-CASE REPORTS

DORSAL IRREDUCIBLE COMPOUND COMPLEXDISLOCATION OF THE METACARPOPHAI-ANGEAL JOINT

OF THE INDEX WITH A CLOSED IRREDUCIBLEDISLOCATION IN THE CONTRAI-ATERAL LFTLE FINGER.

A Case Report and Literature Review.

Freih Abu Hassan A, Shaher El-Haddidy.

ABSiTRACT

A young patient had a Dorsal lrreducible Compound ComplexFracture aiAocatidn of the index finger, with an epiphyseal iniury ot the headof the third metacarpat bone tqether , togather with green stick tracture ofthe distal radial and ulnar metaphyseal region. This was associated with anirreducibta ctosed complex do(al dislocation of the little tinger in thenntralateral hand.

The patient presented a month late, the dislocation were suwssfullyreduced by'open rbduction using the volar qproach, and maintained byKrdtner Wires, which were removed tour weel<s later.

INTRODUCTIONReports of the complex dislocations of the

metacarpophalangeal joints are not common, but fracture dislocationsare rar-e.

'The compound element with a late presentation makes

this entity rather u"ry r"r"( 1' 3 ' 4' 6' 10' 12' 13' 14' 15'20'23'24'25)'

The mechanism of iniury ol the complex dislocation is forcedhyperextension of the proximal phalanx in a fall on the hand which results in

pushing the metacarpal head through the volar Joint capsule ( 20 ).

The lrreducibility of the dislocations were attributed to many factors :

1. Wedging of the fibrocartilagenous volar plate within the ioint ( 3't+'16'20 ).

2.Trapping of the Metacarpal head by the palmar fascia and the transverse

metacarpal ligament ( 3

'20 )

3. Displaced flexor tendons which becomes dorsal to the metacarpal

tread(3'20).

Correepondence should bo addreeeed to :

Dr. Freih Abu Hassan, Jordan University Hospitaf, Amman, Jordan.

-199-

a

a

JORDAN MEDICAL JOURNAL voL. 26 NO. 2.NOV.1992

Also there are rare caus€s ol obstruction, such as :

a. The dorsal aponeurosis ( 1 )

.

b. A pinched sesamoid bone in children above 10 yesrs ( 22 ).

This type ol dislocarion ( 20 ) is diagnosed as the lollowing ground :

t. Ciinic*ty - Shofi, ulnar deviation and rotation of the finger.

- Semi flexed finger in proximal and distal interphalangealjoints.

- No movement ol the dislocated joint can be elicited.- The rnetacarpal head can be palpated just beneath the distal part ot

the palm.

- Dimpling of lhe palmar skin is usually observed.

ll. Radiologically (anterio - postedor, lateral, and oblique films ) :

- Dorsal and ulnar dislocation of the base of the proximal phalanx.

- Wderpd space between the metacarpal heads

( second and thkd in cases of index finger ) ,

( fourth and fifth in cases of llttle lingor ).

Gaee Repon

An eleven-year-old male student was admitted to the hospital as acase of fallen down from about three meters height. The patient wasdiagnosed to have the following prcblems :

1) Head injury manifested by : Semiconsciousness , bleeding lrom bothnostrils., dilated & fixed left pupil, haematoma over the lett forehead andGlasgow coma scale reoorded as 10/15.

2l Abdominal injury were manifested by : Guarding and rigtdity of theabdomen. The peritoneocentesis revealed frank blood.

3) Deep cul wound, about two centimeter over the volar aspect of themetacarpophalangealjoint ol the right index linger.

lmmediate surgery was done : He undenrent splenectomy for splenicinjury. Three bun holes were performed on the lett side and were negative,he also had debridement and closure of the cut wound ol the right palm. Thepatielt recovered well and was transferred to the lcU. He was mecfranically

-ventilated for 48 hours , then he stayed for five days in the normal ward.The patient discharged home on the seventh post operative day to be seen inthe outpatient Department,

-200-

DORSAL IRREDUCI BLE DISLOCATION

JOINT OF INDEX IN LITTLE FING.ER.

