability for treating fracture-dislocations.
Conflict of interest statement This paper has not been published previously, is not under consideration for publication elsewhere, and if accepted, will not be published elsewhere in the same form, in English or in any other language, without the written consent of the publishers. The authors have no financial or personal relationships with other people or organisations that could inappropriately influence (bias) their work.
References 1. Al-Qattan MM, Murray K. An isolated complex dorsal dislocation of the MP joint of the ring finger. J Hand Surg [Br] 1994;19:171–3. 2. Andersen JA, Gjerloff CC. Complex dislocation of the metacarpophalangeal joint of the little finger. J Hand Surg [Br] 1987;12:264–6. 3. Barry K, McGee H, Curtin J. Complex dislocation of the metacarpophalangeal joint of the index finger: a comparison of the surgical approaches. J Hand Surg [Br] 1998;13:466–8. 4. Bohart PG, Gelberman RH, Vandell RF, Salamon PB. Complex dislocations of the metacarpophalangeal joint. Operative reduction by Farabeuf’s dorsal incision. Clin Orthop 1982;164:208–10. 5. Dutton RO, Meals RA. Complex dorsal dislocation of the thumb metacarpophalangeal joint. Clin Orthop 1982;164:160–4. 6. Light TR, Ogden JA. Complex dislocation of the index metacarpophalangeal joint in children. J Pediatr Orthop 1988;8:300–5. 7. Maheshwari R, Sharma H, Duncan RD. Metacarpophalangeal joint dislocation of the thumb in children. J Bone Joint Surg [Br] 2007;89:227–9. 8. May Jr JW, Rochrich RJ, Sheppard J. Closed complex dorsal dislocation of the middle finger metacarpophalangeal joint: anatomic considerations and treatment. Plast Reconstr Surg 1988;82:690–3. 9. Mudgal CS, Mudgal S. Volar open reduction of complex metacarpophalangeal dislocation of the index finger: a pictorial essay. Tech Hand Up Extrem Surg 2006;10:31–6. 10. Stiles BM, Drake DB, Gear AJ, et al. Metacarpophalangeal joint dislocation: indications for open surgical reduction. J Emerg Med 1997;15:669–71. 11. Stowell JF, Rennie WP. Simultaneous open and closed dislocations of adjacent metacarpophalangeal joints: a case report. J Emerg Med 2002;23:355– 8. 12. Viegas SF, Heare TC, Calhoun JH. Complex fracture-dislocation of a fifth metacarpophalangeal joint: case report and literature review. J Trauma 1989;29: 521–4.