Skip to main content

Divergent dislocation of the carpometacarpal joints: a case report

Abstract

Background

Divergent carpometacarpal joint dislocations of the fingers are very rare. Due to severe swelling and overlapping of bones on a radiograph of the wrist and hand, dislocations are missed. The purpose of this clinical case report is to highlight this unusual injury to avoid missing diagnosis.

Case presentation

We report a case of a 24-year-old Moroccan man, an athlete, who presented divergent carpometacarpal joint fracture-dislocations of the ulnar four fingers after a fall during a national cycling competition. Radiographs showed divergent dislocation and associated fractures. He underwent open reduction and fixation with percutaneous Kirschner wires followed by 6 weeks of immobilization. Active physiotherapy was started and the results were satisfactory after a 2-year follow-up.

Conclusions

Divergent carpometacarpal joint dislocations of the fingers are exceptional; their diagnosis is sometimes difficult and may go unnoticed especially in a patient with polytrauma. The functional prognosis depends on the precocity of diagnosis and the quality of the reduction and rehabilitation.

Peer Review reports

Background

Carpometacarpal (CMC) joint dislocations of the fingers are uncommon injuries [1]. These injuries mainly occur in young adults and represent less than 1% of all lesions of the hand [2]. Simultaneous CMC dislocations may be dorsal and volar. Dorsal dislocations are more frequent [3]. The reason why dorsal dislocations are commoner is that stronger static (dorsal ligaments) and dynamic (wrist extensors) restraints may cause the failure of bone dorsally, with the subsequent rupture of the volar ligaments [4]. The increased mobility on the ulnar side may predispose to the known greater frequency of the injury. Stability at the finger CMC joints is provided by a system of four ligaments, namely the dorsal metacarpal, the palmar metacarpal, and the two sets of interosseous ligaments. Divergent varieties are exceptional being the result of a compound traumatic mechanism [5]. The diagnosis of this unusual form of injury requires a high index of suspicion, vigilant examination, and high quality radiography. CMC joint fracture dislocation can be treated by closed reduction immobilization, closed reduction internal fixation, or open reduction internal fixation with Kirschner (K) wires. However, in cases of closed reduction, there is a higher risk of radiolocation of the CMC joint, as compared to open reduction. Open reduction and internal fixation is the recommended treatment for CMC joint dislocation [6]. Due to severe swelling and overlapping of bones on radiographs of wrist and hand, dislocations are missed.

We report the case of a 24-year-old man who presented a CMC fracture-dislocation of the four last fingers of his right hand following a fall in a national cycling competition who had received emergency treatment.

Case presentation

A 24-year-old Moroccan man, an athlete, was admitted to the emergency department of the Ibn Sina University Hospital with complaints of relentless pain, discomfort, and inability to move his dominant right hand following a fall onto his right upper limb during a national cycling competition. He had no pathological antecedents and did not present any history of past surgery or trauma. He was unable to recall the exact mechanism of the injury. An initial clinical examination found that he was hemodynamically stable. An examination of his right upper limb showed a significant edema and a clear deformation at the dorsal face of his right hand with no signs of nerve compression. A vascular examination was normal. Radiographs of his hand showed a divergent CMC fracture-dislocation of the last four fingers, as well as associated fractures of the head of the second and the base of the fifth metacarpals. The last three metacarpals had palmar displacement while the second metacarpal was dislocated posteriorly (Fig. 1). He was immediately admitted to our operating room and underwent open reduction with dorsal approach under aseptic precautions. Two longitudinal incisions were made in the second and fourth web space addressing adjacent respective joints. CMC joint and fractures were exposed and reduction was visually achieved using external maneuvers (traction in the axis of each finger with pressure on the base of the luxated metacarpal) followed by an axial pinning of the second, third, and fifth CMC joints under fluoroscopic control (Fig. 2). Additional plastered immobilization by an intrinsic plus splint was applied for 6 weeks. Our patient underwent physiotherapy and assisted active exercises to increase strength of grip. Pins removal was done at the eighth week; approximately 10 weeks after removal of the cast, he returned to work. Clinical and radiologic examination at the 24-month follow-up visit showed no recurrence of the dislocation or arthritic phenomena. Grip strength and wrist mobility recovered, and there was no pain.

Fig. 1
figure1

Divergent carpometacarpal dislocation of the last four fingers with fracture of the head of the second metacarpal and the fifth metacarpal base

Fig. 2
figure2

Postoperative radiograph after open reduction and stabilization by an axial pinning of the second, third, and fifth carpometacarpal joints under fluoroscopic control

Discussion

Dislocations and fracture-dislocations of the CMC joints are uncommon, although not to the degree implied by the scant amount of literature on the subject. Dislocation of all four medial metacarpals is rare. These injuries mainly occur in young adults. Road traffic accidents and violent trauma are the main etiology [7].

Clinical diagnosis is sometimes difficult due to the edema that takes place early and masks the deformity. This injury may be missed in an acute setting in a busy accident and emergency unit. Swelling around the wrist with shortening of the knuckle should alert the clinician toward the possibility of such an injury. In these cases, radiology remains an important diagnostic benefit although interpretation of radiographic images is sometimes difficult [8]. On routine anteroposterior view, evaluation of CMC joint is done by parallel “M lines” as described by Gilula [9]; overlap of joint surfaces, loss of parallelism, and asymmetry at the CMC joints should raise suspicion of the possibility of a subtle CMC injury. This article highlights the importance of a high index of suspicion, a true lateral radiograph, and careful evaluation of radiographs in diagnosing these injuries. Some authors recommend a computed tomography scan for a better analysis of the lesions and to detect any associated lesions unnoticed by standard radiographs. CMC dislocations are classified into: complete or partial spatula dislocations; palmar dislocations; lateral dislocations, particularly of the fifth ray; and divergent dislocations [3,4,5,6,7,8,9].

