Metacarpophalangeal Dislocations

Most dislocations of the thumb MP joint are dorsal, although volar dislocation has been reported
and may be irreducible.

Preoperative Evaluation

Diagnosis of an MP joint dislocation is generally not difficult. Clinically, the MP joint has an
obvious hyperextension deformity and the metacarpal is adducted. There may be an increased
space between the metacarpal head and the proximal phalanx suggestive of interposed soft tissue.
Interposition of the sesamoids between the metacarpal head and the proximal phalanx is
evidence of a complex, irreducible dislocation.

Treatment Options

The majority of dorsal dislocations can be easily reduced without surgery. Simple longitudinal
traction as a reduction maneuver should be avoided because it might convert a simple
dislocation into an irreducible complex one. The preferred reduction technique is hyperextension
of the MP joint, followed by direct pressure on the dorsal base of the proximal phalanx to gently
push it over the metacarpal head. Less severe hyperextension injuries can cause dorsal
subluxation of the MP joint rather than frank dislocation. This may present as a locked MP joint
in which the joint cannot be flexed actively or passively.

se evita hiperextensie AMF dorsal block splint

tranctiunea in 10 degrees more
longitudina presiune pe baza F1
of flexion than the
point of instability.
la (M1 adductie si flexie, IF si
pumn in flexie pt a relaxa
FLP)

If closed reduction fails, open reduction may be necessary and can be done through several
approaches. The surgical approach may be dorsal, volar, or lateral.

A longitudinal skin incision exposes the extensor tendons. The interval between TELP si SEP is
developed. The dorsal capsule is incised. The tissue interposed in the joint is identified and
mobilized using blunt instruments such as hooks, forceps, and periosteal elevators. The tissue is
pushed over the metacarpal head and the joint is reduced. Occasionally, a dorsal MP dislocation
will present with a volar laceration that necessitates débridement and extension of the volar
wound. The proximal phalanx is hyperextended, and the interposed soft tissue is extricated from
the joint. The advantage of the volar approach is that it allows the interposed structures to be
pulled from within the joint and affords an excellent view of the neurovascular bundles, tendons,
and affected structures. Once reduced, the joint is usually stable, but if not, ligament and volar
plate repair can be performed.

AUTHORS’ PREFERRED METHOD OF TREATMENT

Closed reduction is usually successful with the following technique. Under radial and median
nerve wrist block or Bier block anesthesia, distally directed pressure is applied to the base of the
proximal phalanx with the metacarpal in a position of flexion and adduction. This maneuver
relaxes the noose that the thenar muscles and flexor pollicis longus occasionally create around
the metacarpal neck. If necessary, flexing the IP joint and the wrist will relax an entrapped flexor
pollicis longus tendon that is blocking reduction. After reduction, collateral ligament stability is
tested and a congruous reduction confirmed by radiographs. Stability is assessed by extending
the joint to determine the point at which it starts to subluxate. The thumb should be fitted with a
dorsal block splint in 10 degrees more of flexion than the point of instability. This can be
extended 10 degrees per week. If there is significant collateral ligament instability, consideration
should be given to immobilization of the MP joint for 4 weeks or open collateral ligament repair.

Open reduction is required when closed reduction fails. If the case presents within 24 hours of
injury, we make a small dorsal incision, insert a Freer elevator, and try to push interposed tissue
from within the joint. If that fails or if the dislocation is more than 24 hours old, the joint is
exposed through a volar zigzag incision. Interposed or entrapped structures are reduced with
blunt instruments, avoiding injury to the metacarpal head. Stabilization of the joint in 25 degrees
of flexion with a Kirschner wire should be done if the joint is unstable. If the volar plate is
detached from the base of the proximal phalanx, surgical repair using bone anchors or repair of
surrounding soft tissue is recommended after closed reduction.

Postoperative Management and Expectations

Patients are advised that they will most likely have a stable joint after closed or open reduction.
However, stiffness is possible after any dislocation, and the chance of stiffness is greater if
surgery is required. Recovery of motion can be slow and require several weeks of therapy.
Patients should be counseled at the time of injury that stability is a more important consideration
than full range of motion of the MP joint. The protocol for rehabilitation is similar to that for
acute collateral ligament injury of the MP joint, with a focus on avoidance of forceful extension
while the volar plate is healing during the initial 6 to 8 weeks after the injury.
Chronic Volar Instability of the Thumb Metacarpophalangeal Joint

Preoperative Assessment

Chronic laxity of the thumb MP joint occurs most commonly in the context of generalized
ligament laxity and is rarely symptomatic. Symptomatic laxity may be a manifestation of
systemic conditions such as collagen vascular disease, congenital or acquired paralytic disorders,
collapse deformity secondary to basal joint arthritis, or trauma. Posttraumatic hyperextension of
the MP joint is infrequent and may be the consequence of an unrecognized or undertreated
volar plate injury or MP dislocation. Patients with instability caused by generalized ligament
laxity are able to volitionally maintain the joint in flexion during pinch and grip, whereas those
with posttraumatic laxity cannot, and the resultant collapse of the joint causes pain and
weakness. Radiographs are usually normal but may show an avulsion fleck of bone at the site of
the volar plate injury.