F.ABU HASSAN & S.EL-HADIDY

After two weeks of discharge the patient was transfened to the hand

service complaining of p"in and d6formity of both hands. On examination :

the patient haO upper-ielpi;;t"ty ttact intei,tion whicfr added another week of

delay in management. ifie rign[ nand and forearm showed delormity of the

tnJ"i fing"t in-tne torm oiHyperextensjg.n of the metacarpophalangeal jopt'i6iaiion

-or the fingei ou"'iine mioote tinger, no moJement ol the

metacarpopnaangeiiioint, shortening and ulnar ward deviation of the finger'

"""ibf 'pr6viousti ruirr"O cut wouid over the.palm, complex irreducible

ii["r'rld"ture oistocatf; ;i the metacarpoptialangeal- ioint ol the index

f Fig. z, 3 ), salter and Hanis type il epiphyseal fractures_of the middle finger

l""i""irpii head ( Fig, t, i').anO'g.t;"n stick fractures in the distal

6;iillfiG ;l-botti radjus inO irlna wiih minimal displacement and good

callusformation (Fig. 1' 2 ) .

l{i1

Figure ( 1

Figure ( 2 |

,201-

-li.l

'.i I

IIII

JORDAN MEDICAL JOURNAL voL. 26 NO. 2.NOV.1e92

Also, examination of the lett hand revealed a deformity of the little linger inthe form of ulnar wards rotation and hyperextension of themetacarpophalangeal joint, together with a prominent palpabb head of thelitth metacarpal over the volar aspect of the joinl and a dosed complexineducible dorsal dislocation ol the metacarpophalangeal joint of the littlefinger with Salter and Harris type ll epiphyseal fracture of the fifth rnetacar?alepiphysis(Fig.4).

Figure ( 3 )

Figure ( 4 )

-202-

r

DORSAL IRREDUCIBLE DISLOCATIONJOINT OF INDEX IN LITTLE FINGER.

F.ABU HASSAN & S.EL.HADIDY

Open reduction was elected as the method of trqatment using the

volar Kaplan's approach ( to )

-d if needed to use the dorsal Farabeuf'sincision ( Fig. a, I ) ;the technique of tre operation irrclude the following :

- ldentllicatlon and rebaction of the Neurovascular bundle.- The superlicial transverse metacarpal ligament had to be incised to

facilitate the exposwe & re<luction.- Release ol A1 pulley showed enlrapment of the volar plate inside the ioint.- Using a blunt hook and some dissection the volar plate was removed

from the inside of the ioint.- Reduction of the dislocation was easy without lhe need of.the dorsalincision.

- Repair of the volar plate to its insertion on lhe metacarpal nodc- Kirscfiner wire was used to maintain the reduction in moderate flexion of

the metacarpophalangeal joint.

The Little finger of the left hand was managed by Volar approach andwithout need for the dorsal approach Also, Kirschner wire was used tomaintain the reduction.

Patient was discharged home on the second post operative day. TheKirschner wires were removed at four weeks but the Volar Slab was kept loranother two weeks. After that an intensive exercise program was started.Eight weeks post operatively the patient recovered with a good and full rangeof motion. Six months post operatively, he had full range ol motion, !;oodscare ( Fig 5 , 6, 7 ) and he is play{ulas ewr.

Figure ( 5 )

-203-

,l5if'll

Iljl

IIt

vcL.20 No. 2.NOV.1992JORDAN MEDICAL JOURNAL

Ftgure ( 7 )

-2!0+

I

{$t

{

DORSAL IRREDUCI BLE DISLOCATION

JOINT OF INDEX IN LITTLE FINGER.

F.ABU HASSAN & S.EL.HADIDY

DrscussloNIneducible dislocation of the metacarpophalangeal ioints were first

described in 1855 by Malgaigne ( 17 ). The term coqp]?x dislocation was

coined by the French surgeon Farabeul in 1876 1e) an9 the dorsal

approach is stitt called the Farabeuf 's dorsal incision ( Q 9 ).. tt'" tsrm

T[|fi6;-, (-b;aG;l ir,ir'mi,lripre _anitomic srrucrures whicfr block the

reOuctiin 1 wis introduced to the. English Literature in 1888 and 1910 by

Battle( 7 ) and Barnard

(5 ) ,"rp*riwly.Thepatho|ogicanatomywasnotwide|yappreciatedunti|

Kaplan ( la)in

1957 described the button holing of.the metacarpal.head

i#ffih the voiarplate,wnict -Uieafs

away at its weakest attac{rment to the

neck of the votar aspect of the metacarpal bon€ , |.]t'.*9. into the palmar

ItiuituidJ *tricrr ne'catleo ttte cfrineso iinger traplike. -lo9ki.ns

mechanism'

