High Yield Topics

DISLOCATIONS AND LIGAMENTOUS INJURIES OF THE DIGITS

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Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
> Table of Contents > SECTION
III – THE HAND > Trauma > CHAPTER 39 – DISLOCATIONS AND
LIGAMENTOUS INJURIES OF THE DIGITS

CHAPTER 39
DISLOCATIONS AND LIGAMENTOUS INJURIES OF THE DIGITS
Donald H. Lee
Robert J. Neviaser
D. H. Lee: Division of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, 35294.
R. J. Neviaser: Department of Orthopedic Surgery, George Washington University, Washington, D.C., 20037.

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Through a unique combination of sensibility, stability,
and mobility, the hand allows us to manipulate our environment. The
thumb’s mobile carpometacarpal joint and stable metacarpophalangeal
(MP) and interphalangeal (IP) joints allow both precision pinch and
power movements, including grasp. The stable carpometacarpal joints of
the index and long fingers provide for stability along the central
longitudinal axis of the hand, whereas the relatively mobile ring and
little carpometacarpal joints provide mobility to allow cupping or
flattening of the hand. The hingelike MP and especially the IP joints
allow the ability to grasp objects of varying size.
Because of the constant exposure of the hand to external
forces, dislocations and ligamentous injuries of the digital joints are
quite common (396,397). Proximal interphalangeal (PIP) joint injuries are probably the most common joint injuries in the hand (68,128).
Fortunately, in the acute phase, most digital dislocations and ligament
injuries can be treated by closed or nonoperative means. This chapter
discusses these topics by joint. The fingers are covered as one, except
where a specific injury to a specific joint in a specific finger
requires individual attention. The joints of the thumb are addressed
separately. A general treatment algorithm is provided at the beginning
of each section.
ANATOMY
All the IP and MP joints of the fingers and thumb are
similar in that their stability is provided by a series of ligaments.
The major stabilizers of these joints include the volar plate and the
collateral ligaments. The volar plate is a fibrocartilaginous structure
firmly attached to bone distally, with a filmy proximal recess. On the
sides of each joint are the collateral ligaments, which blend palmarly
with the accessory collateral ligaments. The shape of these collateral
ligaments varies from a slightly fanlike shape at the proximal IP level
to very fan-shaped at the MP joint.
INTERPHALANGEAL JOINTS
The proximal and distal interphalangeal joints are
similar in configuration. The PIP joint is a hinge or ginglymus joint,
consisting of a convex bicondylar proximal phalangeal head articulating
with the biconcave middle phalangeal base. It allows approximately 100°
to 110° of flexion. A centrally located proximal phalangeal notch
articulates with a corresponding middle phalangeal median ridge (Fig. 39.1).
Dorsally, the central slip attaches to a tubercle on the base of the
middle phalanx. Palmarly, the volar plate forms the floor of the joint.
The volar plate has a thickened distal fibrocartilagenous portion that
is thicker along its lateral edges. The volar plate attaches along the
volar base of the middle phalanx, blending with the volar periosteum of
the middle phalanx centrally and the collateral ligaments laterally (Fig. 39.2) (12,14,15,20,28,38,76,77,82,95,137). The proximal portion of the volar plate tapers along its lateral edges to form two check-rein ligaments (Fig. 39.3) (12,14,15,82).
Laterally, the collateral ligaments consist of a thicker dorsal
cordlike collateral ligament proper, and a thinner volar accessory
component (76,91,137).
The collateral ligaments arise from a concavity along the lateral
aspect of the proximal phalangeal head. The ligaments pass obliquely
and palmarly to attach distally into a volar lateral tubercle on the
base of the middle phalanx and along the distal lateral margin of the
volar plate. The volar plate provides resistance to hyperextension
injuries of the PIP joint. Resistance to lateral stresses are provided
mostly by the collateral ligaments and secondarily, if at all, by the
volar plate (68,114). Some stability is also afforded by the surrounding tendon and retinacular system (15,82,124).
Disruption of at least two portions of the volar plate and two
collateral ligaments must occur for displacement of the PIP joint (30).
Figure 39.1. The fit of the articular surfaces of the metacarpophalangeal joint (left) and proximal interphalangeal joint (right). (From Green DP, Butler TE. Fractures and Dislocations in the Hand. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Fractures in Adults, 4th ed. Philadelphia: Lippincott-Raven, 1996:677, with permission.)
Figure 39.2.
Basic anatomy of the proximal interphalangeal joint. A, central
extensor slip; B, intrinsic lateral band; C, transverse retinacular
ligament; D, dorsal cord portion collateral ligament; E, accessory
collateral ligament; F, volar plate. (From Vicar AJ. Proximal
Interphalangeal Joint Dislocations without a Fracture. Hand Clin 1988;4:5, with permission.)
Figure 39.3. The proximal portion of the volar plate tapers along its lateral edges to form two check-rein ligaments. (From Bowers WH, ed. The Interphalangeal Joints. Edinburgh: Churchill Livingstone, 1987, with permission.)
The distal interphalangeal (DIP) joint, in addition to
the stability provided by the collateral ligaments and volar plate, has
some dynamic stability provided by the insertions of the flexor
digitorum profundus and the terminal