CMC joint fracture dislocation can be treated by closed reduction immobilization, closed reduction internal fixation, or open reduction internal fixation with K-wires. However, in cases of closed reduction, there is a higher risk of redislocation of CMC joint, as compared to open reduction. Many authors recommend open reduction especially in fracture dislocations to guarantee anatomical reduction [1, 4, 7, 9]. Orthopedic reduction is usually possible when the dislocation is recent and of less than 10 days. Hartwig and Louis considered that it is not always necessary to stabilize all the rays; for them, the stabilization of the second and third rays is the key to reduction due to the integrity of the intermetacarpal ligaments [10]. Physiotherapy of hand and wrist joint is required after 6 weeks of immobilization to avoid postoperative stiffness [11]. Several complications have been reported in the literature, such as persistence of residual hand pain, decrease of the gripping force, subluxations, and secondary displacements [12]. In addition, Lawlis and Gunther reported that patients with dislocation of the four CMC joints have better results than those with dislocation of the second and third rays [1].

Conclusions

Divergent CMC joint dislocations of the fingers are exceptional; their diagnosis is sometimes difficult and may go unnoticed especially in a patient with polytrauma. The functional prognosis depends on the precocity of diagnosis and the quality of the reduction and rehabilitation.

Abbreviations

CMC:

Carpometacarpal

K:

Kirschner

References

  1. 1.

    Lawlis JF 3rd, Gunther SF. Carpometacarpal dislocations: long-term follow-up. J Bone Joint Surg Am. 1991;73(1):52–9.

    Article  PubMed  Google Scholar 

  2. 2.

    Guimaraes RM, Benaissa S, Moughabghab M, Dunaud JL. Les luxations carpométacarpiennes des doigts longs. À propos de 26 cas dont 20 cas revus. Rev Chir Orthop Reparatrice Appar Mot. 1996;82:598–607.

    PubMed  CAS  Google Scholar 

  3. 3.

    Yadav V, Marya KM. Divergent multiple carpometacarpal fracture dislocation. J Orthop Traumatol. 2002;3:113–5. https://doi.org/10.1007/s101950200038.

    Article  Google Scholar 

  4. 4.

    Kumar R, Malhotra R. Divergent fracture-dislocation of the second carpometacarpal joint and the three ulnar carpometacarpal joints. J Hand Surg. 2001;26A:123–9.

    Article  Google Scholar 

  5. 5.

    Agarwal A, Agarwal R. An unusual farm injury: divergent carpometacarpal joint dislocations. J Hand Surg Br. 2005;30(6):633–4. https://doi.org/10.1016/j.jhsb.2005.06.020.

    Article  PubMed  CAS  Google Scholar 

  6. 6.

    Sharma AK, John JT. Unusual case of carpometacarpal dislocation of all the four fingers of ulnar side of hand. Med J Armed Forces India. 2005;61(2):188–9.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. 7.

    Latifi M, Chafik R, Madhar M, Essadki B, Fikry T. La luxation carpométacarpienne antérieure complète des doigts. À propos d’un cas. Chir Main. 2005;24:106–8.

    Article  PubMed  CAS  Google Scholar 

  8. 8.

    Iqbal MJ, Saleemi A. Indian salutation test in acute dorsal carpometacarpal joint dislocation of the ulnar four fingers. Am J Emerg Med. 2003;21:74–6.

    Article  PubMed  Google Scholar 

  9. 9.

    Gilula LA. Carpal injuries: analytic approach and case exercises. AJR Am J Roentgenol. 1979;133(3):503–17.

    Article  PubMed  CAS  Google Scholar 

  10. 10.

    Hartwig RH, Louis DS. Multiple carpometacarpal dislocations: a review of four cases. J Bone Joint Surg. 1979;61A:906–8.

    Article  Google Scholar 

  11. 11.

    Harwin SF, Fox JM, Sedlin ED. Volar dislocation of the bases of the second and third metacarpals. A case report. J Bone Joint Surg Am. 1975;57:849–51.

    Article  PubMed  CAS  Google Scholar 

  12. 12.

    Jilani LZ, Abbas M, Goel S, Akhtar MN. Multiple volar dislocations of the carpometacarpal joints with an associated fracture of the first metacarpal base. Chin J Traumatol. 2014;17(1):38–40.

    PubMed  Google Scholar 

Download references

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Author information

Affiliations

Authors

Contributions

RH, IJ, and MSB were the consultants responsible for diagnosing and treating the patient and his clinical follow-up. They all reviewed the patient case and data, completed subsequent drafts of the manuscript, and were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Redouane Hani.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hani, R., Jeddi, I. & Berrada, M.S. Divergent dislocation of the carpometacarpal joints: a case report. J Med Case Reports 12, 157 (2018). https://doi.org/10.1186/s13256-018-1695-y

Download citation

Keywords

  • Dislocation
  • Fracture
  • Carpometacarpal joints
  • Reduction