This case report describes a young patient who presented with two irreducible dislocations - a dorsal compound complex dislocation of the right index finger metacarpophalangeal joint associated with fractures, and an irreducible closed dorsal dislocation of the left little finger metacarpophalangeal joint. The dislocations were successfully reduced through open reduction surgery using a volar approach and Kirschner wires, which were removed four weeks later. The patient recovered full range of motion in both fingers.

1. -
CASE REPORTS
DORSAL IRREDUCIBLE COMPOUND COMPLEX
DISLOCATION OF THE METACARPOPHAI-ANGEAL JOINT
OF THE INDEX WITH A CLOSED IRREDUCIBLE
DISLOCATION IN THE CONTRAI-ATERAL LFTLE FINGER.
A Case Report and Literature Review.
Freih Abu Hassan A, Shaher El-Haddidy.
ABSiTRACT
A young patient had a Dorsal lrreducible Compound Complex
Fracture aiAocatidn of the index finger, with an epiphyseal iniury ot the head
of the third metacarpat bone tqether , togather with green stick tracture of
the distal radial and ulnar metaphyseal region. This was associated with an
irreducibta ctosed complex do(al dislocation of the little tinger in the
nntralateral hand.
The patient presented a month late, the dislocation were suwssfully
reduced by'open rbduction using the volar qproach, and maintained by
Krdtner Wires, which were removed tour weel<s later.
INTRODUCTION
Reports of the complex dislocations of the
metacarpophalangeal joints are not common, but fracture dislocations
are rar-e.
'The
compound element with a late presentation makes
this entity rather u"ry r"r"(
1' 3
'
4' 6' 10' 12' 13' 14' 15'20'23'24'25)'
The mechanism of iniury ol the complex dislocation is forced
hyperextension of the proximal phalanx in a fall on the hand which results in
pushing the metacarpal head through the volar Joint capsule
( 20 ).
The lrreducibility of the dislocations were attributed to many factors :
1. Wedging of the fibrocartilagenous volar plate within the ioint
( 3't+'16'20 ).
2.Trapping of the Metacarpal head by the palmar fascia and the transverse
metacarpal ligament
( 3
'20 )
3. Displaced flexor tendons which becomes dorsal to the metacarpal
tread(3'20).
Correepondence should bo addreeeed to :
Dr. Freih Abu Hassan, Jordan University Hospitaf, Amman, Jordan.
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JORDAN MEDICAL JOURNAL voL. 26 NO. 2.NOV.1992
Also there are rare caus€s ol obstruction, such as :
a. The dorsal aponeurosis
( 1 ) .
b. A pinched sesamoid bone in children above 10 yesrs
( 22 ).
This type ol dislocarion
( 20 ) is diagnosed as the lollowing ground :
t. Ciinic*ty - Shofi, ulnar deviation and rotation of the finger.
- Semi flexed finger in proximal and distal interphalangealjoints.
- No movement ol the dislocated joint can be elicited.
- The rnetacarpal head can be palpated just beneath the distal part ot
the palm.
- Dimpling of lhe palmar skin is usually observed.
ll. Radiologically (anterio - postedor, lateral, and oblique films ) :
- Dorsal and ulnar dislocation of the base of the proximal phalanx.
- Wderpd space between the metacarpal heads
( second and thkd in cases of index finger ) ,
( fourth and fifth in cases of llttle lingor ).
Gaee Repon
An eleven-year-old male student was admitted to the hospital as a
case of fallen down from about three meters height. The patient was
diagnosed to have the following prcblems :
1) Head injury manifested by : Semiconsciousness , bleeding lrom both
nostrils., dilated & fixed left pupil, haematoma over the lett forehead and
Glasgow coma scale reoorded as 10/15.
2l Abdominal injury were manifested by : Guarding and rigtdity of the
abdomen. The peritoneocentesis revealed frank blood.