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tendon of the extensor mechanism on the base of the distal phalanx.

METACARPOPHALANGEAL JOINT
The MP joint of the fingers is a condyloid joint,
consisting of a relatively ovoid metacarpal head articulating with an
elliptical cavity at the base of the proximal phalanx. The metacarpal
head is narrower dorsally than palmarly in the sagittal plane, and it
has a proportionately larger anteroposterior diameter than that of the
phalangeal head (Fig. 39.4). Joint motion is
primarily in the sagittal (flexion–extension) plane, but both coronal
(abduction–adduction) plane and small circumduction movements also
occur (217).
Figure 39.4. Comparison of the metacarpal head (top),
which is narrower dorsally than volarly in the sagittal plane and has a
proportionately larger AP diameter than that of the phalangeal head (bottom). (From Green DP, Butler TE. Fractures and Dislocations in the Hand. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Fractures in Adults, 4th ed. Philadelphia: Lippincott-Raven, 1996:677, with permission.)
The MP joint capsule extends from the metacarpal neck to
the base of the proximal phalanx. Volarly, the joint capsule blends
with the volar plate, which consists of a thick fibrocartilagenous
distal portion and a thin membranous proximal portion. The volar plate
is more securely attached to the proximal phalanx than to the
metacarpal neck. The volar plate is also continuous medially and
laterally with the deep transverse metacarpal ligament (Fig. 39.5) (162,167,172,173,192,217).
Dorsally, the MP joint capsule is thin, and it is reinforced by a loose
insertion of the common extensor tendon. The collateral ligaments
extend from the metacarpal head to the base of the proximal phalanx,
and they also insert into the volar plate. In addition, the metacarpal
origin of the collateral ligament is more dorsal than its counterpart
at the PIP joint (207). These factors dictate that the collateral ligaments of the MP joint are at their longest or most taut in full flexion (Fig. 39.6),
while those of the PIP are most taut at only a few degrees of flexion.
It is important to remember this when testing for collateral ligament
stability or when determining

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the
tension appropriate for a repaired ligament, both during the repair and
after surgery. Additionally, the sagittal bands and intrinsic muscle
tendons provide secondary support to the MP joints (124).

