Fractures of the sesamoid bones of the thumb

Sesamoid fractures of the metacarpophalangeal joint of the thumb may be classified into two types: (1) with palmar plate intact, and (2) with palmar plate ruptured. In type 1, the patient maintains a normal flexion posture of the metacarpophalangeal joint as well as the ability to flex the metacarpophalangeal joint and interphalangeal joint. In type 2, the metacarpophalangeal joint assumes a hyperextension posture and the patient is unable to flex the metacarpophalangeal joint. Three cases are described to illustrate the two types of the injury. An open fracture of a thumb sesamoid associated with laceration of the palmar plate in a child was treated by reapproximating the palmar plate and the fracture fragments with sutures. Two additional closed fractures of the thumb sesamoid were treated by splinting the metacarpophalangeal joint in comfortable flexion for 2 to 3 weeks. Normal hand function was restored in all the three patients.     

Reconstruction of traumatic absence of the thumb in the adult by pollicization.

Amputation of the thumb is a severe handicap. In an emergency situation, thumb amputation must be treated by means of reimplantation when possible. If reimplantation cannot be performed or fails, several methods of thumb reconstruction can be used according to various factors. These include the number of surviving fingers and the level of the thumb amputation. Pollicization is the first choice for amputations proximal to the metacarpophalangeal joint when four and even three fingers are present. It is the easiest and safest operation that supplies the best results both from the motor and sensory points of view. Pollicization can be done even in an emergency situation in selected patients. The index finger is preferred because it can be pollicized without palmar scar or tendons, vessels, or nerves crossing over. If a damaged finger is present, it is preferred to the index finger to leave one more sound finger; a damaged finger can frequently be used, because the thumb is shorter than the other fingers, and although its mobility is very important at the trapeziometacarpal joint, it is less important at the metacarpophalangeal and interphalangeal joint levels. It is preferable to take as much second metacarpal bone as necessary to place the transferred second metacarpophalangeal joint at the position of the thumb metacarpophalangeal joint so that the tendons of the index interosseous muscles can be sutured to the intrinsic muscles of the thumb. According to this concept, the distal phalanx of the transferred finger should be amputated. In this manner, the new thumb will have a normal size, only two phalanges, only one extrinsic flexor, and normal insertion of the muscles of the thumb.     

Intrinsic muscle advancement to treat chronic palmar instability of the metacarpophalangeal joint of the thumb

Chronic palmar instability of the metacarpophalangeal joint of the thumb can result in a significant disability. Grasp, particularly pinch, is painful and weak because the thumb goes into hyperextension. Stabilization of the metacarpophalangeal joint can be achieved by distal advancement of the conjoined tendon of the abductor pollicis brevis and lateral fibers of the flexor pollicis brevis.     

Total or subtotal amputation of a long finger with destruction of the metacarpophalangeal joint--regaining function by replantation?

Destruction of the metacarpophalangeal joint represents one of the most unfavourable situations making it extremely difficult to attain useful finger function after replantation. Single fingers damaged in this way may therefore not be replanted. If several long fingers are affected, a slight residual mobility in the metacarpophalangeal joint can be attained by joint reconstruction or prosthesis implantation. If the thumb is destroyed at the same time or is not supplied along with the severed hand, heterotopic replantation of a long finger of which the metacarpophalangeal joint has been destroyed is a way of attaining an adequate thumb length.     

The biomechanics of a thumb carpometacarpal immobilization splint: design and fitting.

