Management of Complex Hand Injuries with Suspension Interposition Arthroplasty and Carpometacarpal Joint Buttress Plating Based on Intra-operative Creativity and Flexibility: A Case Report

@#A young patient presented to our centre with swollen right hand following a motor vehicle accident. He was diagnosed with closed fractures of trapezoid, ulnar three metacarpal bones, radial styloid and ulnar styloid. The hand injuries were complicated with compartment syndrome. Emergent fasciotomy and application of external fixator of the hand were performed. Definitive fixation of the fractures was delayed due to the wound care post fasciotomy. During the definitive fixation of the hand, the trapezoid was found to be comminuted and completely extruded. Abundant callus was found at the fracture sites of the metacarpal bones. Anatomic fixation was not feasible. Principle-based intra-operative creativity and flexibility were of great significance in the unconventional fixation of the complex hand injuries described in this case report.

Clinical Experimental Treatments for Arthrosis of the Carpometacarpal Joint of the Thumb Using Kampo Medicine / 日本東洋医学雑誌

Arthritis of the carpometacarpal joint of the thumb is typically treated with oral anti-inflammatory drugs, external medicines, and temporary external fixation. We report 3 cases of arthritis of carpometacarpal joint of the thumb that were successfully treated with sokeikakketsuto. In cases 1 and 2, a 50-year-old woman and 68-year-old man, respectively, were diagnosed with arthritis of the carpometacarpal joint and were successfully treated with sokeikakketsuto. In case 3, a 66-year-old man complained of pain in the second carpometacarpal joint caused by gout, and was successfully treated with eppikajutsuto and daiobotampito. However, the pain in the carpometacarpal joint of the thumb due to arthritis remained, and was successfully treated with sokeikakketsuto. Eppikajutsuto and daiobotampito were effective for acute arthritis such as gout, and sokeikakketsuto was effective for osteoarthritis. Overall, patients with different diseases in the various local regions may have slightly different clinical presentations even in the same case.

Mini locked-plate trans-carpometacarpal joint internal fixation for treating comminuted fracture of base of the fifth metacarpal / 中国修复重建外科杂志

Objective: To evaluate the effectiveness of open reduction and trans-carpometacarpal joint internal fixation with mini locked-plate for treatment of comminuted fracture of base of the fifth metacarpal. Methods: Between July 2015 and December 2017, 8 cases of comminuted fractures of base of the fifth metacarpals were treated with open reduction and trans-carpometacarpal joint internal fixation with mini locked-plate. There were 7 males and 1 female with an age of 19-45 years (mean, 32.5 years). The causes of injury included 2 cases of hitting hard objects while clenching fist, 6 cases of falling injury. There were 2 cases of subluxation of fifth carpal joints and 1 case of dislocation. The time from injury to operation was 1-5 days (mean, 3.5 days). The stability of fracture ends could not be maintained by preoperative evaluation without over articular fixation or short time over articular fixation. Postoperative complications and fracture healing were observed, and hand function was evaluated at last follow-up according to the total active motion (TAM) recommended by the Branch of Hand Surgery of Chinese Medicine Association. Results: All the incisions healed by first intention without complications such as wound infection, cutaneous necrosis, tendon or nerve injury. All the patients were followed up 6-18 months (mean, 12 months). All fractures healed with the healing time of 12-16 weeks (mean, 13 weeks). Within 4 months after operation, all patients were able to return to pre-injury job. At last follow-up, according to the TAM recommended by the Branch of Hand Surgery of Chinese Medicine Association, the results were excellent in 7 cases, good in 1 case, with the excellent and good rate of 100%. Conclusion: Applying of mini locked-plate for treatment of comminuted fractures of base of the fifth metacarpal, of which cannot obtain stable fixation through non-transarticular or short-time transarticular fixation, can achieve satisfactory functional results with very few complications through trans-carpometacarpal joint approach, thus the procedure can be used as an alternative operation scheme.

