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Complex dorsal dislocation of the second carpometacarpal joint
The Journal of HAND SURGERY
Black, Watson, and Vender
tiIage surface after arthroplasty suffices for these functions without the development of arthritis . Impingement of the CMC joint malunion is relieved by resecting the problematic dorsal portion of the healed fracture dislocation, basing the new joint on the reduced palmar fragment. We recommend this procedure as an alternative to arthrodesis because it preserves motion in treating the malunion and the associated arthropathy of the ulnar CMC joints. REFERENCES 1. Fisher MR, Rogers LF, Hendrix RW. Systemic approach to identifying fourth and fifth carpometacarpal joint dislocations . Am J Rheum 1983;140:319-24. 2. Burk. Ueber die luxatio carpo-metacarpea. Beitr z Klin Chir 190 1;30:525-45 . 3. Hsu JH, Curtis RM. Carpometacarpal dislocations on the ulnar side of the hand . J Bone Joint Surg [Am] 1970; 52:927-30. 4. Petrie PWR , Lamb OW. Fracture-subluxation of base of fifth metacarpal. Hand 1974;6:82-6.
5. Sandzen SC. Fracture of the fifth metacarpal. Resembling Bennett's fracture. Hand 1973;5:49-51. 6. Waugh RL, Yancy AG . Carpometacarpal dislocations . With particular reference to simultaneous dislocation of the bases of the fourth and fifth metacarpals . J Bone Joint Surg [Am] 1948;30:397-404. 7. Clendenin MB, Smith RJ. Fifth metacarpallhamate arthrodesis for posttraumatic osteoarthritis. J HAND SURG 1984;9:374-8. 8. Lilling M, Weinberg H. The mechanism of dorsal dislocation of the fifth carpometacarpal joint. J HAND SURG 1979;4:340-2. 9. Bora WF, Didizian NH. The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg [Am] 1974;56:1459-63 . 10. Hazlett JW. Carpometacarpal dislocations other than the thumb: a report of II cases. Can J Surg 1968;11 : 315-22. II. Green WL, Kilgore ES . Treatment of fifth digit carpometacarpal arthritis with silastic prosthesis . J HAND SURG 1981 ;6:510-4.
Complex dorsal dislocation of the second carpometacarpal joint Isolated dislocation of the carpometacarpal jOint of the index finger is a rare injury. This paper reports a case of an isolated dorsal dislocation of the second carpometacarpal joint not reducible by closed means. At open reduction, the extensor carpi radialis brevis was found to be interposed in the joint, blocking reduction. J HAND SURG 1987;12A:I074-6.)
Paul K. Ho, LCDR, MC, USNR, Stephen J. Choban, LT, MC, USNR, Stephen J. Eshman, LCDR, MC, USNR, and Theodore E. Dupuy, M.D., Portsmouth and Norfolk, Va., and Bethesda, Md.
From the Department of Orthopedic Surgery, Naval Hospital, Portsmouth, Va., the Eastern Virginia Medical School, Norfolk, Va., and the Uniformed Services University of the Health Sciences, Bethesda, Md . No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The views expressed in this article are those of the author and do not reftectthe official policy or position of the Department of the Navy, Department of Defense , or the U.S. Government. Reprint requests: Paul K. Ho, M.D., 3716 Ingersoll Ave. , Des Moines, IA 50312.
1074
THE JOURNAL OF HAND SURGERY
Because of its strong ligamentous and bony stabilizers, isolated dislocation of the second metacarpal is a rare injury. I. 2 We recently treated a patient with an irreducible second carpometacarpal dislocation, which, at open reduction, revealed interposition of the extensor carpi radialis brevis between the second metacarpal base and the trapezoid. We termed this a "complex" dorsal carpometacarpal dislocation of the second ray.
Vol. 12A, No.6 November 1987
Complex dorsal dislocation of second CMC joint
1075
Fig. 1. Lateral radiograph showing a dorsal dislocation of the second metacarpal.