Types of Operations If there has been a relatively recent hyperextension injury of the MP joint,
it may be possible to reattach the volar plate to its metacarpal origin. A zigzag incision is used to
expose the volar aspect of the MP joint. The volar plate is identified and mobilized. Its proximal
end is minimally débrided and reattached to the volar aspect of the metacarpal neck with two
bone anchors. The MP joint is immobilized in a cast for 1 month, after which range of motion
with a 20-degree extension block splint is encouraged for an additional 2 weeks. The procedure
is unlikely to be successful if the injury is chronic and the volar plate attenuated.

Several techniques have been described to treat chronic symptomatic hyperextension of the MP
joint. Kessler transected the SEP proximally and reconstructed the volar plate with the distally
attached segment. The graft was directed in a dorsovolar direction along the radial side of the
MP joint and passed along the volar aspect of the joint in a radioulnar direction. The tendon was
passed through a hole in the metacarpal neck from ulnar to radial and again passed across the
volar aspect of the MP joint to the ulnar side, where it was sutured to the adductor tendon. The
reconstruction creates a static restraint to hyperextension, while simultaneously removing the
extensor pollicis brevis extension moment on the MP joint.

Tonkin reported good results with sesamoid arthrodesis to the metacarpal head for 42 thumbs in
37 patients with either cerebral palsy or osteoarthritis of the CMC joint.

Eaton used a volar capsulodesis as an adjunct to basal joint arthroplasty for osteoarthritis in
patients with MP hyperextension of 30 degrees or more. The joint is approached through a volar
Bruner incision and an interval between the volar plate and the RCL. The cortex of the
retrocondylar fossa is decorticated, one or two suture anchors are placed, and the volar plate is
advanced proximally. The RCL is sutured to the volar plate and the joint transfixed with a 0.045-
inch Kirschner wire for 4 weeks, after which range of motion movement is begun. The joint is
protected in a splint for 2 more weeks.
THUMB CARPOMETACARPAL JOINT

CMC Joint Dislocations

ANATOMY

The articular surfaces of the CMC joint of the thumb resemble two reciprocally opposed saddles
with perpendicular transverse axes. The CMC joint has motion in three principal planes: flexion-
extension, abduction-adduction, and pronationsupination (or opposition-retropulsion).

There are four major ligaments: volar (anterior oblique), intermetacarpal, dorsoradial, and dorsal
oblique (posterior oblique). The volar oblique ligament, which passes from the trapezium to the
volar beak of the thumb metacarpal (Figure 8.39), has traditionally been considered to provide
the primary restraint to dorsal subluxation force that is inherent with pinch. The dorsal ligament
is thin but is reinforced by the expanded insertion of the abductor pollicis longus.

Historical Review All reported CMC dislocations have been dorsal.

Preoperative Evaluation

Injuries to the ligaments of the thumb CMC joint may be complete or partial. Complete rupture
permits the thumb metacarpal to dislocate dorsally (Figure 8.40).
Partial rupture of the ligaments permits varying degrees of displacement. The more extensive the
tear, the greater the displacement and, hence, the more obvious the diagnosis.

A useful diagnostic technique is the stress radiograph, which is a posteroanterior view of both
thumbs positioned parallel to the radiograph plate with the distal phalanges pressed firmly
together along their radial borders. This tends to lever the base of the metacarpal laterally, and in
the presence of a capsular tear or laxity, radial shift of the metacarpal on the trapezium will
occur. Because both thumbs are included on the film, a comparison with the uninjured joint is
possible.

Treatment

Because acute complete dislocations are quite rare and partial tears of the CMC joint are rarely
recognized, the relevant literature is composed largely of case reports with few specific
recommendations about the management of these injuries. Closed reduction and percutaneous
Kirschner wire fixation of acute CMC dislocations and significantly better results with early
ligament reconstruction.

