Isolated dorsal approach for the treatment of neglected volar metacarpophalangeal joint dislocations

Here, we present the clinical and radiological results of three neglected volar metacarpophalangeal dislocations in 2 patients, which were treated with open reductions 10 and 24 mo after the dislocations. There was a mean of a 20°(range 10°-30°) limitation of extension and a 53.3°(range 30°-70°) limitation of flexion preoperatively. Postoperatively, there was no limitation of extension(at 8 and 12 mo) in any of the fingers. In terms of flexion, one finger had full function, one had a 10° and the last one had a 30° limitation of flexion. Two of the fingers presented anesthesia preoperatively, which improved to hypesthesia postoperatively. One finger had hypesthesia, which improved postoperatively. During surgery, a ruptured dorsal capsule was found to have interposed into the joint, making closed reduction impossible. Our experience with these two patients demonstrated that, even in neglected cases, open reduction using an isolated dorsal approach may result in satisfactory clinical andradiological outcomes.     

Isolated complex dislocation of the metacarpophalangeal joint of the third finger

Two unusual cases of isolated closed complex dislocation of the metacarpophalangeal joint of the third finger are presented. The single most important element preventing reduction was interposition of the volar plate between the proximal end of the phalanx and the head of the metacarpal, but the deep transverse ligament was also intimately involved in the entrapment mechanism. Such dislocations require open reduction as in the two cases presented, and we found the dorsal approach to be simple and effective.     

The locked metacarpophalangeal joint: report of four cases and review of the literature

Four cases of locked finger metacarpophalangeal joints are reported. Two of these cases were caused by entrapment of the sesamoid behind an exostosis off the second metacarpal head. The third was from subluxation of the dorsal interosseous tendon over a dorsal osteophyte on the metacarpal. The fourth was from an exostosis tethering the accessory collateral ligament. Surgical exploration using a palmar approach was the treatment of choice. All patients regained full range of motion within two months. A review of the various causes and treatment options for this unusual condition is presented.     

Dislocation of the first metatarsophalangeal joint with fracture of fibular sesamoid. A case report

Dorsal dislocations of the first metatarsophalangeal joint are classified by Jahss into two types. In Type 1, the hallux with the intact intersesamoid ligament dislocates dorsally over the metatarsal head. Such cases in the literature have been irreducible by closed manipulation. In Type 2 the hallux is dislocated dorsally with rupture of the intersesamoid ligament, resulting in wide separation of the sesamoids (Type 2A) or a transverse fracture of one or both sesamoids (Type 2B). The importance in classifying these injuries allows one to predict whether closed reduction will be successful as in Type 2. The patient reported had a fracture of the fibular sesamoid in addition to dislocation of the hallux. The clinical findings were consistent with Type 1 injury, including an intact intersesamoid ligament, but the radiographs showed, in addition to the dislocation, that there was a fracture of the fibular sesamoid. Reduction was achieved surgically through a dorsal approach. Although such injuries have been unreported previously, Type 1 injuries may be associated with a fracture of the fibular sesamoid but without rupture of intersesamoid ligament, so the injury reported is classified as Type 1A.     

Classic article: foot & ankle 1:15, 1980 traumatic dislocations of the first metatarsophalangeal joint

The mechanics, anatomy, and pathomechanics of traumatic dorsal dislocation of the first metatarsophalangeal joint are discussed. There are two basic types of dislocations. In Type I, dislocation of the hallux with the sesamoids occurs without disrupting the sesamoid mass. Such cases are usually irreducible on closed reduction, the metatarsal head being incarcerated by the conjoined tendons with their intact sesamoids. In Type II, there is either associated disruption of the intersesamoid ligament (Type IIA) or a transverse fracture of one of the sesamoids (Type IIB). In Type II, the sesamoid disruption usually permits closed reduction.     

早期手术切开复位治疗新鲜嵌顿性掌指关节脱位

目的:探讨嵌顿性掌指关节脱位的致伤机制及治疗方法.方法:收治新鲜嵌顿性掌指关节脱位7例,其中男6例,女1例;年龄8～33岁,平均17岁.7例均为背侧脱位,食指3例,拇指2例,中指1例,小指1例,均为闭合复位失败予切开复位.术中均见致伤机制为"纽扣"式机制,掌骨头自关节囊掌侧薄弱部穿出,掌板嵌顿在掌骨头背侧.结果:7例随访3～42个月,均解剖复位,伸屈功能良好.结论:对嵌顿性掌指关节脱位若闭合复位失败,不应多作手法整复,应早期手术切开复住,以免导致功能障碍.     

