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Double dislocation of the fifth metacarpal
DOUBLE DISLOCATION
OF THE F I F T H M E T A C A R P A L
C. KHODADADYAN, R. HOFFMANN, Y. MOAZAMI-GOUDARZI, and N. P. S[3DKAMP
From the Free Universityof Berlin, Rudolf Virchow Medical Center, Department of Trauma and Reconstructive Surgery, Berlin, Germany A case of traumatic, simultaneous, double dislocation of the fifth metacarpal bone is presented. Closed reduction was easily achieved and held with transarticular, crossed Kirschner wire fixation. Journal of Hand Surgery (British and European Volume, 1995) 20B: 2:253-254 / CASE REPORT the CM joint was unstable. This joint was stabilized with a transarticular K-wire, inserted from the head of A 42-year-old woman was hit by a car in the street, the fifth metacarpal down to the distal carpal row. resulting in massive swelling on the dorsum of the left Additional distal stabilisation was achieved by a transhand and impaired motion of the fifth finger. X-ray verse K-wire between the fourth and fifth metacarpals examination of the left hand showed a double simul(Fig 2). taneous dislocation of the fifth metacarpal with dorsal A palmar splint was applied for 6 weeks. After 1 dislocation in the fifth carpometacarpal (CM)joint and week, physiotherapy was initiated out of the splint. palmar dislocation in the fifth MP joint (Fig 1). Closed 6 weeks post-operatively the K-wires were removed. reduction was achieved by longitudinal traction on the 1 year later the patient had a full range of wrist and little finger. Fluoroscopy showed that the reduction of finger movement. She was completely pain-free without any residual disability. The CM and MP joints were stable (Fig 3). DISCUSSION
A closed double, simultaneous dislocation of the fifth metacarpal bone has not been reported. Even single dislocations of the CM joint of the little finger are rare. Only t3 cases of fifth MP joint dislocation have appeared in the literature since 1888 (Fultz and Buchanan, 1988; Storm, 1988). The fifth carpometacarpal joint is a saddle joint and is supported by a pisometacarpal ligament, dorsal and volar carpometacarpal ligaments and an intercarpal ligament (Harwin et al, 1975; Tountas and Kwok, 1984).
Fig 1
(a and b) Initial X-ray of the right hand showing a double dislocation of the fifth metacarpal bone.
Fig 2
253
(a and b) Post-operative X-rays of the hand after K-wire fixation.
254
THE JOURNAL OF HAND SURGERY VOL. 20B No. 2 APRIL 1995
diagnosed early it can be reduced easily by applying longitudinal traction (De Beer et al, 1989; Tountas and Kwok, 1984). Because of the capsular damage the dislocation usually remains unstable after reduction, in which case fixation with a percutaneous K-wire is appropriate. The technique is simple, secures anatomical reduction and allows early physiotherapy. K-wire fixation should be maintained for 6 weeks to ensure healing of the disrupted soft tissue (Hsu and Curtis, 1970; Tountas and Kwok, 1984). If diagnosis is delayed, open reduction and K-wire fixation is usually advisable (Hartwig and Louis, 1979). This case shows that an unstable double dislocation of the fifth metacarpal bone can also be treated effectively with percutaneous K-wire fixation. A combination of two crossed K-wires seems to be adequate to maintain anatomical reduction.
Fig 3
X - r a y o f the h a n d after 1 year.
The mechanism of dislocation is believed to be either a direct blow on the palmar and ulnar aspect of the hand or indirect forces acting along the metacarpal shafts, causing various degrees of disruption of the ligamentous structures of the carpometacarpal articulation. They are usually the result of high-energy trauma (De Beer et al, 1989; Oni and MacKenny, 1986). If the dislocation is
References DE BEER, J. D. V., MALOON, S., ANDERSON, P., JONES, G. and SINGER, M. (1989). Multiple carpo-metacarpal dislocations. Journal of Hand Surgery, 14B: 1: 105-108. FULTZ, C. W. and BUCHANAN, J. R. (1988). Complex fracture--dislocation of the metacarpophalangeal joint: Case report. Clinical Orthopaedics and Related Research, 227:255 260. HARTWlG, R. H. and LOUIS, D. S. (1979). Multiple carpometacarpal dislocations: A review of four cases. Journal of Bone Joint Surgery, 61A: 6: 906-908. HARWlN, S. F., FOX, J. M. and SEDLIN, E. D. (1975). Volar dislocation of the second and third metacarpals: A case report. Journal of Bone Joint Surgery, 57A: 6: 849-851. HSU, J. D. and CURTIS, R. M. (1970). Carpometacarpal dislocations on the ulnar side of the hand. Journal of Bone Joint Surgery, 52A: 5: 927-930. ONI, O. O. A. and MACKENNY, R. P. (1986). Multiple dislocations of the carpometacarpal joints. Journal of Hand Surgery, 11B: 1: 47-48. STORM, J. O. (1988). Traumatic dislocation of the fourth and fifth carpometacarpal joints. A case report. Journal of Hand Surgery, 13B: 2:210-211. TOUNTAS, A. A. and KWOK, J. M. K. (1984). Isolated volar dislocation of the fifth carpometacarpal joint: Case report. Clinical Orthopaedics and Related Research, 187: 172-175.
