Abstract
Although rare, thumb Carpometacarpal (CMC) joint dislocations can have significant complications which impact hand function. Optimal management is crucial in restoring pinch and grasp strength, but no agreement exists regarding treatment due to a paucity of literature on this subject. Systematic review was conducted involving non-operative and operative management of the CMC joint. 15 articles with a total of 60 thumbs were evaluated from published literature. 12/60 thumbs with isolated CMC joint dislocations were treated with closed reduction, with 4 cases needing additional ligament repair due to joint instability post-reduction. 51/60 of the isolated CMC joint dislocations had ligament reconstruction, with flexor carpi radialis tendon autograft (29/51) as the most popular option. 60/60 patients regained full function and stability of the CMC joint with significant pain relief. Although good surgical outcomes have been achieved, long term clinical outcome reporting is needed to develop a standardized approach to treatment.
Keywords: CMC dislocation, Thumb, Hand injury, Metacarpal fractures, Ligament reconstruction
1. Introduction
Isolated thumb Carpometacarpal (CMC) joint dislocations are rare injuries, accounting for less than 1% of all hand injuries.1 Optimal management is crucial in restoring pinch and grasp strength, but no agreement exists regarding treatment of these dislocations due to a paucity of literature on this subject. The purpose of this paper is to provide a comprehensive review of the current literature, summarizing non-surgical and surgical intervention strategies which may maximize the repair of thumb CMC joint dislocations.
2. Methods
2.1. Systematic review of the literature
The study protocol followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Search criteria and inclusion criteria were specified in advance. In June 2020, two authors (JSK and KH) independently queried the PubMed database with the following search terms: thumb CMC joint AND isolated traumatic dislocation OR ligamentous reconstruction. Inclusion criteria were studies published in the English language that described management of the thumb CMC joint. Selected articles were screened and cross-referenced to ensure the inclusion of all potential studies. The final articles included in the database were then reviewed for patient demographics, injury characteristics, and treatment strategies.
3. Results
The search query yielded 61 initial articles, of which 17 met inclusion criteria and were selected for review of full text (Fig. 1). After removal of 2 articles due to unextractable data, 15 studies were used for a PRISMA compliant systematic review of the literature – reporting 56 patients with a total of 60 thumbs (4 patients with both thumbs injured) treated for isolated CMC joint dislocation. The patient cohort was 64% female and 36% male, with an average age of 32.8 years (range: 18–56). Mechanisms of injury varied equally, with motorcycle accident, fall injury, and sport injury being the most common. Twelve out of 60 thumbs with isolated CMC joint dislocations were treated with closed reduction (20%), of which 4 cases needed additional ligament repair due to joint instability post-reduction. Eighty-five percent of the isolated CMC joint dislocations had ligament reconstruction (51/60), with flexor carpi radialis (FCR) tendon as the most popular option (29/51) followed by abductor pollicis longus (APL) tendon (15/51). Forty-six percent of the isolated CMC joint dislocations had trapeziectomy (28/60). All patients that were treated with either closed reduction, open reduction internal fixation, or ligament repair regained full function and stability of the CMC joint with significant relief from pain and symptoms (60/60). Of the 3 articles that reported Disabilities of the Arm, Shoulder and Hand (DASH), the mean post-operative score was 47.9. Detailed patient, injury and surgical characteristics are reported in Table 1 and Table 2.
Fig. 1.
PRISMA Flow DiagramPRISMA
(Preferred Reporting items for Systematic Reviews and Meta-Analysis) flowchart of the systematic literature review.
Table 1.