Figure 39.5.
Basic anatomy of the proximal interphalangeal joint. A, central
extensor slip; B, intrinsic lateral band; C, transverse retinacular
ligament; D, dorsal cord portion collateral ligament; E, accessory
collateral ligament; F, volar plate. (From Vicar AJ. Proximal
Interphalangeal Joint Dislocations without a Fracture. Hand Clin 1988;4:5, with permission.)
Figure 39.6.
The collateral ligaments of the metacarpophalangeal joint are taut with
the joint in flexion and lax with the joint in extension.
CARPOMETACARPAL JOINTS
The carpometacarpal (CMC) joints of the hand consist of
a fixed, stable central unit that comprises the index and long CMC
joints and the relatively mobile radial (thumb) and ulnar units (ring
and little). Together they form the fixed transverse metacarpal arch of
the hand (Fig. 39.7). The index and long finger
metacarpals articulate with the trapezoid and capitate with strong CMC
ligaments, providing relatively little motion (242,244,263,271).
Stability of these joints is provided by tight joint articulations,
thick dorsal capsular ligaments, volar ligaments, interosseous
ligaments, and by some support of the transverse carpal ligament.
Additionally, insertions of the flexor carpi radialis and extensor
carpi radialis longus into the base of the index metacarpal, and of the
extensor carpi radialis brevis into the base of the long metacarpal
provide some dynamic stability to the these joints (Fig. 39.8).
Figure 39.7. The carpometacarpal joints of the index through little fingers form the fixed transverse arch of the hand.
Figure 39.8. The carpometacarpal joints with supporting ligaments and tendon insertions. (From Gunther SF. The Carpometacarpal Joints. Orthop Clin North Am 1984;15:25, with permission.)
The ulnar ring and little finger metacarpals are
relatively mobile, providing approximately 10° to 30° of flexion and
extension, respectively, as well as a few degrees of supination (212,244).
They articulate with two separate hamate facets. A slightly convex
fifth metacarpal base articulates with a slightly concave ulnar hamate
facet, whereas a somewhat flatter fourth metacarpal articulates with
the radial hamate facet. Stability to these joints is provided by the
carpometacarpal and interosseous ligaments. Additionally, the
hypothenar muscles and insertions of the extensor carpi ulnaris and
flexor carpi ulnaris via the pisometacarpal ligament (a continuation of
the

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flexor carpi ulnaris insertion) provide some dynamic stability to these joints.

PATHOPHYSIOLOGY
Injuries to the digits and hand can occur from a variety
of external forces. These forces can be direct (crush, burns,
lacerations) and/or indirect forces (rotational, bending, axial
loading). With indirect forces, the direction of the deforming force
determines the type of joint injury, while the amount of force dictates
whether the injury is a subluxation or a dislocation. For instance,
dorsal PIP joint dislocations are often accompanied by a longitudinal
compressive force; the magnitude of compression affects the complexity
of the injury. When greater longitudinal compressive forces are
combined with a hyperextension deforming force, dorsal PIP
fracture–dislocations are produced. The mechanism of injury for a
particular joint disorder is further discussed with each specific
injury.
Secondary dynamic forces, provided by tendon insertions,
frequently accentuate the deformity. For instance, insertion of the
abductor pollicis longus on the base of the thumb metacarpal, and of
the adductor pollicis on the metacarpal shaft, will accentuate a thumb
CMC joint dislocation or fracture–dislocation.
Injuries of the soft tissues, usually through either
direct forces or excessive indirect forces, can produce open wounds or
neurovascular injuries. These injuries will ultimately affect the
course of treatment. The treatment of an open dislocation with
neurovascular compromise is different from that of a simple closed
injury.
GENERAL PRINCIPLES OF TREATMENT
The goal for any treatment of digital dislocations or
ligament injuries is to restore functional, pain-free, and stable joint
motion. To accomplish this goal requires an early, accurate evaluation
and diagnosis of the injury and adequate treatment. The goal of
treatment for injuries seen late is usually to provide pain relief.
Obtain a history of the mechanism of the injury (e.g.,
extension, flexion, lateral deviation force) and timing of the injury
(acute versus chronic). Examine for active joint range of motion,
neurovascular status, flexor and extensor tendon function, areas of
localized tenderness, and, finally, passive joint stability.
Most dislocations or ligament injuries that are closed
and simple can be treated by nonoperative means. Digital block or nerve
block anesthesia can be helpful in evaluating joint stability or
reducing dislocations, but this is often unnecessary. Determine and
record the neurologic status prior to an anesthetic or treatment of the
injury.
Dislocations are usually obvious from clinical
examination, but good radiographs in at least two orthogonal planes
(perpendicular to one another) are necessary. With a digital injury,
radiographs of the digit (not of the hand) before and after treatment
are needed to accurately assess any associated fractures, as well as
the efficacy of treatment.
Use stress views to evaluate ligament injuries if clinical testing leads to a question about the integrity of a ligament (Fig. 39.9A).
If used, anesthesia (usually a digital block or intraarticular
injection) is helpful to reap the maximum benefit from a stress view.
Similarly, stress views of the injured joint under fluoroscopy, when
compared to the uninjured joint in the opposite hand, can be helpful in
detecting ligament injuries (Fig. 39.9B).
Figure 39.9. A:
AP radiograph with lateral stress applied to the proximal
interphalangeal joint. Lateral deviation of more than 20° is indicative
of a complete collateral ligament injury. B: Fluoroscopic stress view of the thumb MP joint showing lateral subluxation of the proximal phalanx.
Other specific radiographs may also be helpful in
evaluating particular joint injuries. An oblique view (Brewerton view)
of the metacarpal heads may be helpful in detecting small metacarpal
head fractures (171,185,189,206).
The Brewerton view is taken as an anteroposterior (AP) view of the hand
with MP joints of the hand flexed approximately 65° and the x-ray beam
tilted 15° from an ulnar to radial direction (185). Evaluation of the thumb CMC joint requires a true AP view and a lateral view of the joint (Robert view) (403).
The AP radiograph is taken with the hand fully pronated and with the
dorsum of the thumb lying flat on the x-ray plate. The x-ray beam is
then centered over the thumb CMC joint. The lateral radiograph of the
joint is taken with the radial side of the thumb lying on the x-ray
plate (thumbnail lying perpendicular to the plate) and the x-ray beam
centered over the joint. Evaluation of the finger CMC joints will
frequently require oblique views of the hand. Occasionally, due to the
difficulty in evaluating these joints, tomography or computed
tomography (CT) may be needed.
After reduction of the joint, assess both active
stability (full active range of motion) and passive stability
(passively applied medial–lateral and anterior–posterior stress). If
the injury is amenable to closed treatment, use

