Vol 44 # 4 December 2012 - Kma.org.kw

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KUWAIT MEDICAL JOURNAL
December 2012
Case Report
Unstable Carpometacarpal Dislocation of Ulnar
Four Fingers – An Easily Overlooked Injury
Kumar Ashok, Singh Pritish, Badole Chandrashekhar
Department of Orthopedics and Traumatology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Maharashtra, India
Kuwait Medical Journal 2012; 44 (4): 341 - 343
ABSTRACT
Multiple carpometacarpal (CMC) joint dislocations are
rare. These clinical entities require significant amount of
force to produce dislocation at this inherently stable joint
level. We present a case of unstable dorsal dislocation
of ulnar four carpometacarpal joints without associated
fractures which was fixed with multiple K-wires with good
functional outcome. Although carpometacarpal dislocations
are uncommon entities, the case is reported here not just by
virtue of its rarity but also because of a tendency for such
injuries to be overlooked by surgeons with resultant delay in
diagnosis and treatment.
KEY-WORDS: internal fixation, k-wire
INTRODUCTION
Carpometacarpal (CMC) dislocations other than
thumb are uncommon injuries accounting for less
than 1% of hand injuries. It is rare for multiple CMC
dislocations to occur without associated fractures [1,2] .
Disability is significantly severe in untreated cases and
initially neglected cases. The dislocation of multiple
joints at CMC junction is not an anticipated diagnosis
in cases of polytrauma with hand swelling. The injury
is often missed or overlooked owing to many factors,
both on the surgeon’s side and patient’s side [3] .
CASE HISTORY
A 26-year-old male presented to the emergency
department after riding his motorbike into a roadside
vehicle with gross swelling on the dorsum of the
right hand and inability to move the wrist. The
wrist movements were grossly restricted but finger
movements were elicitable with pain. Distal hand
perfusion was adequate.
After adequate first aid measures, an X-ray of
the hand in antero-posterior and oblique plane
was ordered. Hand radiographs primarily revealed
no bony injury as screened by emergency medical
officer against awaited metacarpal fracture. A dorsal
splint was applied taking cognizance of severe hand
contusion. Screening of radiographs by consultants
gave a clue to missed diagnosis of CMC dislocation.
There was overlapping of joint surface of metacarpal
bases over carpals. The lateral view hand radiograph
promptly clarified diagnosis of CMC dislocation of
ulnar four fingers. Lateral radiograph revealed a
significant dorsal offset of metacarpal complex over
carpals. There was no associated fracture of adjacent
CMC entities (Fig. 1A, B)
An unsuccessful closed reduction with slab
application was attempted with linear traction along
line of fingers. The reduction could only be maintained
with multiple trans-CMC Kirschner wires (K-wires)
(Fig. 1C). Postoperatively, wrist was splinted on dorsal
side for six weeks; K-wires were removed at the end of
six weeks. Reduction was satisfactorily sustained after
slab removal as confirmed by check radiographs. Full
range of motion of hand was regained with support
of active hand-specific physiotherapy in the early
convalescent period showing excellent functional
result (Fig. 2A, B).
DISCUSSION
Less commonly encountered injury of CMC
dislocation gains importance in emergency scenarios
by virtue of it getting overlooked and a resultant
delayed diagnosis. The delayed diagnosis and
consequent delayed treatment of this joint dislocation
has implications in functional outcome of wrist [4] .
Many factors play a role in such uninvited
overlook. Occurrence in settings of polytrauma,
primary management by junior ranks, customary less
Address correspondence to:
Dr. Ashok Kumar, MS, Associate Professor, Department of Orthopedics and Traumatology, Mahatma Gandhi Institute of Medical sciences, Sewagram
442102, Wardha, Maharashtra, India. Tel: 0919850394016, E-mail ID: drashokbagotia@gmail.com