Patient Characteristics Study population demographics.
| First author (Year) | Type of Study | # of patients | Mean age (year) | Sex | Mechanism of injury/etiology |
|---|---|---|---|---|---|
| Jeong (2018) | Case report | 1 (2 operated thumbs) | 50 | M | Motorcycle accident |
| Lahiji (2015) | Case report and literature review | 6 | 25.8 | 2 F, 4 M | Trauma, motorcycle accident, skiing injury, sport injury |
| Kose (2015) | Case report | 1 | 26 | – | Motorcycle accident |
| Annappa (2015) | Case report | 1 | 47 | M | Motorcycle accident |
| Wollstein (2016) | Case report | 1 | 56 | M | Chronic thumb CMC joint dislocation, without h/o of trauma or isolated incident |
| Takwale (2004) | Retrospective Cohort Study | 26 | 31 | 19 F, 7 M | Fall injury, trauma, sport injury |
| Stauffer (2019) | Retrospective Cohort Study | 12 (15 operated thumbs) | 23.2 | 11 F, 1 M | Chronic CMC instability |
| Baker (2014) | Prospective Case Study | 1 | – | – | Eaton and Lambert Stage IV first CMC osteoarthritis with collapse of the trapezium |
| Chan (2013) | Case report | 1 | 22 | F | Accident (“opening a door at a funny angle”) |
| Matshuhashi (2010) | Case report | 1 | 18 | M | Subluxation following injury of the medial nerve recurrent branch (broken pieces of a bottle) |
| Suresh (2012) | Case report | 1 | 36 | – | Road traffic accident |
| Lyengar (2013) | Case report and literature review | 1 | 21 | F | Accident (forceful hyperextension of the digit) |
| Fotiadis (2010) | Case report | 1 | 27 | M | Fall injury |
| Kraus (2014) | Case report | 1 | 21 | M | Fall/sport injury |
| Slocum (2019) | Case report | 1 | 56 | M | Accident |
Table 2.
Injury and Surgical Characteristics Injury characteristics, treatment details, and clinical results.
| First author (Year) | Other injuries | Affected ligament | Treatment | Follow-up | Clinical results |
|---|---|---|---|---|---|
| Jeong (2018) | – | Dorsal ligament and volar oblique ligament |
|
16 months |
|
| Lahiji (2015) | – | Dorsal and oblique collateral ligament |
|
– |
|
| Kose (2015) | – | – | Closed reduction | 6 months |
|
| Annappa (2015) | – | Dorsal ligament complex |
|
2 years |
|
| Wollstein (2016) | – | – |
|
6 months |
|
| Takwale (2004) | – | Anterior oblique ligament | Ligamentous reconstruction with Flexor Carpi Radialis tendon | 4 years |
|
| Stauffer (2019) | – | – | Ligamentous reconstruction with Abductor Pollicis Longus tendon | Average 3.5 years (1.3–5.8) |
|
| Baker (2014) | – | – |
|
6 months |
|
| Chan (2013) | – | – | Manipulation under anesthesia | 2 months |
|
| Matshuhashi (2010) |
|
– |
|
7 months |
|
| Suresh (2012) | – | – | Closed reduction | 15 months |
|
| Lyengar (2013) | – | Anterior oblique ligament |
|
1 year |
|
| Fotiadis (2010) | – | Dorsoradial ligament |
|
3 years |
|
| Kraus (2014) | – | – | Closed reduction | – |
|
| Slocum (2019) | – | – | Closed reduction | 2 years |
|
DASH: Disabilities of the Arm, Shoulder, and Hand Questionnaire; VAS: Visual Analogue Scale; ROM: Range of Motion; CMC: Carpometacarpal; MCP: Metacarpophalangeal.