3) Deep cul wound, about two centimeter over the volar aspect of the
metacarpophalangealjoint ol the right index linger.
lmmediate surgery was done : He undenrent splenectomy for splenic
injury. Three bun holes were performed on the lett side and were negative,
he also had debridement and closure of the cut wound ol the right palm. The
patielt recovered well and was transferred to the lcU. He was mecfranically
-ventilated for 48 hours , then he stayed for five days in the normal ward.
The patient discharged home on the seventh post operative day to be seen in
the outpatient Department,
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3. DORSAL IRREDUCI BLE DISLOCATION
JOINT OF INDEX IN LITTLE FING.ER.
F.ABU HASSAN & S.EL-HADIDY
After two weeks of discharge the patient was transfened to the hand
service complaining of p"in and d6formity of both hands. On examination :
the patient haO upper-ielpi;;t"ty ttact intei,tion whicfr added another week of
delay in management. ifie rign[ nand and forearm showed delormity of the
tnJ"i fing"t in-tne torm oiHyperextensjg.n of the metacarpophalangeal jopt'
i6iaiion
-or the fingei ou"'iine mioote tinger, no moJement ol the
metacarpopnaangeiiioint, shortening and ulnar ward deviation of the finger'
"""ibf
'pr6viousti
ruirr"O cut wouid over the.palm, complex irreducible
ii["r'rld"ture oistocatf; ;i the metacarpoptialangeal- ioint ol the index
f Fig. z, 3 ), salter and Hanis type il epiphyseal fractures_of the middle finger
l""i""irpii head ( Fig, t, i').anO'g.t;"n stick fractures in the distal
6;iillfiG ;l-botti radjus inO irlna wiih minimal displacement and good
callusformation (Fig. 1' 2 ) .
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Figure ( 1
Figure ( 2 |
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JORDAN MEDICAL JOURNAL voL. 26 NO. 2.NOV.1e92
Also, examination of the lett hand revealed a deformity of the little linger in
the form of ulnar wards rotation and hyperextension of the
metacarpophalangeal joint, together with a prominent palpabb head of the
litth metacarpal over the volar aspect of the joinl and a dosed complex
ineducible dorsal dislocation ol the metacarpophalangeal joint of the little
finger with Salter and Harris type ll epiphyseal fracture of the fifth rnetacar?al
epiphysis(Fig.4).
Figure ( 3 )
Figure ( 4 )
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5. r
DORSAL IRREDUCIBLE DISLOCATION
JOINT OF INDEX IN LITTLE FINGER.
F.ABU HASSAN & S.EL.HADIDY
Open reduction was elected as the method of trqatment using the
volar Kaplan's approach
( to )
-d if needed to use the dorsal Farabeuf's
incision ( Fig. a, I ) ;the technique of tre operation irrclude the following :
- ldentllicatlon and rebaction of the Neurovascular bundle.
- The superlicial transverse metacarpal ligament had to be incised to
facilitate the exposwe & re<luction.
- Release ol A1 pulley showed enlrapment of the volar plate inside the ioint.
- Using a blunt hook and some dissection the volar plate was removed
from the inside of the ioint.
- Reduction of the dislocation was easy without lhe need of.the dorsal
incision.
- Repair of the volar plate to its insertion on lhe metacarpal nodc
- Kirscfiner wire was used to maintain the reduction in moderate flexion of
the metacarpophalangeal joint.
The Little finger of the left hand was managed by Volar approach and
without need for the dorsal approach Also, Kirschner wire was used to
maintain the reduction.
Patient was discharged home on the second post operative day. The
Kirschner wires were removed at four weeks but the Volar Slab was kept lor
another two weeks. After that an intensive exercise program was started.
Eight weeks post operatively the patient recovered with a good and full range
of motion. Six months post operatively, he had full range ol motion, !;ood
scare ( Fig 5 , 6, 7 ) and he is play{ulas ewr.
Figure ( 5 )
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JORDAN MEDICAL JOURNAL
Ftgure ( 7 )
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DORSAL IRREDUCI BLE DISLOCATION
JOINT OF INDEX IN LITTLE FINGER.
