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

 • A 60-year-old was seen immediately after a fall complaining
of pain at the base of the thumb with no pre-injury
complaints. The joint was successfully reduced and casting
was performed. X-rays taken two weeks after reduction are
shown. What is the recommended treatment at this time?

• Cast immobilization Pre-reduction

• Early motion protocol with

hand therapy

• Repeat attempted reduction

• Operative reduction and 2 weeks

joint stabilization

• Hemi-trapeziectomy
 A 36-YEAR-OLD MALE WITH NO SIGNIFICANT PAST MEDICAL
HISTORY PRESENTS WITH RECURRENT PAINFUL THUMB CMC
DISLOCATIONS ALONG WITH MARKED HYPERLAXITY OF ALL MCP
AND IP JOINTS OF BOTH HANDS. WHAT IS THE MOST LIKELY
DIAGNOSIS?

• Cutis laxa

• Ehlers-Danlos syndrome

• Marfan syndrome

• Osteogenesis imperfecta

• Loeys–Dietz syndrome
 st 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
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 Mechanism

✤ All reported dislocations in adults have been dorsal

✤ Axial compression on a exed 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

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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. Con rmed 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
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How to manage st 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

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Kapandji’s
technique for st
CMC joint injuries

✤ Lateral: ∥ to the nail plate

✤ AP: ⟂ to the nail plate with 30°

proximal inclination of the
beam
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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

 A 36-YEAR-OLD MALE WITH NO SIGNIFICANT PAST MEDICAL
HISTORY PRESENTS WITH RECURRENT PAINFUL THUMB CMC
DISLOCATIONS ALONG WITH MARKED HYPERLAXITY OF ALL MCP
AND IP JOINTS OF BOTH HANDS. WHAT IS THE MOST LIKELY
DIAGNOSIS?

• Cutis laxa

• Ehlers-Danlos syndrome

• Marfan syndrome

• Osteogenesis imperfecta

• Loeys–Dietz syndrome
• Cutis laxa is a rare disorder of elastin in which the skin is inelastic and
hangs loosely in folds. This gives the appearance of premature aging.

• Marfan syndrome is a systemic disorder of connective tissue caused by

mutations in brillin 1. Typical manifestations include aortic aneurysm,
dislocation of the ocular lens, arachnodactyly, and long bone overgrowth.

• Osteogenesis imperfecta (OI or brittle bone disease) is one of the most

common heritable disorders of connective tissue. The skeletal features of
OI include excess/atypical fractures, short stature, scoliosis, and skull
deformities. Extraskeletal manifestations may include hyperextensible joints,
but these would be in combination with other skeletal manifestations, such
as a history of multiple fractures.

• Loeys-Dietz (LDS) is a connective tissue disorder predisposing to aortic

and arterial aneurysms. Skeletal features of LDS may overlap with Marfan
syndrome, and hand contractures are common.
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Stress X-rays

✤ Rarely done

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

✤ May reveal widening of

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

✤ Conservative

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

✤ Close reduction 1st

✤ Cast immobilisation

✤ K-wire xation

✤ Ligament reconstruction

✤ Even if there is a tendency in the literature to favor

ligamentous reconstruction, there is no proof of its
superiority
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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 be
recommended
 • A 60-year-old was seen immediately after a fall complaining
of pain at the base of the thumb with no pre-injury
complaints. The joint was successfully reduced and casting
was performed. X-rays taken two weeks after reduction are
shown. What is the recommended treatment at this time?

• Cast immobilization Pre-reduction

• Early motion protocol with

hand therapy

• Repeat attempted reduction

• Operative reduction and 2 weeks

joint stabilization

• Hemi-trapeziectomy
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
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with K-wire xation
 Results of close reduction and
pinning

✤ 8 cases with 2,5 yrs FU: 5 good/excellent, 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 xation of acute CMC dislocations and
signi cantly 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.
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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.