Fig. 2. Intraoperative photograph showing the extensor carpi radialis brevis blocking reduction of the second metacarpal.
Case report
Kirschner wire, and the hand was immobilized in a plaster cast. At 6 weeks the cast and pin were removed. At 6 months postoperatively the patient had regained full function and resumed his job as an engineman in the Navy.
A 24-year old, right-handed man was admitted to the hospital after injuring his right hand in an automobile accident. To the best of his recollection he was driving with both hands on the steering wheel when he was involved in a head-on collision with another car. Examination of the right hand showed a marked swelling over the dorsum of the right hand, diffuse tenderness over the carpometacarpal area, and a dorsal prominence of the base of the second metacarpal. A small superficial abrasion was also noted over the dorsum of the middle phalanx of the right long finger. Finger motion, especially of the index and long digits was painful. Circulation and sensibility were intact. X-ray films showed a dorsal dislecation of the second carpometacarpal (CMC) joint (Fig. 1). After adequate regional anesthesia, two attempts at closed reduction proved to be unsuccessful. A dorsal incision was then made over the second metacarpal. The extensor carpi radialis brevis (ECRB) was found interposed between the second metacarpal and the trapezoid effectively blocking reduction (Fig. 2). The ERCB was retracted, and the second metacarpal was easily reduced with direct pressure and traction. Reduction was maintained with a single O.045-inch
Anatomy The second CMC joint is an arthrodial diarthrosis, which is inherently stable due to the geometry of its articular surfaces, ligamentous integrity about the joint,2. 3 and the tethering action of the long extrinsic wrist extensors. 4 The base of the second metacarpal is traditionally described as being fork-shaped,5 with the radial and ulnar condyles serving as the two prongs of the fork. The ulnar condyle articulates with the styloid process of the third metacarpal while the shorter radial condyle articulates with the trapezium. The concavity between the condyles then receives the distal articular surface of the trapezoid. The joint is further stabilized by the dorsal, palmar, and interosseous ligaments. The dorsal ligaments are comprised of two fasiculi, one
1076
The Journal of HAND SURGERY
Ho et al.
running in a longitudinal direction from the trapezoid and the other obliquely from the trapezium. The weaker, less distinct palmar ligaments are arranged in a fashion similar to the dorsal ligaments. The metacarpal bases are further united transversely by the short, thick interosseous ligaments. The extensor carpi radialis longus tendon passes through a dorsal groove on the trapezoid to insert on the radial condyle of the second metacarpal further strengthening the dorsal aspect of the second CMC joint. 6 In a similar fashion the extensor carpi radialis brevis passes along the ulnar margin of the base of the second metacarpal to insert on the third metacarpal.
2.
3.
4.
5. 6.
Discussion Joseph et al. 2 reviewed the intemationalliterature of 124 CMC dislocations and reported only nine 7- 15 cases of isolated dislocations of the second CMC joint. Several of these cases required open reduction,S. 14. 16 with two reported in the English-language literature. 14. 16 In 1906 Lyman 14 reported a case in which the second metacarpal could not be reduced by the usual traction and manipulation. He described an open reduction that required "prying" the second metacarpal into position with a chisel. In 1973 Lewis 16 presented a patient with a dislocation in which the second metacarpal was' 'buttonholed through the dorsal ligaments of the wrist." The strong structural supports of the second CMC joint explain why this dislocation is such a rare occurrence. To the best of our knowledge this case represents the only report in the English-language literature of an isolated second CMC dislocation in which closed reduction was blocked by the extensor carpi radialis brevis. We would like to express our appreciation to Ms. Suad Jones, librarian, Naval Hospital, Portsmouth, Va., for her help with this paper.
REFERENCES 1. Waugh RL, Yancey AG. Carpometacarpal dislocations with particular reference to simultaneous dislocation of
7.
8.
9. 10. II.
12. 13.
