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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 77-79

Surgical treatment of complex metacarpophalangeal joint dislocation


Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medical, Selcuk University, Konya, Turkey

Date of Submission23-May-2019
Date of Acceptance08-Jul-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Gokce Yildiran
Department of Plastic, Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Faculty of Medical, Selcuk University, Konya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_42_19

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  Abstract 


Dorsal dislocations of the metacarpophalangeal joint (MPJ) are relatively uncommon injuries. Complex dislocations of metacarpophalangeal dorsal dislocations are characterized with extended MPJ without flexion and flexed distal joints. Complex dislocation injuries usually require surgical reduction. A 25-year-old male patient was admitted with pain, swelling, and tingling following a hyperextension injury. X-rays demonstrated dorsal dislocation of the proximal phalanx of the index finger without fracture. Open surgical reduction was planned via volar approach. Treating a complex MPJ dislocation with closed reduction is rarely successful. Especially, the volar approach is useful in open dislocations, and anatomy of the volar structures can be best explored and demonstrated.

Keywords: Complex dislocation, dorsal dislocation, metacarpophalangeal joint


How to cite this article:
Sutcu M, Yildiran G, Akdag O. Surgical treatment of complex metacarpophalangeal joint dislocation. Turk J Plast Surg 2020;28:77-9

How to cite this URL:
Sutcu M, Yildiran G, Akdag O. Surgical treatment of complex metacarpophalangeal joint dislocation. Turk J Plast Surg [serial online] 2020 [cited 2020 Feb 28];28:77-9. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/77/274443




  Introduction Top


Dorsal dislocations of the metacarpophalangeal joint (MPJ) are relatively uncommon injuries. These injuries can be either simple subluxation or complex dislocation. Complex MPJ dislocations were described by Kaplan.[1] The injury mechanism is the dorsally interposed and entrapped volar plate inside the MPJ due to the hyperextended digit and ruptured volar plate. Typically falling on the stretched hand causes this injury. Complex dislocations are characterized with extended MPJ without flexion and flexed distal joints. Complex dislocation injuries are usually caused by significant trauma and they require surgical reduction. The index finger is the most frequently involved finger.[2] The complex dislocations must be managed by open surgical reduction to reduce the dislocation and realign the volar plate.[2] It is aimed to present an interesting, complex second MPJ dislocation case.


  Case Report (Procedure) Top


A 25-year-old male patient was admitted with pain, swelling, and tingling involving his right index finger following a hyperextension injury. Clinical examination revealed that the right index finger MPJ was in slight extension and the interphalangeal joints were in mild flexion [Figure 1]a and [Figure 1]b. Palmar skin wrinkle over the metacarpal head was noted. A volar prominence was palpated at the MPJ corresponding to the metacarpal head with a void dorsally. The digit was intact and restricted, and there was no flexion motion. Radiographs demonstrated dorsal dislocation of the proximal phalanx of the index finger without fracture [Figure 2]a. There was no sensorial defect. Open surgical reduction was planned via volar approach. Via volar incision over the metacarpal head, A1 pulley was released, and there was not any osteochondral lesion. The joint was reduced on the first attempt in the patient without complication, and the skin was closed primarily. The joint was stable after reduction and allowed active motion with an extension block splint postoperatively. Full, painless range of motion was achieved in the patient, and he had no recurrent instability on subsequent follow-up visits. The patient had no tendon or nerve injuries. The patient was satisfied with the result at postoperatively 12th week and returned to their preinjury functional status [Figure 2]b and [Figure 3]a, [Figure 3]b.
Figure 1: (a) Metacarpophalangeal hyperextension and wrinkle over the metacarpal head in lateral aspect, preoperatively. (b) Dorsal view, preoperatively

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Figure 2: (a) Preoperative X-ray. (b) Postoperative X-ray

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Figure 3: (a and b) Postoperative view of hand motions