Splinting for the common osteoarthritis of the carpometacarpal (CMC) joint of the thumb is infrequently described in the literature, but the few splints that are described include one or both adjacent joints. This paper describes the design and biomechanics of a custom-molded thumb CMC immobilization splint that excludes the thumb metacarpophalangeal and wrist joints. The problem of the imbalance of extrinsic extensor/abductor forces against the intrinsic flexor/adductor forces is described. The accompanying weakening of the thumb CMC capsule allows dorsal shifting of the proximal end of the metacarpal, producing pain. The splint described in this paper 1) prevents motion of the first metacarpal in relation to the other metacarpals, 2) prevents tilting (flexion) of the first metacarpal during pinch, and 3) allows unrestricted thumb metacarpal and wrist joint motion. Attention to detail during construction is required for an accurate pattern, precise positioning of the CMC joint during molding, accurate molding around the first metacarpal, and well-distributed pressure. This design may also be used for protection following thumb CMC arthroplasty or thumb CMC sprain or strain and as a base for thumb metacarpophalangeal and/or interphalangeal mobilization splinting.     

Surgical approaches to the metacarpophalangeal joint of the thumb for repair and reconstruction of the collateral ligaments and capsule

Surgical repair and reconstruction of the ulnar and radial collateral ligaments at the thumb metacarpophalangeal joint require an adequate exposure to identify and repair or reconstruct the disrupted collateral ligaments. The authors have used the approach to be described with safety and convenience over a several year period for repair and reconstruction of both the ulnar and radial collateral ligaments at the thumb metacarpophalangeal joint. This dorsal approach gives a comprehensive exposure without significant disruption of the extensor tendons or hood mechanism.     

Closed reduction and treatment of 2 volar thumb metacarpophalangeal dislocations: report of 2 cases

Volar dislocation of the metacarpophalangeal joint of the thumb may be irreducible by closed means. We describe 2 patients with volar dislocation of the thumb metacarpophalangeal joint treated with closed reduction and casting.     

拇指籽骨翻转脱位致掌指关节绞锁的诊治

目的:探讨拇指籽骨翻转脱位致掌指关节绞锁的诊断和治疗.方法:对5例掌指关节绞锁患者(男4例,女1例;年龄18～47岁,平均35岁)行闭合手法复位,成功3例,另2例闭合复位失败后行手术切开复位.术中见拇指籽骨翻转脱位,与掌板、拇短屈肌腱一起卡入掌指关节间隙的掌侧,形成绞锁.籽骨复位后,绞锁即得到纠正.结果:5例均获得随访,时间3～34个月,平均15个月.治疗后所有患者局部疼痛症状消失,无红肿,手指感觉正常,掌指关节屈曲35°～60°,平均45°,不影响正常生活及正常工作,治疗后绞锁无复发.结论:拇指籽骨翻转脱位是导致掌指关节绞锁的重要原因之一.     

The sesamoid bones of the hand and their pathology

Three cases of sesamoid bone pathology are presented, including two cases of sesamoid fracture and a case of sesamoid periostitis. The literature is reviewed.Sesamoid bones probably function in the body as pulleys. Most people have five sesamoid bones in each hand. Two at the thumb metacarpophalangeal joint, one at the interphalangeal joint of the thumb, one at the metacarpophalangeal joint of the index finger on the radial side, and one at the metacarpophalangeal joint of the little finger on the ulnar side.Sesamoid bones have been seen with periostitis in Reiter's syndrome. The medial sesamoid bone of the thumb metacarpophalangeal is frequently enlarged in acromegaly. The sesamoid bones of the thumb have been fractured or trapped inside the joint during injury to the thumb metacarpophalangeal joint.The treatment of disabling rain in a sesamoid bone is enucleation of the bone.     

The windblown hand: correction of the complex clasped thumb deformity.

The complex clasped thumb deformity associated with a windblown hand requires correction of three distinct deficits: an adduction contracture of the thumb-index web space, a flexion-volar subluxation contracture of the thumb metacarpophalangeal joint, and severe hypoplasia of the superficial thenar muscles. Severe contractures of the thumb web space are best released by an extensive soft-tissue release and skin coverage with a large, dorsal ration-advancement flap. The thumb metacarpophalangeal joint flexion contracture is corrected by an extensive soft-tissue release, often accompanied by metacarpophalangeal joint fusion. An opponensplasty substitutes for the lack of thenar muscle. Correction of all of the deficits is required to achieve good thumb function.     