14. 15. 16.
the bases of the fourth and fifth metacarpals. J Bone Joint Surg [Am) 1948;30A:397-404. Joseph RB, Linscheid RL, Dobyns JH, Bryan RS. Chronic sprains of the carpometacarpal joints. J HAND SURG 1981;6:172-80. Green DP, Rowland SA. Fracture and dislocation in the hand. In: Rockwood, CA, Green DP, eds. Fractures in adults. Philadelphia: JB Lippincott, 1982:383-8. Kleinman WB, Grantham SA. Multiple volar carpometacarpal joint dislocations . J HAND SURG 1978;3: 377-82 . Kaplan EB. Functional and surgical anatomy of the hand. 3rd ed. Philadelphia: JB Lippincott, 1983:27. Marwin SF, Fox JM, Sedlin ED. Volar dislocation of the bases of the second and third metacarpals. J Bone Joint Surg [Am] 1975;57:849-51. Berdach J, Herzog A. Ein Pall von traumatischer isolirter luxation des metacarpus indicis. Wien Klin Wochenschr 1902;15:940. Zilch M. Dorsal dislocation in the carpometacarpal joint II with additional rotation dislocation . Handchirurgle 1978;10:63-5. Bourquet. Observatin pur servir a I'historie des luxatien des doigts de la main. Rev Med Chir 1853;14:94. Foucher. BulietMemSocAnatdeParis 1856;1 (2Serie): 6-8. Hamilton FH. A practical treatise on fractures dislocations . 7th ed. Philadelphia: Henry C. Lea's Son Co , 1884:794. Humbert G. Luxation due deuxieme metacarpum en arriere. Univ Med 1868;5(3 Serie):527. Key JA, Cinwell ME. The management of fractures dislocations and sprains . 3rd ed. St. Louis: The CV Mosby Company, 1942:831. Lyman CB. Backwards dislocation of the second carpometacarpal articulation . Ann Surg 1906;43:905. Oggioni G. Lussazione dorsali isolati carpometacarpale, Gior di Med, Mil 1947;94:293. Lewis MM. Dislocation of the second metacarpal. Clin Orthop 1973;93:253-5 .
Black, Watson, and Vender
tiIage surface after arthroplasty suffices for these functions without the development of arthritis . Impingement of the CMC joint malunion is relieved by resecting the problematic dorsal portion of the healed fracture dislocation, basing the new joint on the reduced palmar fragment. We recommend this procedure as an alternative to arthrodesis because it preserves motion in treating the malunion and the associated arthropathy of the ulnar CMC joints. REFERENCES 1. Fisher MR, Rogers LF, Hendrix RW. Systemic approach to identifying fourth and fifth carpometacarpal joint dislocations . Am J Rheum 1983;140:319-24. 2. Burk. Ueber die luxatio carpo-metacarpea. Beitr z Klin Chir 190 1;30:525-45 . 3. Hsu JH, Curtis RM. Carpometacarpal dislocations on the ulnar side of the hand . J Bone Joint Surg [Am] 1970; 52:927-30. 4. Petrie PWR , Lamb OW. Fracture-subluxation of base of fifth metacarpal. Hand 1974;6:82-6.
5. Sandzen SC. Fracture of the fifth metacarpal. Resembling Bennett's fracture. Hand 1973;5:49-51. 6. Waugh RL, Yancy AG . Carpometacarpal dislocations . With particular reference to simultaneous dislocation of the bases of the fourth and fifth metacarpals . J Bone Joint Surg [Am] 1948;30:397-404. 7. Clendenin MB, Smith RJ. Fifth metacarpallhamate arthrodesis for posttraumatic osteoarthritis. J HAND SURG 1984;9:374-8. 8. Lilling M, Weinberg H. The mechanism of dorsal dislocation of the fifth carpometacarpal joint. J HAND SURG 1979;4:340-2. 9. Bora WF, Didizian NH. The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg [Am] 1974;56:1459-63 . 10. Hazlett JW. Carpometacarpal dislocations other than the thumb: a report of II cases. Can J Surg 1968;11 : 315-22. II. Green WL, Kilgore ES . Treatment of fifth digit carpometacarpal arthritis with silastic prosthesis . J HAND SURG 1981 ;6:510-4.