These complex structures were demonstrated properly ( 3' 20 )

'

Recent studies showed that it is most frequently affecting the

index ( 1' 3' 4' 8' 12' 13' 14'?f.'tt), fol6*"d bythethumb,

(1a'21) tten by

the little finger ( 5

'7'13 ) ' 23 ) the middle and dng finger are being the

. ( 1,3,4,7,12,13)rare6t

lmbriglia and Sciuli concluded that the border-digits-were rnore otten

attected Ueci-use of inJpnysical vulnerability and lack ol stabilization of the

adjacent intermelacarpal ligamenF ( 13 ).

Asscociated volar wound with the irreducible dislOcation are

,"r" (to' 1t ) . Th" oombination of a complex compound irreducible dorsal

dislocation together with a fracture was reported- byviegas 9'"l ( a )*he'e

;-t"-rfii iuiiiineO I iomptex compdund frahura dislocation of the

ri"""rpophalangealioint ot ine fttn finger with a cominuted fracture of the

proximal phalanx . In 1988 gglan.et 9l ' ls ).reportedloYlgTg oJ gqmplgl

illedutiUie -Oislocaiion- oiiil index metaiarpophalangeal ioint with

Osteoctrondral fractures which were treated by open surgery'

Late presentation of the irreducible dislocation of the

metacarpophalingeal ioints are rare reaching up to few months

( 4'5'6'8'20' 21'24'25 ).Th" l"t" presentation is attributed to delayed palient

advice ( s )

"nd failure of proper reduction by using lateral

"ppro"rr,

( m ).

]t is thought that the prognosis was poor il the treatment

of the Oislocaiion started 'thiee weeks or more following

-?n

JORDAN MEDICAL JOURNAL voL. 26 NO. 2.NOV.1gg2

inlury ( 3'4'5'8'15'20'24'25)

, MC Lar4ghlin proposed a pdmary artrrodesis as

the best treatment ( 18 ) , while other advocated metacarpal head

,"u""tion ( 21 ).

' Delayed cases could be also treated suecess fully with open

reduc{ion using modilled Kaplan's volar approacfi with radial extension ( & )

or exlended midlaterally or medially (24'25 ). rn" Association with arm

bones fractures were previously reported ( 121 Ou cass presented the

oombination of ineducible dorsaldislocation with epiphyseal lractures type lltogether with green sick fracturos of both radius and ulna with a vdar healedwound.

Although lhe surgical management of chronic dislocation in

associated with a limited movernent of the metacarpophalangeal ;oint ( m )

and ischaemic necrosis ol the metacarpal head ( 3' 15 ) . Our case

demonstrated that chronic dislocation can still be succeselully managed byan open method wilhout the need to resort to arthrcdoels or resection.

REFERENCES

1. Adle, GA ; and Llght TR. : Simullanoous oomplex dislocation of themetacarpophalangoaljoinb ol the long and index fingers. J.Bone JointSurg. ( AM ) d?: 1007€, 1981.

2. Arbdtlang, E ; and Torian,.E. : lrreponible finger Luxationen Mschr.Lffidl Heik. ffi,45 - 7, 1963.

3. Badwln, L.W., lllller, DL., Lockha$ DL., et el.: lrletacarpophalangealjoint dislocation of the finger. J. Bone Joint &trg. ( Am ) 4tl :1587 - 901967.

Barcnfeldd, P.A., and Werclcy ll.S.: Dorsal dislocation of themetacarpophalangeal joint. Glinknl Orhopaedics and related rosoarch,Number 27,255 - 260, Feb. 1988.