Palmar lunate dislocation

Palmar lunate dislocation as the end stage of a perilunate dislocation is a very uncommon injury.Having treated 19,534 hospitalized patients between 1 January 1986 and 1 October 2001 the diagnosis was recorded in four male trauma patients (33, 36, 37 and 62 years old).Among the operatively treated carpal dislocations and carpal fracture dislocations those of the lunate were seen in five per cent.The dislocation was caused in by an acute hyperextension injury resulting of falls from heights in three cases, and of a motorcycle accident in a further case. In two of these cases a complete palmar lunate dislocation was analysed that were produced by fall from seven meters heights of a young craftsman and by accident of a motorcyclist.First using a longitudinal palmar approach in both cases a revision of the hemorrhagic carpal canal was performed urgently, the largely denuded lunate was reduced and the repair of identified ligamentous structures was performed by means of sutures respectively suture anchors.Reduction was stabilized with Kirschner wires. Afterwards performed computed tomography identified the result of reduction and associated defects (subluxation distal radioulnar joint). In one patient a soft tissue infection prevented the dorsal ligamentous repair. In spite of a consequent after-treatment and a good functional result a scapho-lunate dissociation was proved.An avascular defect of the lunate could be excluded by magnetic resonance imaging. In case of a secondary performed dorsal repair a persisting carpal stabilization with a satisfactory functional result could achieved.At second hand an advanced carpal collapse was proved. CONCLUSIONS: If reduction cannot be achieved by closed manipulation or a loss of reduction is shown, open reduction is indicated first by a palmar approach. An additional dorsal ligamentous repair seems to be necessary.Transfixation by Kirschner wires and suture anchors stabilize the restored anatomic relationships.Wrist immobilization in a cast for at least eight weeks is recommended.Although ligamentous insufficiency, osteoarthrosis and avascular necrosis are often proved, functional results are satisfactory.     

Transient bone resorption following finger replantation: a report of 3 cases

Radiographic changes consisting of alterations in mineral content, osteopaenia or destructive neuropathy that occur following successful finger replantation have already been described. We report our experience about four fingers in three individuals in whom bone changes developed in the first three months postoperatively with complete "restitution ad integrum".Three patients, 21-49 years old (average 36 years) sustained a clean-cut amputation of four fingers. The first patient had an amputation at the base of the middle phalanx of the index finger and the second patient at the base of the proximal phalanx of the ring finger. The third had an amputation at the base of the first metacarpal bone and the proximal phalanx of the small finger in a five finger amputation. In the first case, two dorsal veins and two palmar digital arteries and nerves were repaired. In the second case, one palmar artery and one dorsal vein were reanastomosed. In the third case at the thumb, two dorsal veins and two palmar digital arteries and nerves were reconstructed. At the small finger, one dorsal vein, one palmar digital artery and two digital nerves were reconstructed. Bone fixation was achieved with two and three K-wires or tension-band wiring. Replantation was successful in all cases. Three weeks after replantation, the X-rays showed rapid development of osteopaenia in the juxtaartieular region and metaphyses of the bone. These changes were followed by subperiosteal,intracortical and endosteal bone resorption. No further surgical procedures or splintage were needed and hand therapy was not discontinued. At 10-13 weeks (average 12 weeks)postoperatively, the X-rays showed a complete recovery with new periosteal bone formation.We suggest that the radiographic changes after finger replantation are transient, first evident subperiosteally and progressing centrally. They may reflect small-vessel compromise and microinfarction and transient hyperemia secondary to neurovascular damage or to sympathetic progressive recovery.     