4. Discussion
4.1. Anatomy of the thumb CMC joint
CMC joint dislocation of the thumb is an uncommon injury because of its strong capsule-ligamentous structure. Unlike the interphalangeal joints and MCP joints, the CMC joint is a biconcave saddle joint capable of a wide range of motion.3 Because of the essential role the thumb plays in the majority of handling maneuvers from fine pinch to forceful grasp, loss of thumb function may impart up to 50% rate of upper extremity impairment.8 The thumb CMC joint is stabilized by sixteen ligaments, with anterior oblique ligament, dorsoradial ligament, 1st inter-metacarpal ligament, posterior oblique ligament, and ulnar collateral ligament being the main contributors.6 There exists some controversy about which ligament provides the most stability, but multiple studies identify the dorsoradial ligament as the main restraint to dorsal subluxation in both traumatic and degenerative conditions.3,7 In a cadaveric study of 38 thumbs, Strauch et al. found the largest degree of joint subluxation when the dorsoradial ligament was cut while all other ligaments were intact.16 These findings, which highlighted the importance of the dorsoradial ligament complex in CMC joint dislocations, were supported by several other biomechanical studies.17, 18, 19 Most CMC joint dislocations result from forceful flexion of the thumb metacarpal base and dorsal translation with or without an accompanying axial load.7 The volar capsule is reinforced by multiple ligaments and relatively stronger and thicker than the thin dorsal capsule; as such, an avulsion of the metacarpal base is usually seen.7
4.2. Clinical presentation
Understanding the pathophysiology of thumb CMC joint dislocations is important in determining appropriate management. The mechanisms of dislocation can be largely divided into posttraumatic and degenerative conditions. Injuries to the hand account for up to 15% of all sport injuries.9 These injuries are particularly prevalent in contact sports and in sports with a higher risk of falling, such as football, skiing, and biking.9 Motorcycle accidents are another major contributor to hand injury as noted in multiple case reports.2,10, 11, 12, 13, 14, 15 In particular, metacarpal fractures account for 30% of all hand fractures and are the most common injuries examined in the emergency setting.22, 23, 24 Injuries to the thumb CMC joint can be partial or complete, with partial being significantly more common.34 Complete injuries occur with axial force when flexed, resulting in dorsal dislocation and tearing of the dorsal radial ligament and anterior oblique ligament.34 CMC joint dislocations are most frequently associated with metacarpal fractures, namely Bennett and Rolando fractures. Degenerative conditions that can contribute to the thumb CMC joint location include osteoarthritis, synovitis associated with rheumatoid arthritis, and postmenopausal laxity.33 With the extensive motion allowed for in the CMC joint comes inherent instability. The continuous physical stresses on the base of the thumb make it prone to attenuation of the ligamentous structures and subsequent joint arthritis.20 The main consequences of CMC joint instability are pain, weakness, ecchymosis, and edema in the thenar region.33
4.3. Treatment approach
Relatively little agreement exists regarding optimal treatment options for thumb CMC joint dislocations. Many studies state that joint stability after reduction is the most critical factor when deciding whether to manage a dislocation with non-operative or operative treatment.2,34 If the joint is stable upon reduction, immobilization of the joint in a thumb spica cast for 4–6 weeks may be sufficient.2,34 Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections may be supplemented to alleviate inflammation and reduce pain.33 In most cases, however, the joint tends to remain unstable after reduction and surgical interventions are indicated.2,34 Though some may prefer conservative treatments, non-operative management of thumb metacarpal fractures has fallen out of favor for the purpose of preventing persistent articular incongruity and subsequent posttraumatic arthritis.21 Surgical options include closed reduction percutaneous pinning (CRPP) and open reduction internal fixation (ORIF).