F.ABU HASSAN & S.EL.HADIDY
DrscussloN
Ineducible dislocation of the metacarpophalangeal ioints were first
described in 1855 by Malgaigne
( 17 ). The term coqp]?x dislocation was
coined by the French surgeon Farabeul in 1876
1e) an9 the dorsal
approach is stitt called the Farabeuf 's dorsal incision
( Q 9 ).. tt'" tsrm
T[|fi6;-, (-b;aG;l ir,ir'mi,lripre _anitomic
srrucrures whicfr block the
reOuctiin 1 wis introduced to the. English Literature in 1888 and 1910 by
Battle(
7 ) and Barnard
(5 )
,"rp*riwly.
Thepatho|ogicanatomywasnotwide|yappreciatedunti|
Kaplan
( la)in 1957 described the button holing of.the metacarpal.head
i#ffih the voiarplate,wnict
-Uieafs
away at its weakest attac{rment to the
neck of the votar aspect of the metacarpal bon€ , |.]t'.*9. into the palmar
ItiuituidJ *tricrr ne'catleo ttte cfrineso iinger traplike.
-lo9ki.ns
mechanism'
These complex structures were demonstrated properly
( 3' 20 )
'
Recent studies showed that it is most frequently affecting the
index
( 1' 3' 4' 8' 12' 13' 14'?f.'tt), fol6*"d bythethumb,
(1a'21)
tten by
the little finger
( 5
'7'13 ) '
23 ) the middle and dng finger are being the
. ( 1,3,4,7,12,13)
rare6t
lmbriglia and Sciuli concluded that the border-digits-were rnore otten
attected Ueci-use of inJpnysical vulnerability and lack ol stabilization of the
adjacent intermelacarpal ligamenF
( 13 ).
Asscociated volar wound with the irreducible dislOcation are
,"r"
(to' 1t ) . Th" oombination of a complex compound irreducible dorsal
dislocation together with a fracture was reported- byviegas 9'"l
( a )*he'e
;-t"-rfii iuiiiineO I iomptex compdund frahura dislocation of the
ri"""rpophalangealioint ot ine fttn finger with a cominuted fracture of the
proximal phalanx . In 1988 gglan.et 9l ' ls ).reportedloYlgTg oJ gqmplgl
illedutiUie
-Oislocaiion-
oiiil index metaiarpophalangeal ioint with
Osteoctrondral fractures which were treated by open surgery'
Late presentation of the irreducible dislocation of the
metacarpophalingeal ioints are rare reaching up to few months
( 4'5'6'8'20' 21'24'25 ).Th" l"t" presentation is attributed to delayed palient
advice
( s )
"nd
failure of proper reduction by using lateral
"ppro"rr,
( m ).
]t is thought that the prognosis was poor il the treatment
of the Oislocaiion started
'thiee weeks or more following
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8. JORDAN MEDICAL JOURNAL voL. 26 NO. 2.NOV.1gg2
inlury
( 3'4'5'8'15'20'24'25)
, MC Lar4ghlin proposed a pdmary artrrodesis as
the best treatment
( 18 )
, while other advocated metacarpal head
,"u""tion
( 21 ).
' Delayed cases could be also treated suecess fully with open
reduc{ion using modilled Kaplan's volar approacfi with radial extension
( & )
or exlended midlaterally or medially
(24'25 ).
rn" Association with arm
bones fractures were previously reported
( 121
Ou cass presented the
oombination of ineducible dorsaldislocation with epiphyseal lractures type ll
together with green sick fracturos of both radius and ulna with a vdar healed
wound.
Although lhe surgical management of chronic dislocation in
associated with a limited movernent of the metacarpophalangeal ;oint
( m )
and ischaemic necrosis ol the metacarpal head
( 3' 15 ) . Our case
demonstrated that chronic dislocation can still be succeselully managed by
an open method wilhout the need to resort to arthrcdoels or resection.
REFERENCES
1. Adle, GA ; and Llght TR. : Simullanoous oomplex dislocation of the
metacarpophalangoaljoinb ol the long and index fingers. J.Bone Joint
Surg. ( AM ) d?: 1007€, 1981.
2. Arbdtlang, E ; and Torian,.E. : lrreponible finger Luxationen Mschr.
Lffidl Heik. ffi,45 - 7, 1963.
