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THUMB MP JOINT DISLOCATION

DOCTOR CARMES
HAND CENTER
CLINIQUE DES EAUX CLAIRES
GUADELOUPE
1- DORSAL THUMB DISLOCATION

• Rare

• To reduce this dislocation, the maneuver is particular.
An inadequate maneuver increases the severity of
the injury and makes surgical treatment mandatory.
MECHANISM OF THE INJURY
• Hyperextension with a part of
rotation

➙ The head is going to pass
between the FPL and the thenar
muscles 

➙ The volar plate and the
sesamoid bones may lock into the
joint.

• The collateral ligaments are
usually intacts (because they are
tense in flexion).
CLINICAL PRESENTATION

Clinical diagnosis is usually easy:

• Pain, functional limitation,

• More or less severe deformity of
the thumb

X-rays confirm the diagnosis 

But their analysis is delicate

Two types of lesions are described
1) SIMPLE DORSAL DISLOCATION

• Pain

• Functional limitation

• Thumb in hyper-extension

• X-rays: sesamoids are still
in contact with the
metacarpal head
2) COMPLEX DORSAL DISLOCATION

• Pain

• Functional limitation

• Thumb is no more
extended but parallel to
the metacarpal. The MP
joint deformity is minimal

• X-rays: Sesamoids are
posterior to the
metacarpal head
X-RAYS

• Confirm the diagnosis

• Visualize possible associated
fractures

• Different anatomical types
have been described but they
are of limited use
TAKE HOME MESSAGE

• If you fail to do the correct maneuver,
you will change a simple dislocation to a
complex one, most often now irreducible

• It only exists one maneuver of reduction
which needs adequate pain relief

• After reducing the dislocation, you must
test the joint under fluoroscopy, another
good reason for adequate sedation
REDUCTION WITH THE
MANEUVER OF FARABEUF

• Was invented by Louis Farabeuf
(1841-1910), French surgeon who described
the anatomical lesions, the reduction
maneuver and the instrument he used.
MANEUVER OF FARABEUF

• Under local or regional
anesthesia +/- MEOPA
(Kalinox*)

• Do not pull in the axis of the
thumb ➙ risk of incarceration of
the metacarpal head between
the FPL and thenar muscles,
while the sesamoids and volar
plate go dorsally over the
metacarpal head
MANEUVER OF FARABEUF

• Explain the patient how you
will perform the reduction

• Increase the deformity

• Then push the phalanx
distally while pressing the
base of P1 over the
metacarpal to reduce en
bloc the phalanx with the
sesamoids, the volar
plate and the FPL

Close reduction of this dislocation is easier if the insertions of the thenar muscles on the sesamoids are intact as
they serve as a guide for the solar plate to get back into its initial position (Weeks 1981)
• No traction in the thumb axis

➙ sesamoids will interpose into the
joint
TESTING AFTER REDUCTION IS MADE
IN THE TWO PLANES
• In the frontal plane

• If there is a severe lesion
of one of the collateral
ligament (mostly MCL):
surgery is needed
• Then testing under fluoroscopy to better
understand the anatomical lesions and the
potential evolution to chronic volar instability
IN DORSAL DISLOCATION W/O FRACTURE

Which are the injured structures ?

Volar plate

3: metacarpal-sesamoid lgt
4: phalangeal-sesamoid lgt
5: Sesamoid

FPB (radial) or Adductor (ulnar)
RUPTURE OF THE METACARPAL-SESAMOID
LIGAMENT

• The most frequent injury (80%)

• Close reduction is stable

• In extension sesamoids stay close to the phalanx

• Immobilisation 3-4 weeks with a gauntlet opening the
1st web
IF

Rupture of the
• Rupture of the phalangeal-
active sling
sesamoid ligament

• Fracture of a sesamoid

• Rupture of FPB tendon

Evaluation of the
necessity for surgery
RUPTURE OF THE PHALANGEAL-
SESAMOID LIGAMENT
Sesamoids do not follow the base
of the phalanx in extension
FRACTURE OF A SESAMOID BONE

Difficult to see !

The name sesamoid comes from the greek, it is the flat and oval sesame plant
seed, an Indian plant used by the physicians as a purgative
TWO TYPES OF SESAMOID FRACTURE

• First description in 1915

• Type 1: without volar plate rupture - stable with no
necessity for surgery

• Type 2: with volar plate rupture (also described by
Stener) - unstable, needs surgical treatment.


3 clinical signs: 

- Injury in hyper-extension, 

- Palmar ecchymosis along the FPL tendon, at the level of
the MP joint, extending to the thenar eminence, 

- Pain during pressure of the fractured sesamoid.
RUPTURE OF FPB TENDON

Hematoma, proximal pain,
pain increased by resisted
MP flexion if seen late

US can help for diagnosis
2- PALMAR DISLOCATION OF THE THUMB MP

• The EPL tendon is no more palpable, there
is a radial or ulnar displacement of the
tendon (EPL, EPB) with a paradoxal flexion
of the MP with an IP extension when the MP
is extended

• Most often (15/17 cases) open reduction is
needed as the dorsal capsule and extensor
tendons tend to interpose.

• Beware of an associated collateral ligament
injury which should be repaired surgically
CONCLUSION

• Rare injuries

• Severe, complex injuries should be treated
surgically

• A meticulous clinical examination with a complete
ligamentous testing is the key for choosing the
optimal treatment
Hand center
Guadeloupe

MARIA
hurricane

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