Barned , HL : Dorcal dislocatbn of the first phalanx of the little linger ;

reductkrn by Farabanf's dorsal incidon. Lawt;1 :88 - 90, lg)t.Barton, N. : Fractures and joint injurieo of the hild Waston-Jones :

Fractures and joint inluries , ediled by Wson J. 782-783, vol. 2, SixthEditlon, Churchill Uvingstone 1982.

Battle , W.l{.: Back Ward Dlslocatlon of the fingers upon themetacarpus. The ratlef 2 :1283 - 4, 1988.

Bohart PG ot d.: Complex dislocations ol the mqtacarpophalangealloint. Operative reduction by Farabeuf's dorsal lnclsion. Clin. Orthop.1O4 :208-10, 1982.

9. Farabout LHF : De la luxation du porce en arrlere. Bull Soc. Ghir. 11:21-.62, 1876. -20G

:

IIgtttItI*rFp

t

I

sL

t,I,&JE

I

Ia

lt

i

t,Iad

*tt

rh

I

it

J

i

{.fIb*ij

4.

5.

7.

8.

DORSAL IRREDUCI BLE DISLOCATIONJOINT OF INDEX IN LITTLE FINGER.

F.ABU HASSAN & S.EL-HADIDY

10. Fergueon, D., lloorg G.P. and tllcke K.A.: Dorsal dislocation ofEmergency ifedicine, ( United States ) 18 ( 2l:204-2016, Feb. 1989.

11. Green , DP., and Terry , GC. : Complex dislocation of themetacarpophalangeal joint. Conelative pathological anatomy., J.BoneJoint Surg. ( Am ) 55;1480 - 6, 1973.

12. Hall, R.F., Glcacon , T.F., and Kata, R. : Simultaneous GlosedDislocatlons of the Metacarpophalangealjoints of the Index, long andring fingers. A Case Report . The Journal of Hand Surgery : 10 A : ( 1 )81 -85,January1985.

13. lmbrlglla, JE, and Sclull, R. : Open complex metacarpophalangealjoint dislocation . Two cases : index finger and long finger, J.Hand Surg.4:72- 5,1979.

14. Kaplan , EB. : Dorsal dislocation of the metacarpophalangealjoint ofthe index finger. J.Bone Joint Surg. ( An ) 39 : P 1081 - 6, 1957.

15. Llght, T.R. , and Ogden , J.A. : Complex dislocation of the indexmetacarpophalangeal joint in children. Journal of Pediatric Orthopaedics,8:300-305,1988.

16. Leclere' R.: Luxations de I'index sur son metacarpien. Rev. dOrhq.2:227 - 42,1911.

17. llalgaigne , J.F. : Traite des fractures et des luxations. Paris . J.B.Baillere, 1855.

18. McLaughlln , HL. : Complex n locked ' dislocation of themetacarpophalangealjoints. J. Trauma5 : 683 - 8.

19. Milford, Lee. : The hand in Campbell , s Operative Orthopedics ,

Edited by A.H. Crenshaw F:d.7. p. 247 -245 St. Louis. G.V. Mosby ,

1987.

n. Murphy AF. , and Stark HH.: Closed dislocation ol themetacarpophalangealjoint of the index finger. J.Bone Jolnt Surg. ( Am )49 :1579-86, 1967.

21. Onuba, O., and Esrlet, A.: lrreducible Dislocation of the MP Joint ofthe fhumb due to tendon interposition. Jwmal of Hand *trgory. 12 B : 1

60 - 61 February 1987.

2.. Swelerlltsch, PR, Torg, JS, Pollack, H. : Entrapment of a sesamoidin the index metacarpaljoint. Report of two cases. J.Bone Joint Surg.(An)51:995-B1969.

23. Vlegar , S.F.; Hears , T.O.; and Calhoun, H.: Complex fracturedislocation of a fifth MP joint Case Report and Literature review.IheJwmal ot Ttauma. 29 ( 4 ) :521 -524, 1989.

24. .Wolov R.B. : Complex Dislocation of the Metacarpophalangealjoints@thopdic Review. XVll ( I ):T7O -775.

?5. Wood, ll.B., and Dobynr, J.H. : Chronic Gomplex Dislocation of themetacarpophalangeal joint. Report of three cases. Journal of HandSurgqry. 6:73- 76, 1981. -2A7-

t

]

{I

d