Transient bone resorption following finger replantation: a report of 3 cases

Radiographic changes consisting of alterations in mineral content, osteopaenia or destructive neuropathy that occur following successful finger replantation have already been described. We report our experience about four fingers in three individuals in whom bone changes developed in the first three months postoperatively with complete “restitution ad integrum”.Three patients, 21-49 years old (average 36 years) sustained a clean-cut amputation of four fingers. The first patient had an amputation at the base of the middle phalanx of the index finger and the second patient at the base of the proximal phalanx of the ring finger. The third had an amputation at the base of the first metacarpal bone and the proximal phalanx of the small finger in a five finger amputation. In the first case, two dorsal veins and two palmar digital arteries and nerves were repaired. In the second case, one palmar artery and one dorsal vein were reanastomosed. In the third case at the thumb, two dorsal veins and two palmar digital arteries and nerves were reconstructed. At the small finger, one dorsal vein, one palmar digital artery and two digital nerves were reconstructed. Bone fixation was achieved with two and three K-wires or tension-band wiring. Replantation was successful in all cases. Three weeks after replantation, the X-rays showed rapid development of osteopaenia in the juxtaarticular region and metaphyses of the bone. These changes were followed by subperiosteal, intracortical and endosteal bone resorption. No further surgical procedures or splintage were needed and hand therapy was not discontinued. At 10-13 weeks (average 12 weeks) postoperatively, the X-rays showed a complete recovery with new periosteal bone formation.We suggest that the radiographic changes after finger replantation are transient, first evident subperiosteally and progressing centrally. They may reflect small-vessel compromise and microinfarction and transient hyperemia secondary to neurovascular damage or to sympathetic progressive recovery.     

Late presentation of a complete complex thumb metacarpophalangeal joint dislocation: A case report

Metacarpophalangeal (MP) joint injuries and dislocations of the fingers and thumb are not uncommon. They can be classified directionally as either being volar or dorsal, and are further categorized as incomplete, simple complete or complex complete. Complex dislocations are described as dislocations that are irreducible and often require surgical intervention. This is often because tissue has become entrapped within the MP joint, precluding its anatomical reduction. For the thumb MP joint, anatomical structures that may become trapped include the volar plate, sesamoid bones, bony fracture fragments or the flexor pollicis longus tendon. Both dorsal and volar surgical approaches have been described, and their relative merits will be discussed. The unusual case of a late presentation (two months postinjury) of a complex complete dorsal dislocation of the thumb MP joint approached from a dorsal incision is presented.     

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.     

La luxation palmaire de l’articulation métacarpophalangienne des doigts longs A propos d’un cas

Palmar dislocation of the metacarpophalangeal (MCP) joint of the long finger represents a rare event. The first case was published by Mc Laughlin in 1965, and only nine other cases have been reported. We present one more case and discuss the mechanisms of these dislocations and treatment. Case report: A 22-year-old biker presented with complex injuries of his right hand after a road accident. Examination revealed an extensive palmar wound on the ulnar side of his right hand, with another on the MCP joint of the little finger, and shortening of the little and the ring fingers. Any attempt at active movement was impossible. Roentgenograms showed a palmar dislocation of the MCP joint of the ring finger and a very displaced fracture of the fifth metacarpal head. During surgery we observed on the ring finger a tear of the distal membranous attachment of the volar plate on the base of proximal phalanx, entrapped in the MCP joint, with an ulnar dislocation of the flexor tendons. On the little finger we observed a complex fracture of the fifth metacarpal head and a lesion of the ulnar collateral nerve. After opening the A2 pulley we repaired the volar plate by fixing it with 2 sutures through the base of the proximal phalanx and the metacarpal head fracture by a difficult open reduction and fixation with an axial pin. At the end of the operation, the fingers were immobilized on a palmar block splint for one month. Passive range-of-motion exercises were started after one month and active excercises after two months. Now, one year after initial injury, the patient has recovered complete function of the MCP joints of the two fingers. Discussion: Many different mechanisms can be discussed to explain this rare lesion. According to our case report we think that this dislocation was assumed to occur by hyperextension and translational force applied to the dorsum of the proximal phalanx. Like Wood [8] and Kaplan [3] we stress the importance of this translational force : a purely forced movement on the MCP joint generally causes a dorsal dislocation. Entrapment of the volar plate in the MCP joint is the most common mechanism for irreductibility of the dislocation (Renshaw [7],Betz [1]), but in some other cases the irreductibility of the dislocation was linked to the entrapment of the dorsal capsule of the MCP joint. A surgical approach is required in all cases where easy closed reduction is impossible. The operative approach depends on the mechanism of dislocation, but a palmar approach is preferred when no mechanism is defined. Indeed this route allows us to control the volar plate and possibly its repair or stabilisation. A sound and solid repair of these lesions seems very important to stabilize the MCP in the long term joint. Earlier range-of-motion exercises are recommended for complete rehabilitation of the MCP joint.     

Staged reduction of neglected transscaphoid perilunate fracture dislocation: A report of 16 cases

ABSTRACT: BACKGROUND: Transscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome. Material & Methods 16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation. RESULTS: The mean duration between two surgeries was 2.4 weeks (range 2- 4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results. CONCLUSION: Staged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.     