A simple method of osteosynthesis for avulsion fractures of the thumb metacarpophalangeal joint.

Five cases with an avulsion fracture of the thumb metacarpophalangeal joint treated by a simple method of internal fixation are described. This method is designed as a form of modified tension band wiring using the combination of a single Kirschner wire and a pull-out wire, and is technically easy.     

Verletzungen der Grundgelenke und ihre Folgen

Injuries of the metacarpophalangeal joints of the thumb and fingers are of a bony or ligamentous nature. They can heal without subsequent problems if correctly diagnosed and treated but incorrect or absent diagnostics and therapy can result in chronic instability, dislocation, fusion as well as subsequent arthritis and functional limitations. They can lead to substantial impairment of the gripping function. Fractures with inclusion of joints and with fragments sufficiently large for refixation are as a rule treated operatively just as differences in torsion and instability. Persisting instabilities are secondarily stabilized by ligamentoplasty and arthritis of the metacarpophalangeal joint of the thumb is treated by fusion. For metacarpophalangeal joints of the fingers the main concern is preserving motion. Established salvage operations for arthritis include denervation, resection arthroplasty and systematic arthrolysis for impairment of the joint and contractures with intact joint surfaces. Even in chronic conditions, with appropriate treatment good functional results for metacarpophalangeal joints of the thumb and fingers can be achieved. This article presents the current pathophysiological principles and concepts for diagnostics and therapy of acute and chronic injuries of the metacarpophalangeal joints of fingers and thumbs.     

微型骨锚一期重建急性拇指掌指关节尺侧副韧带损伤

目的 评估应用微型骨锚对急性拇指掌指关节尺侧副韧带损伤进行手术修补的临床疗效.方法 2004年7月至2009年5月,对11例急性拇指掌指关节尺侧副韧带完全损伤的患者,采用Mitek micro微型带线骨锚一期植入第一掌骨头或拇指近节指骨基底侧方尺侧副韧带断裂的附着处,用锚尾部的缝合线缝合撕脱的侧副韧带重建起止点.结果 术后随访6个月至4年,平均2.4年.按Saetta标准评定:优7例,良3例,可1例;优良率为90.9%.X线片显示骨锚未见松动、脱落.结论 应用骨锚对急性拇指掌指关节尺侧副韧带损伤进行手术修补不仅操作简便,而且容易掌握,疗效可靠.     

Definition and classification of basal joint osteoarthritis. A critical analysis and proposals. Treatment options

Several definitions and classifications of basal joint osteoarthritis exist. Each of them can be criticized. The authors propose to define basal thumb osteoarthritis as osteoarthritis of the trapezometacarpal joint associated or not with lesions of scapho-trapezio-trapezoid and/or metacarpophalangeal joints. The proposed classification is derived from the Eaton-Littler classification. Stage O is identical to stage I of the Eaton-Littler classification: trapeziometacarpal instability without cartilage lesions. Stage I is osteoarthritis of the trapeziometacarpal joint only, without metacarpophalangeal deformity. Stage II is trapeziometacarpal osteoarthrites combined with reductible hyperextension deformity of the metacarpophalangeal joint. Stage III is trapeziometacarpal osteoarthrites combined with irreductible metacarpophalangeal deformity. Stage IV is identical to stage IV of the Eaton-Littler classification: combined trapeziometacarpal and scapho-trapezio-trapezoid osteoarthritis. The advantage of the proposed classification is that basal joint osteoarthritis is not only defined as real or potential (stage O) osteoarthritis of the trapeziometacarpal joint, but also includes precise evaluation of two other joints at the base of the thumb. This classification can be a guide for treatment options.     

Palmar capsulodesis for treatment of symptomatic hyperextensibility of the metacarpophalangeal joints.