Accepted: 7 September 1994 Cyrus Khodadadyan, MD, Unfall- und Weiderherstellungschirurgie,Freie Universit~itBerlin, Universitatsklinikum Rudolf Virchow, Augustenburger Platz 1, D-13353 Berlin, Germany. © 1995 The British Society for Surgery of the Hand
OF THE F I F T H M E T A C A R P A L
C. KHODADADYAN, R. HOFFMANN, Y. MOAZAMI-GOUDARZI, and N. P. S[3DKAMP
From the Free Universityof Berlin, Rudolf Virchow Medical Center, Department of Trauma and Reconstructive Surgery, Berlin, Germany A case of traumatic, simultaneous, double dislocation of the fifth metacarpal bone is presented. Closed reduction was easily achieved and held with transarticular, crossed Kirschner wire fixation. Journal of Hand Surgery (British and European Volume, 1995) 20B: 2:253-254 / CASE REPORT the CM joint was unstable. This joint was stabilized with a transarticular K-wire, inserted from the head of A 42-year-old woman was hit by a car in the street, the fifth metacarpal down to the distal carpal row. resulting in massive swelling on the dorsum of the left Additional distal stabilisation was achieved by a transhand and impaired motion of the fifth finger. X-ray verse K-wire between the fourth and fifth metacarpals examination of the left hand showed a double simul(Fig 2). taneous dislocation of the fifth metacarpal with dorsal A palmar splint was applied for 6 weeks. After 1 dislocation in the fifth carpometacarpal (CM)joint and week, physiotherapy was initiated out of the splint. palmar dislocation in the fifth MP joint (Fig 1). Closed 6 weeks post-operatively the K-wires were removed. reduction was achieved by longitudinal traction on the 1 year later the patient had a full range of wrist and little finger. Fluoroscopy showed that the reduction of finger movement. She was completely pain-free without any residual disability. The CM and MP joints were stable (Fig 3). DISCUSSION
A closed double, simultaneous dislocation of the fifth metacarpal bone has not been reported. Even single dislocations of the CM joint of the little finger are rare. Only t3 cases of fifth MP joint dislocation have appeared in the literature since 1888 (Fultz and Buchanan, 1988; Storm, 1988). The fifth carpometacarpal joint is a saddle joint and is supported by a pisometacarpal ligament, dorsal and volar carpometacarpal ligaments and an intercarpal ligament (Harwin et al, 1975; Tountas and Kwok, 1984).
Fig 1
(a and b) Initial X-ray of the right hand showing a double dislocation of the fifth metacarpal bone.
Fig 2
253
(a and b) Post-operative X-rays of the hand after K-wire fixation.
254
THE JOURNAL OF HAND SURGERY VOL. 20B No. 2 APRIL 1995
diagnosed early it can be reduced easily by applying longitudinal traction (De Beer et al, 1989; Tountas and Kwok, 1984). Because of the capsular damage the dislocation usually remains unstable after reduction, in which case fixation with a percutaneous K-wire is appropriate. The technique is simple, secures anatomical reduction and allows early physiotherapy. K-wire fixation should be maintained for 6 weeks to ensure healing of the disrupted soft tissue (Hsu and Curtis, 1970; Tountas and Kwok, 1984). If diagnosis is delayed, open reduction and K-wire fixation is usually advisable (Hartwig and Louis, 1979). This case shows that an unstable double dislocation of the fifth metacarpal bone can also be treated effectively with percutaneous K-wire fixation. A combination of two crossed K-wires seems to be adequate to maintain anatomical reduction.
Fig 3
X - r a y o f the h a n d after 1 year.
The mechanism of dislocation is believed to be either a direct blow on the palmar and ulnar aspect of the hand or indirect forces acting along the metacarpal shafts, causing various degrees of disruption of the ligamentous structures of the carpometacarpal articulation. They are usually the result of high-energy trauma (De Beer et al, 1989; Oni and MacKenny, 1986). If the dislocation is
References DE BEER, J. D. V., MALOON, S., ANDERSON, P., JONES, G. and SINGER, M. (1989). Multiple carpo-metacarpal dislocations. Journal of Hand Surgery, 14B: 1: 105-108. FULTZ, C. W. and BUCHANAN, J. R. (1988). Complex fracture--dislocation of the metacarpophalangeal joint: Case report. Clinical Orthopaedics and Related Research, 227:255 260. HARTWlG, R. H. and LOUIS, D. S. (1979). Multiple carpometacarpal dislocations: A review of four cases. Journal of Bone Joint Surgery, 61A: 6: 906-908. HARWlN, S. F., FOX, J. M. and SEDLIN, E. D. (1975). Volar dislocation of the second and third metacarpals: A case report. Journal of Bone Joint Surgery, 57A: 6: 849-851. HSU, J. D. and CURTIS, R. M. (1970). Carpometacarpal dislocations on the ulnar side of the hand. Journal of Bone Joint Surgery, 52A: 5: 927-930. ONI, O. O. A. and MACKENNY, R. P. (1986). Multiple dislocations of the carpometacarpal joints. Journal of Hand Surgery, 11B: 1: 47-48. STORM, J. O. (1988). Traumatic dislocation of the fourth and fifth carpometacarpal joints. A case report. Journal of Hand Surgery, 13B: 2:210-211. TOUNTAS, A. A. and KWOK, J. M. K. (1984). Isolated volar dislocation of the fifth carpometacarpal joint: Case report. Clinical Orthopaedics and Related Research, 187: 172-175.
Accepted: 7 September 1994 Cyrus Khodadadyan, MD, Unfall- und Weiderherstellungschirurgie,Freie Universit~itBerlin, Universitatsklinikum Rudolf Virchow, Augustenburger Platz 1, D-13353 Berlin, Germany. © 1995 The British Society for Surgery of the Hand