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a
cast dressing that immobilizes the hand and wrist as well as all the
fingers and, if necessary, the thumb. Take care when using a digital
splint, as an acutely injured digit can be further harmed by
immediately taping it to a digital splint. After surgical intervention,
a similar cast dressing is applied.

In most cases with closed treatment, the dressing is
changed within 5 days. Begin an appropriate active motion program,
modifying for the specific injury. The same is recommended for many
postoperative cases. The goal is to provide joint stability and
adequate protection against reinjury or disruption of the repair while
gaining maximal motion to prevent tendon adherence or joint stiffness.
CLASSIFICATIONS
Dislocations and ligamentous injuries of the
interphalangeal, metacarpophalangeal, and carpometacarpal joints can be
classified similarly. Classification can be based on the status of the
skin (closed versus open), the duration of injury (acute versus
chronic), the degree of joint displacement (subluxation versus
dislocation), the status of the joint surface (dislocation versus
fracture–dislocation), and the ability to reduce the joint dislocation
(simple versus complex).
Joint subluxations occur with disruption of some of the
joint soft tissue supporting structures, but some contact remains
between the articular surfaces. With dislocations, there is a loss of
contact between the joint surfaces. Joint dislocations and subluxations
can be further subclassified based on the direction of displacement of
the distal portion of the injured digit relative to the proximal
portion, that is, dorsal, lateral, or palmar (volar) dislocations.
Specific classifications of an injury pertaining to a particular joint will be discussed separately.
FINGERS
DISTAL INTERPHALANGEAL JOINT
Assessment and Indications for Treatment
In addition to an obvious DIP joint dislocation, flexor or extensor tendon avulsion injuries, nail bed injuries, and

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open injuries are common (Table 39.1).
Assess these structures and obtain true AP and lateral radiographs of
the digit and particularly of the DIP joint. Open dislocations require
adequate debridement and antibiotics.