Evaluation of Anti-Subsidence Effect of Abductor Pollicis Longus Suspensionplasty in Carpometacarpal Arthritis of the Thumb

PURPOSE: To evaluate the anti-subsidence effect of suspensionplasty using abductor pollicis longus (APL) tendon in carpometacarpal (CMC) arthritis of the thumb. METHODS: From June 2009 to May 2016, hematoma distraction arthroplasty (HDA; group A, 10 cases) and HDA with suspensionplasty using APL tendon (group B, 7 cases) were performed in total 17 patients with CMC arthritis. The K-wire was fixed from 1st metacarpal to 2nd metacarpal in both group to maintain the empty space for 6 weeks until the fibrous tissue fill the space. We measured the preoperative trapezium space height with picture archiving and communication (PACS) system and compare the height with that was measured postoperatively. Additionally the subsidence rate checked sequentially with follow-up plain radiography. RESULTS: The subsidence ratios (subsidence/trapezium height) were average 33.2% in group A and 31.4% in group B. There is no statistical difference between two groups. Six weeks after pin removal almost of subsidence occurred, and then from 3 months after surgery to 6 months after surgery, few subsidence was occurred and it is average only 8% of total subsidence. The trial of distraction the empty space when perform the Kirschner wire (K-wire) fixation, it does not influence the prevention of subsidence. Between distraction height and subsidence, there was no statistical relevance. CONCLUSION: Although suspensionplasty was known as one of methods to prevent the subsidence, it is thought to be not very helpful method to prevent subsidence of thumb in CMC arthritis.

Chronic Instability of the Carpometacarpal Joint of the Thumb after Trauma: A Report of 3 Cases

Posttraumatic instability of the carpometacarpal joint of the thumb are rarely reported. Consequently little is known about clinical and radiologic diagnosis, natural progress or treatment method. We report three cases of chronic instability of the carpometacarpal joint of the thumb treated with Eaton and Littler's ligament reconstruction. Satisfactory thumb functions were restored without arthritic change or recurrent subluxation.

Results of Abductor Pollicis Longus Suspension Ligamentoplasty for Treatment of Advanced First Carpometacarpal Arthritis

BACKGROUND: Suspension ligamentoplasty using abductor pollicis longus (APL) tendon without bone tunneling, was introduced as one of the techniques for treatment of advanced first carpometacarpal (CMC) arthritis. The purpose of this study was to evaluate the radiologic and clinical results of APL suspension ligamentoplasty. METHODS: The medical records of 19 patients who underwent APL suspension ligamentoplasty for advanced first CMC arthritis between January 2008 and May 2012 were reviewed retrospectively. The study included 13 female and 6 male patients, whose mean age was 62 years (range, 43 to 82 years). For clinical evaluation, we assessed the grip and pinch power, radial and volar abduction angle, thumb adduction (modified Kapandji index), including visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Radiologic evaluation was performed using simple radiographs. RESULTS: The mean follow-up was 36 months (range, 19 to 73.7 months). Mean power improved from 18.3 to 27 kg for grip power, from 2.8 to 3.5 kg for tip pinch, and from 4.3 to 5.4 kg for power pinch. All patients showed decreased VAS from 7.2 to 1.7. Radial abduction improved from 71degrees preoperatively to 82degrees postoperatively. The modified Kapandji index showed improvement from 6 to 7.3, and mean DASH was improved from 41 to 17.8. The height of the space decreased from 10.8 to 7.1 mm. Only one case had a complication involving temporary sensory loss of the first dorsal web space, which resolved spontaneously. CONCLUSIONS: The APL suspension ligamentoplasty for treatment of advanced first CMC arthritis yielded satisfactory functional results.

Fourth and Fifth Metacarpal Base Arthrodesis for Posttraumatic Arthritis of Fifth Carpometacarpal Joint

Posttraumatic arthritis of the fifth carpometacarpal joint occurs as a sequelae of intraarticular comminuted fracture or missed and untreated fracture. If it is inappropriately managed, persistent pain and functional disability of the hand can occur. Arthrodesis, resection arthroplasty, or interposition arthroplasty has been reported as the treatment for the arthritis. However, outcome studies for operative treatment of the fifth carpometacarpal arthritis have been rarely reported. We report a case of the fifth carpometacarpal arthritis occurred after missed fracture, which was successfully treated with fourth, fifth metacarpal base arthrodesis.

Arthroplasty for Neglected Dislocation of the Carpometacarpal Joint of the Thumb: A Case Report

Pure dislocation of 1st carpometacarpal (CMC) joint is uncommon and may be missed initially. The neglected dislocation of 1st CMC joint can be reduced by open method and required capsular repair or ligament reconstruction for stability of 1st CMC joint. We experienced the patient with an old dislocation of 1st CMC joint which was recognized 9 months after the injury. Open reduction was impossible, therefore we treated by the trapezial excision and ligament reconstruction tendon interposition arthroplasty, resulting in painless functional joint.

