Case report
Volar dislocation of the second and third carpometacarpal joints – the Lisfranc injury of the hand?Luxation palmaire des deuxième et troisième articulations carpo-métacarpiennes : traumatisme de Lisfranc de la main ?

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Abstract

A case of an isolated volar dislocation of the second and third carpometacarpal (CMC) joints in an 18-year-old man is described. He presented following a game of rugby unable to move his hand or wrist. He was managed by manipulation and K-Wire fixation. Hand function was excellent following wire removal and mobilization. This is an extremely rare injury, easily missed. The mechanism of injury described leads to comparison with the Lisfranc injury of the foot.

Résumé

Nous présentons le cas d’une luxation palmaire isolée de la 2e et de la 3e articulation carpo-métacarpienne chez un homme de 18 ans, qui s’est présenté avec une incapacité à bouger le poignet et la main à la suite d’un match de rugby. Il fut traité par réduction par manœuvres externes et brochage. La fonction de la main était excellente après l’ablation des broches et la rééducation. Il s’agit d’une lésion rare, facilement omise. Le mécanisme lésionnel décrit amène à comparer cette lésion à celle de l’interligne de Lisfranc au pied.

Introduction

Hand fractures make up a large proportion of those attending the emergency department (ED), accounting for 1.5% of all ED admissions in the US [1]. Carpometacarpal dislocations account for a much lower proportion of hand injuries [2], with the vast majority of them being described in the literature as small case series and case reports.

Although there are many case reports and series describing the dorsal dislocations of the CMC joints [3], descriptions of volar dislocations in the literature appear to be much rarer. Despite the scarcity of these injuries, Buchholz et al. were keen to illustrate that these dislocations particularly at this CMC level have to be monitored closely to prevent suboptimal future outcomes associated with high energy injury and prolonged swelling [4]. With the exception of a few case reports of volar CMC dislocations of the relatively mobile thumb [5], only small numbers of CMC dislocations have been described from second to fifth fingers [6], [7]. To date there has only been a couple of other case reports involving only the volar dislocation of the 2nd and 3rd CMC joints including that described by Harwin et al. [8]. These authors highlighted the importance of the firm soft tissue attachments in terms of capsule and ligament which is thought to contribute to the infrequency of this injury pattern. Harwin et al. went on to describe the joint articulations and the rigid central pillar of the hand formed by the 2nd and 3rd metacarpals [8] – this was later confirmed through kinematic analysis analyzing differences in movements arcs of the 2nd and 3rd CMC joints [9].

This case report is presented to highlight the importance of rare injuries that can potentially present to any clinician treating hand injuries. This report also presents a case for further cross-sectional imaging essential in delineating the injury pattern whilst also guiding operative management.

Section snippets

Case report and mechanism of injury

This 18-year-old right hand dominant male presented to our emergency department with right hand swelling and discomfort following a rugby injury. He gave a clear history of his injury mechanism which began as he fell onto his outstretched hand. After landing with his hand effectively planted in the ground, he remembered his metacarpophalangeal joints hyperextended, his wrist in neutral and the elbow extended. At this point another player landed over his shoulder, effectively transmitting an

Discussion

The precise anatomical relationships of the CMC joints are required for normal function of the hand. Buchholz et al. clearly demonstrate that with disruption and dislocation of CMC joints can result in persistent swelling with poor outcomes [4]. They described the importance of nearby soft tissue structures with the deep branch of ulnar nerve closely related with the volar surface of the 5th CMC joint, with the deep palmar arch closely related to the 3rd CMC joint. Therefore, the importance of

Conclusion

Isolated volar dislocation of the 2nd and 3rd CMC joints is a rare injury. We present this method of fixation to clarify early assessment and management. This is a similar mechanism of a Lisfranc injury in the foot [14] and highlights again the importance of recognizing clearly the mechanism of the injury, which will guide the appropriate radiographic assessment.

The injury described is likely to occur at a relatively similar frequency to other potentially debilitating hand injuries such as

Disclosure of interest

The authors declare that they have no competing interest.

References (14)

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Cited by (3)

  • Pure divergent dislocation of the index and middle finger carpometacarpal joints: A rare case

    2019, Trauma Case Reports
    Citation Excerpt :

    Therefore, the divergent dislocation is very complicate to produce, they need multiple forces to the hand including deceleration and rotation, even more enough forces to dislocate the keystone of the hand corresponding to the third CMC joint [8]. Gunther suspected a torsional force pushing the carpus to rotate on a fixed metacarpal base with the hand firmly fixed on the motorbike handle [7]. Anteroposterior radiographs showed apparent shortening of metacarpals and loss of parallelism between metacarpal bases and carpal bones, but CMC dislocation can be concealed by overlapping of the joints.

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