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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 88-90

Dislocations of all the carpometacarpal joints: A rare injury pattern


1 Department of Orthopedics, GGS Medical College and Hospital, BFUHS, Faridkot, Punjab, India
2 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital (SMCH), Banur, Patiala, Punjab, India

Date of Web Publication6-Jun-2014

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab - 147 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.134029

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  Abstract 

Orthopedic injuries can be misdiagnosed if physical examination is not feasible. The literature is abundant with different pattern of hand injuries. Carpometacarpal fracture dislocations constitute one of the rarest patterns of injuries of the hand. These injuries can often be missed because of the gross swelling and edema of the hand. The diagnosis of this unusual form of injury requires a high index of suspicion, vigilant examination and high-quality radiography. Apart from the routine antero-posterior and oblique radiographs, a lateral radiograph of the hand is essential for making an accurate diagnosis in suspected cases of carpometacarpal dislocations. Although many such case reports are described in the literature, we are reporting a rare case of dislocation involving all the five carpometacarpal joints which has never been reported in the literature till date.

Keywords: Carpometacarpal fracture, carpometacarpal dislocations, hand injury, K-wires


How to cite this article:
Goyal N, Paul R, Bhatty SM, Bajwa SS. Dislocations of all the carpometacarpal joints: A rare injury pattern. J Orthop Traumatol Rehabil 2014;7:88-90

How to cite this URL:
Goyal N, Paul R, Bhatty SM, Bajwa SS. Dislocations of all the carpometacarpal joints: A rare injury pattern. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Jul 19];7:88-90. Available from: http://www.jotr.in/text.asp?2014/7/1/88/134029


  Introduction Top


Injuries of hands can vary from simple to complicated pattern with altogether different management of such injuries. Sometimes such injuries can pose diagnostic and therapeutic dilemmas to the attending emergency physician and the orthopedician. Carpometacarpal fracture dislocations of the hand are a relatively uncommon pattern of injuries. These injuries are often missed because of the gross swelling and edema of the hand which makes it difficult to diagnose precisely during the initial inspection. The diagnosis of this unusual form of injury requires a high index of suspicion, vigilant examination and high-quality radiography. As such these injuries are liable to be missed in peripheral centers where all the diagnostic facilities are not available.

Apart from the routine antero-posterior and oblique radiographs, a lateral radiograph of the hand is essential for making an accurate diagnosis in suspected cases of carpometacarpal dislocations.

Although many such case reports are described in the literature, to our knowledge dislocation involving all the five carpometacarpal joints has never been reported and we believe this is the first case report being presented here.


  Case report Top


A 40-year-old male patient was brought to the emergency department of our hospital following a road traffic accident and sustained polytrauma which included bilateral femoral shaft fractures and the hand injury. The patient was conscious and responding but was suspected to be in hemorrhagic shock which was successfully stabilized with intravenous fluids and blood transfusions in the emergency ward only without any ionotropic support.

Physical examination revealed abnormal mobility and crepitus in bilateral thigh region along with swelling of involved hand [Figure 1]. The antero-posterior diameters of the hand was increased but as the patient was in shock all the attention was focused to resuscitate and stabilize the patient and manage his lower limb injuries. Injury to the hand was missed initially as the whole focus was on stabilizing the patient. However, no neurovascular compromise of the hand was observed as the pulse oximetry findings revealed a saturation of 100%.
Figure 1: Side view of the involved hand showing the increased anteroposterior diameter of the hand in the carpometacarpal region due to swelling and deformity

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After the patient was successfully resuscitated and his consciousness level improved, he complained of persistent pain in the hand along with limitation of movements at the wrist and the hand. The patient was then evaluated for this particular injury and X-rays and CT scan were done to delineate the injuries. The radiologic investigations revealed dislocation of all the five carpometacarpal articulations [Figure 2] and [Figure 3].
Figure 2: The X-ray image showing all 5 arpometacarpal joint
dislocationns


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Figure 3: CT images of the injured hand showing all carpometacarpal joints dislocated

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An attempt of closed reduction was made under deep sedation, which failed. The patient was planned for open reduction under general anesthesia. An internal fixation with multiple Kirschner wires was done by two incision approach. One incision was given in the first web space and the other was given in the fourth web space. The dislocated joints were reduced and stabilized with four Kirschner wires and a below elbow cast was applied after the surgical procedure [Figure 4].
Figure 4: Post-operative check X-rays showing reduced carpometacarpal fractures stabilized by 4 k-wires

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After six weeks, the K-wires and the cast were removed and active physiotherapy of the wrist and hand was started. Dorsiflexion of 50 degrees and palmar flexion of 40 degrees was achieved within one month of follow-up after which the patient did not follow.


  Discussion Top


Posterior dislocation of the carpometacarpal joints is a very rare injury and is often missed. Routinely antero-posterior and oblique views are done for delineating hand injuries. In case of carpometacarpal dislocations these views may not be sufficient to identify this injury therefore leading to an increased incidence of missed injuries. An additional lateral radiograph is required to accurately diagnose this type of injury.

A late diagnosis is often made either in cases of multiple injuries or where a lateralradiograph of the wrist was not taken in suspected cases of carpometacarpal injuries. [1],[2],[3] Old unreduced dislocations are usually reported but such dislocations do not cause significant discomfort to the patient. [4],[5] However, these dislocations can disrupt both the longitudinal and the transverse arches ofthe hand, resulting in gross morbidity of the hand later. [6]

Although closed reduction can be attempted, best results are usually obtained by open reduction and internal fixation with K-wires. This helps in the accurate reduction of the dislocations and an early functional recovery [7] which we successfully achieved in the present case.


  Conclusions Top


Carpometacarpal dislocations are relatively rare injuries and are often missed. The injury requires a high degree of suspicion in a trauma patient for timely diagnosis. The injury may not cause significant discomfort initially but can later on lead to wrist stiffness and joint arthritis leading to significant morbidity and hampering daily activities of the patient. The absence of such rare dislocation of all five carpometacarpal joints makes this case report unique literary global fact.

 
  References Top

1.Kumar R, Malhotra R. Divergent fracture dislocation of the secondcarpometacarpal joint and the three ulnar carpometacarpal joints. J Hand Surg Am 2001;26:123-9.  Back to cited text no. 1
    
2.Parkinson RW, Paton RW. Carpometacarpal dislocation: An aid todiagnosis. Injury 1992;23:187-8.  Back to cited text no. 2
    
3.Nalebuff EA. Isolated anterior carpometacarpal dislocation of the fifthfinger: Classification and case report. J Trauma 1968:8:1119-23.  Back to cited text no. 3
    
4.Shorbe HB. Carpometacarpal dislocations: Report of a case. J Bone Joint Surg 1938:20:454-7.  Back to cited text no. 4
    
5.Whitson RO. Carpometacarpal dislocation: A case report. Clin Orthop 1955:6:189-95.  Back to cited text no. 5
    
6.Imbriglia JE. Chronic dorsal carpometacarpal dislocation of the index, middle, ring, and little fingers: A case report. J Hand Surg 1979,4:343-5.  Back to cited text no. 6
    
7.Sharma AK, John JT. Unusual Case of Carpometacarpal. Dislocation of All the Four Fingers of Ulnar Side of Hand. MJAFI 2005;61:188-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case report
Discussion
Conclusions
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