Bilateral Carpometacarpal Joint Dislocations of the Thumb

A traumatic carpometacarpal joint dislocation of the thumb accounts for less than 1% of all hand injuries. Optimal treatment strategies for this injury are still a subject of debate. In this article, we report a case of bilateral thumb carpometacarpal joint dislocations: a unique combination of injuries. We believe our case is the second report of bilateral carpometacarpal joint dislocation regarding the thumb in English literature. It was successfully treated with closed reduction and percutaneous K-wires fixation on one side, and an open reduction and reconstruction of the ligament on the other side.

Volar Ligament Reconstruction or Trapeziectomy for Thumb Carpometacarpal Joint Osteoarthritis

PURPOSE: The purpose of this study was to evaluate surgical outcomes of thumb carpometacarpal osteoarthritis treated either by volar ligament reconstruction or trapeziectomy with suspensionplasty. MATERIALS AND METHODS: From July 2004 to January 2011, we treated 43 patients with thumb carpometacarpal joint arthritis by volar ligament reconstruction in stages I and II, and by trapeziectomy with suspensionplasty in stages III and IV. Out of the 43, we evaluated 19 patients (9 treated by volar ligament reconstruction, 10 treated by trapeziectomy with suspensionplasty) at an average of 36.8 months (range: 8 to 65 months) after surgery. Outcome measures included pain visual analogue scale (VAS), ranges of motion, and grip and pinch strengths. RESULTS: The mean VAS was 1.2 in the volar ligament reconstruction group and 2.0 in the trapeziectomy with suspensionplasty group at final follow-up. The ligament reconstruction group had significantly better thumb radial abduction and opposition ranges of motion, and key grip strength. No further radiographic arthritic changes were noted in the ligament reconstruction group at a mean follow-up of 39 months. CONCLUSION: The authors obtained satisfactory pain control in patients with thumb carpometacarpal osteoarthritis by volar ligament reconstruction for stages I-II and trapeziectomy with suspensionplasty for stages III-IV.

Artrodese do punho com fixação mínima preservando as articulações carpometacarpianas / Wrist arthrodesis with minimal internal fixation preserving the carpometacarpal joints

OBJETIVO: Artrodese do punho é uma cirurgia que deve ser sempre considerada em casos de patologias que alteram sua estrutura anatômica e funcional. Em geral os resultados são muito satisfatórios, principalmente no alívio da dor e na maioria das vezes a melhora funcional é considerável. Existem várias técnicas descritas, com variações no método de fixação interna e a maioria delas incluindo as articulações carpometacarpianas na fusão. O objetivo deste estudo é avaliar os resultados da artrodese do punho com uma técnica mais simples, mais biológica, menos dispendiosa e que não inclui as articulações carpometacarpianas. MÉTODOS: foram avaliados 15 pacientes (seis sequelas de traumatismo, quatro de artrite reumatoide, três de Kienbock grau IV, um de Preiser e um de pan-artrose). A técnica consistiu no uso de placa óssea do ilíaco e fixação com fios de Kirschner, sem incluir as articulações carpometacarpianas. RESULTADOS: A avaliação foi feita conforme o tempo de consolidação (93 por cento em sete semanas); movimentos dos dedos e de pronossupinação; da força de pinça e preensão; avaliação funcional pelo questionário DASH, da dor e satisfação dos pacientes. Em geral, os resultados foram semelhantes aos das outras técnicas mais agressivas e a não inclusão das articulações carpometacarpianas na artrodese não afetou o resultado final. CONCLUSÃO: A artrodese do punho com fixação através de fios de Kirschner e uso de placa óssea do ilíaco preservando as articulações carpometacarpianas dá resultado bom ou excelente, não inferior ao de outras técnicas descritas. Apresenta, porém uma grande vantagem sobre as demais: é menos agressiva, mais barata e não apresenta os inconvenientes do uso de placas e parafusos sujeitos a maiores complicações

OBJECTIVE: Wrist arthrodesis is a surgical procedure that should always be considered in pathologies where there is alteration of the anatomical and functional structures. In general, the results are very satisfactory, particularly for pain relief, and in the majority of cases, there is considerable functional improvement. Various techniques are described, with different methods of internal fixation, most of which include the carpometacarpal joints (CMJ) in the fusion. The objective of this study is to evaluate the results of wrist arthrodesis through a technique which is simpler, more biological, more inexpensive, and does not involve the carpometacarpal joints. METHODS: 15 patients with wrist arthrodesis were evaluated (6 with sequelae of trauma, 4 Rheumatoid Arthritis, 3 Kienbock's grade IV, 1 Preiser and 1 panarthrosis). The technique consisted of the use of an iliac bone plate and internal fixation with Kirschner wires, avoiding the carpometacarpal joints. RESULTS: The evaluation was based on consolidation time (93 percent in 7 weeks); movements of the fingers and pronosupination; pinch and grasp strength; functional evaluation through the DASH questionnaire, pain and patient satisfaction. In general, the results were similar to those of other, more aggressive techniques, and the non-inclusion of the carpometacarpal joints did not affect the final result. CONCLUSION: wrist arthrodesis with fixation using Kirschner wires and the use of an iliac bone plate, preserving the carpometacarpal joints, gives good or excellent results which are similar to those of other techniques described. However it presents major advantages over other methods: it is less aggressive, less expensive, and does not have the inconvenience and complications associated the use of plates and screws.