AUTHORS’ PREFERRED METHOD OF TREATMENT

Patients with acute posttraumatic pain in the CMC joint of the thumb but without gross clinical
instability or radiographic subluxation should be considered to have a partial volar ligament tear
and immobilized in a long opponens or thumb spica splint with the metacarpal in palmar
abduction and extension for 4 to 6 weeks. The thumb should be positioned to prevent its tip from
opposing the digits, which would create axial compression along the thumb ray.

Patients with a documented dislocation or with clinical instability and radiographic subluxation
require special consideration. If postreduction radiographs show the metacarpal to be well
reduced initially and maintained at 5 to 7 days, cast immobilization may be adequate treatment.
However, if the metacarpal is not well seated radiographically or is clinically lax, surgical
reduction is indicated. The indications for closed reduction under anesthesia with percutaneous
Kirschner wire fixation of the CMC joint should be narrow

Technique of Volar Ligament Reconstruction of the Thumb Carpometacarpal Joint.

The CMC joint of the thumb is exposed through a modified Wagner volar approach that curves
ulnarly into the distal wrist flexion crease. Care is taken to avoid injury to the palmar cutaneous
branch of the median nerve, the superficial radial artery, and branches of the lateral antebrachial
cutaneous and radial nerves. The thenar muscles are elevated extraperiosteally. The intact volar
and radial capsule is incised, and any interposed tissue is removed from the joint. The FRC
tendon is identified at the wrist flexion crease and unroofed distally as far as the midportion of
the trapezium. Reconstruction of the volar ligament is begun by first creating a channel in the
base of the metacarpal in a sagittal plane perpendicular to the thumbnail. A small incision is
made in the dorsal periosteum through which a hole is made in the metacarpal base and enlarged
with progressively larger handheld gouges. It emerges just distal to the volar beak, at the site of
the volar ligament insertion. A 28-gauge stainless steel wire is placed through this channel for
subsequent passage of the tendon graft used for ligament reconstruction (Figure 8.41).

The radial half of the flexor carpi radialis is mobilized, beginning 6 to 8 cm proximal to the wrist
through one or more short transverse incisions. Alternatively, a looped monofilament suture or
an arthroscopic suture passer can be passed from the incision at the wrist crease, beneath the skin
bridge, to emerge through a proximal forearm incision and thereby avoid the need for multiple
incisions on the forearm. The loop of the suture or the suture passer is placed through a split in
the flexor carpi radialis tendon and firmly pulled distally into the distal wound to continue the
split longitudinally. The distal end is left in continuity with the index metacarpal insertion, and
the transected proximal end is passed through the channel in the volar base of the metacarpal to
emerge dorsally. The metacarpal is held reduced under direct vision as the tendon is drawn tight
to remove any kinks along its passage, and then traction is relaxed slightly to keep the
reconstruction from being too tight. The tendon is sutured to the dorsal periosteum to set proper
tension in the new ligament, and its free end is passed deep to the insertion of the abductor
pollicis longus on the metacarpal base. It is sutured at this point to reinforce the dorsal capsule.
The free end is further passed volarly around the intact flexor carpi radialis tendon and finally
reflected distally across the radial aspect of the joint, where it is sutured to a remnant of the
capsule. Kirschner wire fixation of the trapeziometacarpal joint is optional. It is important that
the new volar ligament not be sutured with excessive tension, which may restrict joint motion,
particularly rotation. The thenar muscles are reattached. Immobilization is continued for 4
weeks, at which time the cast and Kirschner wire are removed and gentle progressive motion is
begun.

Postoperative Management and Expectations

During the 4 weeks of immobilization after volar ligament reconstruction, patients are
encouraged to move the digits and thumb IP joint within the limits of the cast. The cast and
Kirschner wire are removed after 4 weeks, and patients are referred to a hand therapist. A
custom-molded thermoplastic long opponens splint is worn for 2 weeks and removed for range-
of-motion exercises. Patients are encouraged to oppose the tip of the thumb to the index and long
fingers during the first 2 weeks. In the ensuing 2 weeks (beginning at 6 weeks postoperatively),
they oppose the tip of the thumb to the ring and small fingers.

Strengthening of the thenar musculature begins 2 months postoperatively and strengthening of

pinch and grasp at 10 to 12 weeks postoperatively. It is important that the therapist not be overly
aggressive with strengthening during the first 2 months postoperatively, because this may
contribute to the reconstruction “stretching out.” Patients are allowed essentially full use of the
thumb at 3 months. Patients are advised that volar ligament reconstruction predictably stabilizes
the unstable basal joint, whether due to dislocation, subluxation, or atraumatic laxity of the basal
joint, provided there is no degenerative disease.

Neurapraxia resulting from traction almost invariably resolves completely over weeks to months.