Complex dorsal dislocation of the second carpometacarpal joint Isolated dislocation of the carpometacarpal jOint of the index finger is a rare injury. This paper reports a case of an isolated dorsal dislocation of the second carpometacarpal joint not reducible by closed means. At open reduction, the extensor carpi radialis brevis was found to be interposed in the joint, blocking reduction. J HAND SURG 1987;12A:I074-6.)
Paul K. Ho, LCDR, MC, USNR, Stephen J. Choban, LT, MC, USNR, Stephen J. Eshman, LCDR, MC, USNR, and Theodore E. Dupuy, M.D., Portsmouth and Norfolk, Va., and Bethesda, Md.
From the Department of Orthopedic Surgery, Naval Hospital, Portsmouth, Va., the Eastern Virginia Medical School, Norfolk, Va., and the Uniformed Services University of the Health Sciences, Bethesda, Md . No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The views expressed in this article are those of the author and do not reftectthe official policy or position of the Department of the Navy, Department of Defense , or the U.S. Government. Reprint requests: Paul K. Ho, M.D., 3716 Ingersoll Ave. , Des Moines, IA 50312.
1074
THE JOURNAL OF HAND SURGERY
Because of its strong ligamentous and bony stabilizers, isolated dislocation of the second metacarpal is a rare injury. I. 2 We recently treated a patient with an irreducible second carpometacarpal dislocation, which, at open reduction, revealed interposition of the extensor carpi radialis brevis between the second metacarpal base and the trapezoid. We termed this a "complex" dorsal carpometacarpal dislocation of the second ray.
Vol. 12A, No.6 November 1987
Complex dorsal dislocation of second CMC joint
1075
Fig. 1. Lateral radiograph showing a dorsal dislocation of the second metacarpal.
Fig. 2. Intraoperative photograph showing the extensor carpi radialis brevis blocking reduction of the second metacarpal.
Case report
Kirschner wire, and the hand was immobilized in a plaster cast. At 6 weeks the cast and pin were removed. At 6 months postoperatively the patient had regained full function and resumed his job as an engineman in the Navy.
A 24-year old, right-handed man was admitted to the hospital after injuring his right hand in an automobile accident. To the best of his recollection he was driving with both hands on the steering wheel when he was involved in a head-on collision with another car. Examination of the right hand showed a marked swelling over the dorsum of the right hand, diffuse tenderness over the carpometacarpal area, and a dorsal prominence of the base of the second metacarpal. A small superficial abrasion was also noted over the dorsum of the middle phalanx of the right long finger. Finger motion, especially of the index and long digits was painful. Circulation and sensibility were intact. X-ray films showed a dorsal dislecation of the second carpometacarpal (CMC) joint (Fig. 1). After adequate regional anesthesia, two attempts at closed reduction proved to be unsuccessful. A dorsal incision was then made over the second metacarpal. The extensor carpi radialis brevis (ECRB) was found interposed between the second metacarpal and the trapezoid effectively blocking reduction (Fig. 2). The ERCB was retracted, and the second metacarpal was easily reduced with direct pressure and traction. Reduction was maintained with a single O.045-inch
Anatomy The second CMC joint is an arthrodial diarthrosis, which is inherently stable due to the geometry of its articular surfaces, ligamentous integrity about the joint,2. 3 and the tethering action of the long extrinsic wrist extensors. 4 The base of the second metacarpal is traditionally described as being fork-shaped,5 with the radial and ulnar condyles serving as the two prongs of the fork. The ulnar condyle articulates with the styloid process of the third metacarpal while the shorter radial condyle articulates with the trapezium. The concavity between the condyles then receives the distal articular surface of the trapezoid. The joint is further stabilized by the dorsal, palmar, and interosseous ligaments. The dorsal ligaments are comprised of two fasiculi, one
1076
The Journal of HAND SURGERY
Ho et al.
