You are on page 1of 29

Case Dr Carmès: Thumb injury, 35 years old male, complained of pain and

deformity of the base of the thumb: diagnostic and treatment ?
Carpo-metacarpal dislocation of the
thumb
Christian Dumontier, MD, PhD

Centre de la Main, Guadeloupe
1st Take home message

✤ Rare injuries (less than 1% of hand injuries) - 59 cases
in the English literature in 2014

✤ Indications for treatment are unclear as many case
reports have contradictory results with various
techniques
Anatomy of the CMC
joint of the thumb

✤ Articular surfaces resemble
two reciprocally opposed
saddles whose transverse axes
are perpendicular.
4 major ligaments (out of
16) of the CMC joint of
the thumb

✤ Volar (anterior oblique), from
the trapezium to the volar beak
of the thumb metacarpal (2).

✤ Intermetacarpal (1),

✤ Dorsal-radial (3),

✤ Dorsal oblique (posterior
oblique) (4).

✤ Dorsal ligaments are thin, but
reinforced by the APL
Biomechanics of
the 1st CMCj
✤ Motion in three planes: flexion-
extension, abduction-adduction,
and pronation-supination (or
opposition-retropulsion).

✤ Conjunct rotation in pronation that
results from the asymmetric height
of the radial and ulnar condyles of
the trapezial articulating surface.

✤ These concavo-convex contours
produce a degree of intrinsic
stability. Ligaments play the
principal role in stabilization.
Mechanism

✤ All reported dislocations in adults have been dorsal

✤ Axial compression on a flexed thumb metacarpal,
driving the metacarpal base out dorsally

Pequignot JP et al. Luxation traumatique de la trapézo-métacarpienne. Ann Chir Main 1988;7(1):14-24
What are the injured ligaments ?
✤ Nobody really knows !

✤ The volar or anterior oblique was considered for many years the basic key stabilizer
for preventing dorsal dislocation of the joint.

✤ Other reported that the anterior oblique as well as the radial collateral and the ulnar
collateral ligaments should be considered the main dynamic stabilizers of the thumb

✤ Strauch found that the dorsoradial ligament complex was the primary restraint to
dorsal dislocation and responsible for obtaining joint stability in thumb opposition.
Pequignot found that sectioning the dorso-radial ligament was responsible for TMj
instability. Confirmed clinically with no disruption of volar capsule or ligament in 4
cases with thumb CMC dislocation (Shah).
Strauch RL et al. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J
Hand Surg 1994, 19A:93-98.
Shah J, Patel M: Dislocation of the carpometacarpal joint of the thumb. A report of four cases. Clin Orthop Relat
Res 1983, 175:166-169.
Pequignot JP. Luxation traumatique de la trapézo-métacarpienne. Ann Chir Main 1988;7(1):14-24
How to manage 1st CMC joints
ligamentous injuries ?

✤ Benign sprain (painful, stable) to severe sprain
(painful, unstable) to complete dislocation (highly
unstable)

✤ 1st: Plain X-rays (AP and Lateral according to
Kapandji) to eliminate a Bennett’s fracture, much
more frequent +++

✤ 2nd: Clinical testing +/- stress X-rays
Kapandji’s
technique for 1st
CMC joint injuries

✤ Lateral: ∥ to the nail plate

✤ AP: ⟂ to the nail plate with 30°
proximal inclination of the
beam
Bennett’s fracture, not to be tested clinically ?
1st CMCj dislocation that was missed due to poorly realized X-rays
Clinical testing

✤ Mostly young males

✤ Palpation (localisation of pain)

✤ Mobilisation under stress
Stress X-rays

✤ Rarely done

✤ Posteroanterior view of
both thumbs positioned
parallel to the x-ray plate
with the distal phalanges
pressed firmly together
along their radial borders.

✤ May reveal widening of
the joint space or a slight
dorsal- radial shift of the
metacarpal.
Hyperlax patient
Treatment of sprains

✤ Conservative

✤ Strapping (benign) to
spica cast/orthosis for
severe sprains
Treatment of dislocations

✤ Close reduction 1st

✤ Cast immobilisation

✤ K-wire fixation

✤ Ligament reconstruction

✤ Even if there is a tendency in the literature to favor
ligamentous reconstruction, there is no proof of its
superiority
Close reduction and cast
immobilisation
✤ It can give good results

✤ Good results in 2 patients at 3 years FU (Bosmans)

✤ Good result in 1 patient with bilateral thumb dislocation
(Khan )

✤ Good result in 1 patient (Kural)

✤ However it is almost impossible to control perfect centering of
the joint and cartilage damage are not treated - Should not bee
recommended
Close reduction
and K-wire fixation

✤ Two 0.045- inch Kirschner
wires:

✤ The metacarpal should be
held in abduction and
extension and pressure at its
dorsal-radial base seats the
metacarpal to control
centering

✤ Various type of pinning
Highly unstable TM
dislocation treated
with K-wire fixation
Results of close reduction and
pinning

✤ 8 cases with 2,5 yrs FU: 5 good/exc, 2 poor results
with degenerative changes

✤ 7 cases with 8 years FU. 7 good results

Obert L et al. Recent, closed trapezio-metacarpal luxation, treated by pinning. Apropos of 7 cases with a median
follow-up of 8 years. Ann Chir Main Memb Super. 1997;16(2):102-110.
Toupin JM, Milliez PY, Thomine JM. Recent post-traumatic luxation of the trapeziometacarpal joint. Apropos of 8
cases. Rev Chir Orthop Reparatrice Appar Mot. 1995;81(1):27-34.
Ligament
reconstruction

✤ Most frequently used is the Eaton-
Littler technique with a strip of the FCR
to reconstruct the volar ligament
Recent (2015) English Literature review
Comparative studies ?

✤ Not really, retrospective and few cases

✤ 12 patients (Watt and Hooper): 1/3 of cast pts and 2/3 of K-
wires pts had an unstable and dorsally subluxating joint.

✤ Simonian and Trumble reported persistent instability in four
of eight patients after closed reduction and percutaneous
Kirschner wire fixation of acute CMC dislocations and
significantly better results with early ligament reconstruction.

Simonian PT, Trumble TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous
reconstruction versus closed reduction and pinning.J Hand Surg Am. 1996;21(5):802-6.
Conclusion

✤ Very rare injury

✤ Do not miss it ➤ ask for good X-rays that allow
analysis of the CMC joint

✤ Surgical treatment is probably preferable: If you
choose percutaneous k-wires, be sure you are perfectly
reduced. Otherwise consider open reduction and
ligamentoplasty.