Divergent multiple carpometacarpal fracture dislocation

Abstract

IntroductionFracture dislocations of more than one carpometacarpal joint are energy-intensive injuries that are infrequently encountered [1,2]. Given the high-energy nature of the causal trauma, these injuries are quite often accompanied by more serious life-threatening injuries that require urgent attention [3]. Consequently, accurate diagnosis and definitive management of these injuries may be delayed. Most of the cases reported are of dorsal fracture dislocations. The greater relative mobility of the two ulnar rays ordains that fracture dislocations be more common in these two. A dislocation of all four ulnar metacarpal bases upon the second row of carpals is rare [4,5]. We report a case of volar dislocation of all the four ulnar metacarpals with mediolateral divergence between the fourth and fifth rays. Case reportA 17-year-old boy's hand was run over by a tractor. He presented in the accident and emergency department with a huge swelling of the right hand associated with severe pain. No other associated injuries were noted. There was no distal neurovascular deficit in the injured extremity.The anteroposterior roentgenogram showed a fracture of the base of the fourth metacarpal, an abnormal overlapping of the articular surfaces of the fifth carpometacarpal joint, medial dislocation of second through fourth carpometacarpal joints and a divergence in the mediolateral plane between the fourth and fifth rays (Fig. 1). The lateral view showed a volar dislocation of all the four metacarpal bases (Fig. 1). The soft tissue oedema was marked in both views.The fracture dislocation was reduced closely under Carm visualization under general anesthesia (Fig. 2). Provocation to reproduce the dislocation revealed the stability of the reduction and a short arm cast was applied to hold the reduction. The cast had to be changed after 3 days when it became loose as the oedema subsided. The cast was continued for 6 weeks.At the last follow up (12 months after the trauma) the patient had a painless hand and full hand and wrist movements. There was only mild weakness of grip strength as compared to the contralateral normal hand and the patient was able to perform all activities of daily living without discomfort.Abstract Multiple divergent dislocations of carpometacarpal joints are uncommon injuries. The Authors describe a heretofore unreported mediolateral divergence between the fourth and fifth rays coexisting with carpometacarpal dislocation that was reduced and retained by closed technique.

Carpometacarpal fracture dislocation of the fourth and fifth finger: mid-term results of 15 patients

“…Thus, dorsal dislocations are more frequent than volar ones. [10] Oblique radiographic images with the hand pronated 30° are mandatory for the diagnosis of this injury. Gillespy et al [11] and Takami et al [12] emphasized that the fragment could be seen on pronation oblique and/or lateral view instead of posteroanterior view.…”

Multiple Carpometacarpal Dislocations of the Hand – An Uncommon Variant: A Rare Case

“…7) Kumar and Malhotra 8) and Kumar et al 9) described a "divergent variant" of multiple CMC joint dislocations in which divergence is defined as a volar dislocation of ≥ 1 joint with concomitant dorsal dislocation of ≥ 1 joint. In our patient, the most likely mechanism of injury would appear to be a fall on the dorsum of hand with direct force applied to the bases of metacarpals.…”

An unusual combination of divergent carpometacarpal joints dislocations, distal radius fracture, and posterior elbow dislocation

“…[1][2][3][4][6][7][8][9][10][14][15][16][17]19 Divergent carpometacarpal dislocations are even rarer, with only a few documented cases, 1,2,4,10,17 resulting from either automobile accidents or falls from a height. An association with a distal radius fracture and a posterior elbow dislocation has never been reported before.…”

“…[1][2][3][4][6][7][8][9][10][14][15][16]19 Divergent carpometacarpal dislocations are even rarer. 1,2,4,10,17 The second most common joint dislocated in adults is the elbow, which accounts for 20% of all dislocations. There is posterolateral displacement in most cases.…”