A modification of the technique of palmar capsulodesis described by Filler et al. (1976) for the treatment of hyperextensibility in the metacarpophalangeal joint of the thumb was used in the metacarpophalangeal joints of the fingers. Seven of eight patients regained normal range of motion without pain.     

Reconstruction of a balanced thumb through tendon transfers

The ability to use the thumb determines its functional relation to the fingers and the resulting dexterity of the hand. Median palsy results in a failure of abduction and pronation. Ulnar palsy results in loss of adduction and flexion at the metacarpophalangeal joint. Following median, ulnar, and even radial palsy, the thumb can develop adduction deformity. Thumb contracture must be released prior to tendon transfers. Abduction and pronation are best substituted by transfer of the extensor indicis proprius. Adduction is best substituted by transfer of the extensor carpi radialis brevis and arthrodesis of the metacarpophalangeal joint. Median cutaneous sensibility should be reconstructed after appropriate tendon transfers are functional.     

Traumatic boutonniere deformity of the thumb

We report three patients who presented 3 to 8 months after sustaining a closed injury to the dorsoradial aspect of the metacarpophalangeal joint of the thumb. All three patients had an extensor lag of the metacarpophalangeal joint and paradoxical hyperextension of the interphalangeal joint. There were no collateral ligament injuries. The patients required surgical treatment which included advancement and reattachment of the extensor pollicis brevis insertion and imbrication of the dorsoradial capsule to restore the anatomical alignment of the extensor pollicis longus. Surgical treatment of dorsoradial injuries to the thumb metacarpophalangeal joint may be required for injuries that result in subluxation of the extensor pollicis longus tendon and a boutonnière deformity of the thumb.     

Opera-glass hand in rheumatoid arthritis.

Characteristic deformities occur in the fingers, thumb, and wrist in the opera-glass hand in rheumatoid arthritis. Shortening and instability are the result of bone resorption and dislocation and can be severely disabling. Early spontaneous fusion of the proximal interphalangeal joint preserves digital length. Functional improvement can be obtained in the fingers by interphalangeal joint arthrodesis and metacarpophalangeal prosthetic arthroplasty and in the thumb with metacarpophalangeal and/or interphalangeal arthrodesis. With interphalangeal arthrodesis, interposition grafts often are required in order to restore length and secure fusion. "Prophylactic" arthrodesis of interphalangeal joints should be considered when resorption seems imminent.     

Simultaneous dislocation of both joints of the thumb with a fracture involving the interphalangeal joint. A case report and a review of the literature

Combined dislocation of the metacarpophalangeal and interphalangeal joints of the thumb is uncommon, only five cases having been previously reported. In this case report, a previously unreported case characterized by volar-ulnar dislocation of the metacarpophalangeal joint and dorsal dislocation of the interphalangeal joint, associated with a unicondilar open fracture of the proximal phalanx, is presented. Only open reduction for the interphalangeal joint was needed and both (metacarpophalangeal and interphalangeal) joints were treated with K-wire fixation after reduction. Internal fixation of the phalangeal fracture was not performed because of the size of the bone fragment. Although the diagnosis of dislocation of the interphalangeal joint is obvious, a simultaneous dislocation of the metacarpophalangeal joint can be easily overlooked, which is a fact that underlines the importance of this article. It is therefore recommended to examine the whole hand.     

拇指爪形指的病因分析与治疗

目的：探讨拇指爪形指形成的原因及治疗方法。方法总结16例由于正中、尺神经损伤导致拇指爪形指的成因并采用外在肌移位加关节囊及韧带修复,单纯关节囊韧带修补,拇掌指关节融合术矫正畸形。结果所有病例畸形均得到矫正,术后Froment征阴性,拇食指捏力增加平均70%。单纯软组织矫正成功率83%,复发率17%。结论拇指爪形指是由于正中、尺神经合并损伤导致,联合修复效果理想,掌指关节融合术效果肯定。