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  Conclusion Top


Dislocations of the MPJ are complex injuries.[3] The first irreducible dorsal MPJ dislocation was defined in 1855. Kaplan described the pathologic anatomy of a complex dislocation in 1957.[4] The common mechanism of injury is forced hyperextension of the vulnerable digit.[5] Knowledge of the pathoanatomy is critical for safe surgical intervention. Entrapment of the metacarpal head generally occurs by the ulnar flexor tendons, radial lumbrical muscle, and the palmar superficial transverse ligament.[3] In this case, index finger MPJ dislocation was described. Treating a complex MPJ dislocation with closed reduction is rarely successful. It is better not to attempt for a closed reduction for complex dorsal MPJ dislocations. Volar or dorsal approaches are described to reduce this dislocation.[6] Especially, the volar approach is useful in open dislocations, and anatomy of the volar structures can be best explored and demonstrated [Figure 4]. However, in the volar approach, the radial digital neurovascular bundles are at risk.[7],[8] With a careful dissection, the risk can be minimized with the protection of neurovascular structures. The volar approach allows you to arrive directly to the lesion and allows restoration of joint anatomy and repairment of the volar plate. This approach reduces the risk of late instability.[3],[6] On the other hand, the dorsal approach is simple and has no risk of digital nerve injury.[8] The dorsal approach is simple and safe, but the volar plate cannot be repaired. Furthermore, the MPJ has delayed healing, and this approach also leads to instability.[3],[6]
Figure 4: An algorithm for dorsal metacarpophalangeal joint dislocations

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To achieve the optimal outcomes in complex MPJ dislocations, early treatment is crucial. Delayed treatment or prolonged postoperative immobilization and rehabilitation treatment lead to failed results. It is important to avoid hyperextension for a few days postoperatively. Otherwise, digital nerve damage, decreased range of motion, and degenerative arthritis can be seen.[9] In our patient, physical and radiological examinations revealed a complex MPJ dislocation with entrapment of the volar plate into the joint space. Referral to the operating room for open surgical reduction led to successful treatment of the dislocation, which allowed for healing of the joint without complications.

Complex MPJ dislocations are diagnosed by physical findings. Attempts for closed reduction of complex dislocations are typically unsuccessful, and repeated attempts often lead to further complications. Open surgical reduction may reduce these complex dislocations and allow joint healing without complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaplan EB. Dorsal dislocation of the metacarpophalangeal joint of the index finger. J Bone Joint Surg Am 1957;39-A: 1081-6.  Back to cited text no. 1
    
2.
Mudgal CS, Mudgal S. Volar open reduction of complex metacarpophalangeal dislocation of the index finger: A pictorial essay. Tech Hand Up Extrem Surg 2006;10:31-6.  Back to cited text no. 2
    
3.
Durakbasa O, Guneri B. The volar surgical approach in complex dorsal metacarpophalangeal dislocations. Injury 2009;40:657-9.  Back to cited text no. 3
    
4.
Stiles BM, Drake DB, Gear AJ, Watkins FH, Edlich RF. Metacarpophalangeal joint dislocation: Indications for open surgical reduction. J Emerg Med 1997;15:669-71.  Back to cited text no. 4
    
5.
Stowell JF, Rennie WP. Simultaneous open and closed dislocations of adjacent metacarpophalangeal joints: A case report. J Emerg Med 2002;23:355-8.  Back to cited text no. 5
    
6.
Barry K, McGee H, Curtin J. Complex dislocation of the metacarpo-phalangeal joint of the index finger: A comparison of the surgical approaches. J Hand Surg Br 1988;13:466-8.  Back to cited text no. 6
    
7.
Patterson RW, Maschke SD, Evans PJ, Lawton JN. Dorsal approach for open reduction of complex metacarpophalangeal joint dislocations. Orthopedics 2008;31:1099.  Back to cited text no. 7
    
8.
Chadha M, Dhal A. Vulnerability of the radial digital neurovascular bundle of the index finger while using the Kaplan's volar approach for irreducible dislocation of the second metacarpophalangeal joint. Injury 2004;35:1182-4.  Back to cited text no. 8
    
9.
Light TR, Ogden JA. Complex dislocation of the index metacarpophalangeal joint in children. J Pediatr Orthop 1988;8:300-5.  Back to cited text no. 9
    


    Figures

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



 

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