Carpometacarpal Joint Dislocation of the Thumb Associated with Fracture of the Trapezium: A Case Report

We report a dislocation of the thumb carpometacarpal joint associated with an oblique fracture of the trapezium. This case was treated with open reduction and internal fixation using two Kirschner wires for the trapezial fracture and repair of the ruptured dorsal capsular ligament and additional Kirschner wire fixation for the carpometacarpal joint stability. At the 12 months follow-up examination, there was no pain or chronic instability. There was no evidence of post-traumatic arthritic changes.

Operative Treatment of the Fracture and Dislocation of the Fourth and Fifth Carpometacarpal Joints Simultaneously: Two Cases Report

Simultaneoulsy carpometacarpal fracture and dislocation is known to be uncommon past days. But Fisher1 reported that it is quite common injury of hand in 1984. Also high energy injury causes carpometacarpal joint fracture and dislocation, the result of treatment has wide spectrum of prognosis, so early diagnosis and treatment is essential. We reported 2 patients who had the fourth and fifth carpometacarpal fracture and dislocation.

Fracture-Dislocation of the Carpometacarpal Joint with the Fracture of Hamate

PURPOSE: To evaluate the classification and treatment results about the injury of carpometacarpal (CMC) joint with the fracture of hamate. MATERIALS AND METHODS: The authors categorized into 3 types (I, II, III) according to the location of injured CMC joint and type II was subdivided into 2 type (a, b) according to the size of coronal fragment of hamate fracture-type I: fracture-dislocation of 5th CMC joint with small-sized fragment or avulsion fracture of hamate, type IIa: fracture-dislocation of 4th and 5th CMC joint with small-sized fragment or avulsion fracture of hamate, type IIb: fracture-dislocation of 4th and 5th CMC joint with coronal fracture of hamate body presenting an oblique or coronal splitting fracture, and type III: type II injury associated with injury of 3rd CMC joint or coronal plane fracture of capitate. All cases were carried out the operative treatment. And radiologic results and clinical results were evaluated. RESULTS: Type I were 2 cases, type IIa 4, type IIb 5, and type III 3. Twelve of 14 cases were excellent or good results, 1 case (type III) was fair, and 1 case (type IIa) was poor. All cases obtained anatomic reduction of CMC joint. But, the posttraumatic arthritis was observed in 1 case (poor) and the displacement of non-fixed hamate fragment was observed in 1 case (fair). CONCLUSION: We think that it may get more favorable outcomes by the fixation of the relative large fragment of hamate with anatomical reduction of CMC joint.

Operative Treatment in Fracture-Dislocations of Carpometacarpal Joints

PURPOSE: To present our operative experiences with carpometacarpal (CMC) injuries, excluding thumb. MATERIALS AND METHODS: Thirty four fracture and dislocations of CMC joint excluding thumb were reviewed retrospectively. Emphases were placed on injury mechanisms, anatomical location, times between diagnosis and surgery, treatment and complications. RESULTS: The average age of patients was 31.5 years. 19 cases of axial loading by blow as an injury mechanism. The 5th CMC joint was found to be the most frequently involved single joint (18 cases of 34 cases). Dorsal dislocation of CMC joints was present in 12 cases. Comminution of the carpal or metacarpal bone was present in 18 cases. The average time to surgery was 6 days. Twenty-seven cases were operated upon by closed reduction and percutaneous pinning. Seven cases were treated by open reduction and internal fixation. In the last follow up period, a clinically full hand function was restored in 31 cases. Intermittent pain was present in 6 cases in which there was grip weakness in 4 cases and limitation of motion in 3 cases. However, all cases were able to activities of daily living. CONCLUSION: We obtained good outcomes in CMC joint injuries through the accurate diagnosis and proper operative treatment.