Carpal antelunar dislocation and Fenton syndrome: Extremely rare association

Carpal antelunar dislocations are much rarer than posterior dislocations. Their frequencies are between 3 and 6% of carpal perilunar dislocations. Out of 23 cases of carpal antelunar dislocations listed in the literature, there are only 11trans-scapho antelunar dislocations.Carpal antelunar dislocation and Fenton syndrome are two exceptional entities in the literature. In the case of Fenton syndrome, the head of the capitatum is described with a rotation of 90° to 180°. The association of these two entities remains anecdotal (3 cases described).The anterior approach of carpal antelunar fracture-dislocation was recently honored. This approach offers the benefit of better control of associated intracarpal fractures. In our case, the fracture of the capitatum forced us to a dorsal approach. This approach allowed the reduction and osteosynthesis of the scaphoid satisfactorily. At 3 months, the patient has very good clinical and radiological results.     

Dorsal carpometacarpal dislocation of the index finger: a report of three cases and a review of the English-language literature.

Isolated dorsal carpometacarpal dislocation of the index finger is a rare injury. We treated three patients with such an injury; two cases by delayed open reduction and internal fixation, and one case by direct closed reduction and internal fixation. Satisfactory functional results were obtained in two of the three cases (follow-up of 4 and 2 years, respectively). Anatomic factors, the mechanisms of injury, and management as discussed in the English-language literature are reviewed.     

Dorsal Dislocation of the Distal Interphalangeal Joint and Volar Dislocation of the Metacarpophalangeal Joint in the Same Finger: A Case Report

Double dislocations of the finger interphalangeal and/or metacarpophalangeal joints are a rare entity. Sixty-four cases of distal and proximal interphalangeal joint double dislocations have been previously reported. Five cases of metacarpophalangeal and interphalangeal double dislocations of the thumb have also been reported. Only one case has been reported in the English literature regarding simultaneous dislocations of the distal interphalangeal and metacarpophalangeal joints in the nonthumb digit. The directions of the dislocation were the same; both were dorsal. We report, to our knowledge, the first ever case of a double dislocation a non-thumb digit in opposing directions—volar at the metacarpophalangeal joint and dorsal at the distal interphalangeal joint.     

Locked thumb metacarpophalangeal joint caused by sesamoid entrapment.

We report an unusual case of locked thumb in a 24-year-old man, caused by entrapment of the radial sesamoid in the metacarpophalangeal joint. Tomography clearly revealed sesamoid entrapment in the joint. Surgical exploration and cadaver dissection demonstrated that avulsion of the proximal portion of the palmar plate and some dissociation of the sesamoid from the palmar plate with intraarticular displacement were necessary for the sesamoid to be trapped in the joint.     

Perilunate dislocations and fracture-dislocations of the wrist, a review of 14 cases

OBJECTIVES: We report a retrospective series of 14 dislocations or perilunate fracture-dislocations. The results of our series are compared with the data of the literature and we discuss epidemiology, types of lesions, surgical treatment, complications and prognosis of this pathology. METHODS: The series included seven pure dislocations and seven fracture-dislocations including three trans-scapho-lunate forms (including one Fenton's syndrome). The displacement of all these lesions was posterior. The mean age was 35 years. Sixty-four percent were manual workers. All 14 patients had undergone surgical treatment through a dorsal approach in the first seven days following the injury. They were reviewed clinically and radiologically with a mean follow-up of 25 months. RESULTS: The average Cooney functional score was 72/100 with two excellent, six good, four fair and two poor results. Average flexion-extension motion arc was 74%, the grip strength was 77% compared to the other wrist. Persistent wrist pain was almost constant. One carpal instability was observed and one patient required a four-corner arthrodesis for SLAC wrist. Eighty-five percent of all patients were employed at least. CONCLUSIONS: Early diagnosis and anatomical reduction can provide satisfactory functional results. Emergency surgical treatment is required. We prefer a dorsal approach and we do not perform primary closed reductions.     

First Metatarsophalangeal Joint Dislocation With Open Fracture of Tibial and Fibular Sesamoids

Traumatic dislocations of the first metatarsophalangeal joint were first described by Mouchet in 1931. The anatomical complexity of the first metatarsophalangeal joint makes this injury one of a kind. There have been only been a limited number of case reports of this injury, but none in combination with open fractures of both sesamoids. We would like to report 1 case of an open traumatic dislocation of the first metatarsophalangeal joint with open fracture of the fibular and tibial sesamoid. Open reduction and internal fixation of the injury led to a successful outcome.