The literature provides conflicting viewpoints on superiority of surgical technique. At a mean follow up of 7 years, Lutz and colleagues demonstrated no significant differences in clinical outcome or the prevalence of posttraumatic arthritis between those who received CRPP and ORIF in the treatment of Bennett's fracture.25 In contrast with such findings, Simonian and Trumble reported unsatisfactory outcome secondary to degenerative arthritis and recurrent instability in 50% of the patients who were initially treated with CRPP.26 These patients were able to achieve improved range of motion and pain relief after switching to early ligamentous reconstruction.26 In accordance with Simonian and Trumble, several other studies noted favorable clinical outcome with ligamentous reconstruction and underlined its importance in the setting of unresolving instability.4,27 Improved outcome after additional ligament repair in 4 out of the 12 thumbs that were initially treated with closed reduction demonstrated joint instability post-reduction. Regardless of the treatment strategy, the goal should be timely repair that prevents chronic joint instability and arthritic pain while maximizing return of function.11
Because thumb CMC joint dislocations result in ligamentous injury, ORIF is often performed with ligamentous reconstruction. Shah and Patel reported ORIF alone was not sufficient in treatment of the thumb CMC joint dislocation – highlighting the importance of simultaneous capsular and ligamentous reconstruction in restoring function.28 While there currently exists no universal protocol, FCR is a popular autograft option originally introduced by Eaton and Littler.29 FCR is considered as an excellent autograft choice because of its proximity to the dislocated site and its ability to correct hypermobility of the CMC joint. Several studies utilized FCR for ligamentous reconstruction and reported satisfactory results in re-gaining of full range of motion in the CMC joint, without pain or signs of subluxation.2,14,27,35 Other published treatment modalities regarding tendon autograft include APL tendon and palmaris longus (PL). The APL tendon was utilized by Stauffer and colleagues to successfully restore stability of the thumb CMC joint at the mean follow-up of 3.5 years.30 Baker and Sood used PL tendon to perform first CMC joint suspension arthroplasty and found improved pinch and grip strength without any complications at 6 months.31 In comparison with FCR and APL, PL was noted to be advantageous for allowing a surgical technique that anchors the first metacarpal in a more distal position.31 In our study, 85% of the isolated CMC joint dislocations had ligament reconstruction, with FCR as the most popular option (57%) followed by APL (29%). All patients that were treated with either FCR or APL demonstrated normal range of motion without tenderness or signs of instability, supporting the efficacy of both tendons in ligamentous reconstruction.
4.4. Post-operative management
Postoperative therapeutic management is vital in enhancing function and range of motion of the repaired thumb. Complications limiting range of motion can arise from either non-operative or operative management of the thumb dislocation; both tendinous adhesions from ORIF and post-injury stiffness from extended splinting can result in decreased range of motion.21 Once the reconstructed joint gets necessary rest, light to moderate exercises are encouraged to maintain the soft tissue flexibility.33 Wollstein and colleagues in a case report of a chronic thumb CMC joint dislocation showed the importance of exercises aimed at lengthening and strengthening the soft-tissue dynamic and static stabilizers of the joint.20 A systematic review of poor-quality studies by Feehan and Bassett suggested in simple closed metacarpal fractures, early motion (<21 days) of joints could help achieve earlier recovery of mobility and strength.32 However, it is important to note that the scientific validity of this claim has yet to be proven by higher quality studies.
4.5. Limitations
Currently, the literature lacks consensus on the main ligament stabilizer of the CMC joint and on the optimal management after dislocation. This is mainly due to the small number of case reports and retrospective studies due to the uncommon nature of thumb CMC joint dislocations. In addition, there exists a lack of uniform functional outcomes reporting. Quantified results of standardized methods such as DASH in measuring postoperative outcomes lack sufficient quantity of published literature in order to form a unified consensus on standard of care. Post-operative results reported in subjective terms like “satisfactory” cannot be appropriately assessed to draw precise conclusions. Lastly, there is a lack of quality of life reporting across the literature. Successful surgical outcome does not always translate to better functional outcome and quality of life. The primary goals of treatment are to help the patient return to their prior level of function with as much unrestricted motion as possible, and measures of quality of life can be used to evaluate the effect of treatment.
5. Conclusion
Despite being rare injuries, CMC joint dislocations of the thumb are important orthopedic complications that may have a significant impact on hand function. Good surgical outcomes have been reported in limited case reports, however heterogenous reporting of clinical outcomes in the literature underscore the need for improved quality of life and functional outcomes reporting with long term follow-up. Higher quality research, such as prospective cohort study and randomized controlled trial, is necessary to determine the best management technique.
Author Statement
Contributorship: JK and KH researched literature and conceived the study. JK performed systematic review and statistical analysis. JK wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.
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