3. Badwln, L.W., lllller, DL., Lockha$ DL., et el.: lrletacarpophalangeal
joint dislocation of the finger. J. Bone Joint &trg. ( Am ) 4tl :1587 - 90
1967.
Barcnfeldd, P.A., and Werclcy ll.S.: Dorsal dislocation of the
metacarpophalangeal joint. Glinknl Orhopaedics and related rosoarch,
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Barned , HL : Dorcal dislocatbn of the first phalanx of the little linger ;
reductkrn by Farabanf's dorsal incidon. Lawt;1 :88 - 90, lg)t.
Barton, N. : Fractures and joint injurieo of the hild Waston-Jones :
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Editlon, Churchill Uvingstone 1982.
Battle , W.l{.: Back Ward Dlslocatlon of the fingers upon the
metacarpus. The ratlef 2 :1283 - 4, 1988.
Bohart PG ot d.: Complex dislocations ol the mqtacarpophalangeal
loint. Operative reduction by Farabeuf's dorsal lnclsion. Clin. Orthop.
1O4 :208-10, 1982.
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9. DORSAL IRREDUCI BLE DISLOCATION
JOINT OF INDEX IN LITTLE FINGER.
F.ABU HASSAN & S.EL-HADIDY
10. Fergueon, D., lloorg G.P. and tllcke K.A.: Dorsal dislocation of
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11. Green , DP., and Terry , GC. : Complex dislocation of the
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Joint Surg. ( Am ) 55;1480 - 6, 1973.
12. Hall, R.F., Glcacon , T.F., and Kata, R. : Simultaneous Glosed
Dislocatlons of the Metacarpophalangealjoints of the Index, long and
ring fingers. A Case Report . The Journal of Hand Surgery : 10 A : ( 1 )
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13. lmbrlglla, JE, and Sclull, R. : Open complex metacarpophalangeal
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4:72- 5,1979.
14. Kaplan , EB. : Dorsal dislocation of the metacarpophalangealjoint of
the index finger. J.Bone Joint Surg. ( An ) 39 : P 1081 - 6, 1957.
15. Llght, T.R. , and Ogden , J.A. : Complex dislocation of the index
metacarpophalangeal joint in children. Journal of Pediatric Orthopaedics,
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16. Leclere' R.: Luxations de I'index sur son metacarpien. Rev. dOrhq.
2:227 - 42,1911.
17. llalgaigne , J.F. : Traite des fractures et des luxations. Paris . J.B.
Baillere, 1855.
18. McLaughlln , HL. : Complex n locked ' dislocation of the
metacarpophalangealjoints. J. Trauma5 : 683 - 8.
19. Milford, Lee. : The hand in Campbell , s Operative Orthopedics ,
Edited by A.H. Crenshaw F:d.7. p. 247 -245 St. Louis. G.V. Mosby ,
1987.
n. Murphy AF. , and Stark HH.: Closed dislocation ol the
metacarpophalangealjoint of the index finger. J.Bone Jolnt Surg. ( Am )
49 :1579-86, 1967.
21. Onuba, O., and Esrlet, A.: lrreducible Dislocation of the MP Joint of
the fhumb due to tendon interposition. Jwmal of Hand *trgory. 12 B : 1
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2.. Swelerlltsch, PR, Torg, JS, Pollack, H. : Entrapment of a sesamoid
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(An)51:995-B1969.
23. Vlegar , S.F.; Hears , T.O.; and Calhoun, H.: Complex fracture
dislocation of a fifth MP joint Case Report and Literature review.Ihe
Jwmal ot Ttauma. 29 ( 4 ) :521 -524, 1989.
24. .Wolov R.B. : Complex Dislocation of the Metacarpophalangealjoints
@thopdic Review. XVll ( I ):T7O -775.
?5. Wood, ll.B., and Dobynr, J.H. : Chronic Gomplex Dislocation of the
metacarpophalangeal joint. Report of three cases. Journal of Hand
Surgqry. 6:73- 76, 1981. -2A7-

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