Fractures of the Wrist and Hand after Punching Injury / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to describe the patterns and results of treatment of fractures of the hand and wrist after punching injury. MATERIALS AND METHODS: The authors retrospectively reviewed 91cases of fractures of the hand and wrist after punching injury in 67 patients from January 1998 to September 2002. The mean follow-up was 18 months. The mean age was 25.7 years old, ranging from 11 years old to 41 years old. The results were evaluated by modified criteria of Bruce and Maudsley. RESULTS: The most common fractures were metacarpal base fractures (42.9%), and the second most common fractures were distal metacarpal fractures (19.8%). Metacarpal base fractures were usually combined with dislocation of carpometacarpal joint, especially in the fourth and fifth metacarpal bone and single fifth metacarpal bone (29.7%). There were a few complications of limitation of motion (4 cases), pain (1 case), angular deformity of distal metacarpal bone (1 case), malunion of metacarpal shaft (2 cases) and nonunion of metacarpal shaft (1 case). There were excellent results in 84 cases, good in 4 cases and fair in 3 cases. CONCLUSION: The most common fractures after punching injury were metacarpal base fractures, especially the forth and fifth metacarpal bone. Distal metacarpal and metacarpal shaft fractures were mostly single fractures. There were diverse patterns of fracture-dislocation of the hand and wrist after punching. We must be careful to evaluate combined injury when a patient visits after punching injury.

Fracture and Dislocation of Carpometacarpal Joint Excluding Thumb / 대한정형외과학회잡지

PURPOSE: We present our operative experiences with uncommon carpometacarpal (CMC) injuries, excluding the thumb. MATERIALS AND METHODS: Twenty four fractures and dislocations of the CMC joint excluding thumb, which were followed up for an average of 18 months were reviewed retrospectively. Emphases were placed on associated injuries, radiographic findings, treatment and complications. RESULTS: The average age of patients was 35 years with 14 cases of indirect trauma as an injury mechanism. Eighteen of 24 cases involved the 4-5th CMC joint, one case involved the 2-3rd joint and one case involved the 3-4th joint. In addition, there were 4 cases that involved all of the CMC joints. Seven cases were operated upon by closed reduction and percutaneous pinning, 16 cases were treated by open reduction and internal fixation, and 1 case received fusion for neglected injury. Eighteen cases had satisfactory results, 2 cases had residual pain, 2 cases showed a limitation of motion and 2 cases had grip weakness. CONCLUSION: Proper diagnosis and treatment of CMC joint injuries can reduce complications and avoid additional procedures.

Closed Reduction and Percutaneous Pinning in Fracture-Dislocations of Carpometacarpal Joints / 대한정형외과학회잡지

PURPOSE: There is little information about the treatment of carpometacarpal (CMC) fracture-dislocations. The purpose of this study was to investigate treatment methods and times between diagnosis and surgery in CMC fracture-dislocations. MATERIALS AND METHODS: In 18 cases treated by surgery, the 4, 5th CMC joints were found to be the most frequently involved in 13 cases. Comminution of the carpal or metacarpal bone was present in 8 cases. The time to surgery was within 3 days in 10 patients, within 5 days in 6, within 9 days in one patient and more than 4 weeks in one. All the injuries were managed by closed reduction and K-wire fixation except for one which was detected after 4 weeks since initial trauma. RESULTS: A painless full hand function was restored in 13 cases. Intermittent pain was present in 5 cases in which there was comminution in 4. However, clinically full hand function was restored in 4 cases except for one in whom the treatment was delayed. CONCLUSION: If the treatment of CMC fracture-dislocation is not delayed a successful result can be gained using the closed method even though comminution occurs.

Isolated Simultaneous Dislocation of All Five Carpometacarpal Joints: A Case Report / 대한정형외과학회잡지

Isolated dislocation of all five carpometacarpal joints is extremely rare, only eleven cases had been reported since 1873. In Korea, we have not seen it probably. We experienced one case of isolated dislocation of all five carpometacarpal joints with a good result in I year after closed reduction and internal fixation.

Multiple Carpometacarpal Dislocations: A Report of 2 Cases / 대한정형외과학회잡지

Carpometacarpal dislocations occur in less thsn 1% of osseous hand injuries. Sine Dec. 1987, two cases of multiple carpometacarpal dislocations were treated at Hanyang University Hospital. All of these were successfully treated by closed reduction and percutaneous pinning with K-wires. Follow-up periods were 6 months and 5 months respectively. All patients were asymptomstic, but one patient had occasional discomfort and diminished grip strength.