running in a longitudinal direction from the trapezoid and the other obliquely from the trapezium. The weaker, less distinct palmar ligaments are arranged in a fashion similar to the dorsal ligaments. The metacarpal bases are further united transversely by the short, thick interosseous ligaments. The extensor carpi radialis longus tendon passes through a dorsal groove on the trapezoid to insert on the radial condyle of the second metacarpal further strengthening the dorsal aspect of the second CMC joint. 6 In a similar fashion the extensor carpi radialis brevis passes along the ulnar margin of the base of the second metacarpal to insert on the third metacarpal.
2.
3.
4.
5. 6.
Discussion Joseph et al. 2 reviewed the intemationalliterature of 124 CMC dislocations and reported only nine 7- 15 cases of isolated dislocations of the second CMC joint. Several of these cases required open reduction,S. 14. 16 with two reported in the English-language literature. 14. 16 In 1906 Lyman 14 reported a case in which the second metacarpal could not be reduced by the usual traction and manipulation. He described an open reduction that required "prying" the second metacarpal into position with a chisel. In 1973 Lewis 16 presented a patient with a dislocation in which the second metacarpal was' 'buttonholed through the dorsal ligaments of the wrist." The strong structural supports of the second CMC joint explain why this dislocation is such a rare occurrence. To the best of our knowledge this case represents the only report in the English-language literature of an isolated second CMC dislocation in which closed reduction was blocked by the extensor carpi radialis brevis. We would like to express our appreciation to Ms. Suad Jones, librarian, Naval Hospital, Portsmouth, Va., for her help with this paper.
REFERENCES 1. Waugh RL, Yancey AG. Carpometacarpal dislocations with particular reference to simultaneous dislocation of
7.
8.
9. 10. II.
12. 13.
14. 15. 16.
the bases of the fourth and fifth metacarpals. J Bone Joint Surg [Am) 1948;30A:397-404. Joseph RB, Linscheid RL, Dobyns JH, Bryan RS. Chronic sprains of the carpometacarpal joints. J HAND SURG 1981;6:172-80. Green DP, Rowland SA. Fracture and dislocation in the hand. In: Rockwood, CA, Green DP, eds. Fractures in adults. Philadelphia: JB Lippincott, 1982:383-8. Kleinman WB, Grantham SA. Multiple volar carpometacarpal joint dislocations . J HAND SURG 1978;3: 377-82 . Kaplan EB. Functional and surgical anatomy of the hand. 3rd ed. Philadelphia: JB Lippincott, 1983:27. Marwin SF, Fox JM, Sedlin ED. Volar dislocation of the bases of the second and third metacarpals. J Bone Joint Surg [Am] 1975;57:849-51. Berdach J, Herzog A. Ein Pall von traumatischer isolirter luxation des metacarpus indicis. Wien Klin Wochenschr 1902;15:940. Zilch M. Dorsal dislocation in the carpometacarpal joint II with additional rotation dislocation . Handchirurgle 1978;10:63-5. Bourquet. Observatin pur servir a I'historie des luxatien des doigts de la main. Rev Med Chir 1853;14:94. Foucher. BulietMemSocAnatdeParis 1856;1 (2Serie): 6-8. Hamilton FH. A practical treatise on fractures dislocations . 7th ed. Philadelphia: Henry C. Lea's Son Co , 1884:794. Humbert G. Luxation due deuxieme metacarpum en arriere. Univ Med 1868;5(3 Serie):527. Key JA, Cinwell ME. The management of fractures dislocations and sprains . 3rd ed. St. Louis: The CV Mosby Company, 1942:831. Lyman CB. Backwards dislocation of the second carpometacarpal articulation . Ann Surg 1906;43:905. Oggioni G. Lussazione dorsali isolati carpometacarpale, Gior di Med, Mil 1947;94:293. Lewis MM. Dislocation of the second metacarpal. Clin Orthop 1973;93:253-5 .