Table 39.1. Algorithm for Assessment of Distal Interphalangeal (DIP) Joint Injuries
Distal interphalangeal joint dislocations are uncommon.
The more common injuries occur secondary to a hyperextension force
(dorsal dislocation, dorsal lip fracture or fracture–dislocation),
forced extension against resistance (flexor profundus tendon avulsion
injury), flexion injury (extensor tendon avulsion injury), hyperflexion

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force
(palmar dislocation), and lateral deviation force (collateral ligament
injury). The addition of a longitudinal compression force usually adds
some form of an intraarticular fracture.

DIP Joint Dislocations
Dislocations of the DIP joint are almost always dorsal and are rare (42,83).
These injuries are usually produced by a longitudinal compression and
hyperextension of the joint. Occasionally, a lateral, and even less
commonly a palmar, dislocation can occur. Look for flexor (jersey
finger) (Chapter 48) or extensor tendon (mallet finger) (Chapter 49)
avulsion injuries, which are common. Simultaneous dislocation of the
distal and proximal interphalangeal joints has been described and
should be detectable by careful clinical examination and adequate
radiographs of the injured digit (5,6,9,32,45,47,50,52,54,57,73,75,99,117,139,142).
  • Perform a closed reduction, with or without digital block anesthesia, using longitudinal traction on the distal phalanx.
  • Place direct pressure on the dorsal base of the distal phalanx, displacing it distally and palmarly.
  • Postreduction radiographs should confirm congruous reduction of the joint.
  • After joint reduction, assess joint
    stability and flexor and extensor tendon function. If joint instability
    is present after joint reduction, splint the joint for 2 to 3 weeks in
    10° to 20° of flexion (for dorsal dislocations).
  • With a palmar dislocation, dorsal lip
    fracture–dislocation, or terminal extensor tendon avulsion (mallet
    finger) injury, avoid splinting the DIP joint in hyperextension. This
    prevents dorsal skin wound problems. Splint, generally, for 6 weeks or
    more to promote healing (see Chapter 49). Fracture–dislocations of the joint can occur (46,51).
  • If the flexor digitorum profundus is avulsed with the volar fragment, reattach the tendon.
  • Open dislocations of the DIP joint are
    frequent and require irrigation, debridement, and antibiotics. Repair
    any associated nail bed injuries or nail plate avulsions.
  • When the dislocation is chronic (greater
    than 3 weeks) or irreducible, perform an open reduction. Irreducible
    DIP joint dislocations may be secondary to interposed volar plate,
    flexor tendon, fracture fragment, or a sesamoid bone (32,44,53,58,67,70,98,103,107,108,112,118,122,123,130,133,150). Remove the interposed structure to reduce the joint.
Open Reduction of an Irreducible DIP Joint Dislocation
  • Make a straight dorsal midline,
    transverse, or H-shaped incision and split the extensor tendon
    longitudinally in the midline. Alternatively, divide the tendon
    transversely and repair it at the time of closure.
  • If the volar plate is interposed between the joint surfaces, incise as much of it as necessary to displace it palmarly.
  • Release the collateral ligaments
    subperiosteally at their insertion into the middle phalanx and continue
    the dissection until the joint can be reduced. Test the joint for
    stability.
  • If the joint is grossly unstable,
    transfix the joint with smooth 0.035–0.045 Kirschner (K-) wire(s) for 3
    weeks. If the joint is fairly stable, immobilize it in a splint for a
    few days for comfort.
  • Then apply a dorsal-block splint and allow active flexion. Remove the splint after 3 weeks.
  • If the joint surface damage is extensive, perform a primary arthrodesis (see Chapter 72).
Complications
Complications in the treatment of DIP joint injuries
will usually occur from a failure in diagnosis, from a delay in
treatment, or from undertreatment. Failure to recognize a concomitant
injury to soft tissues (e.g., flexor or extensor tendons) will result
in a deformity (e.g., jersey finger or mallet finger) (186).
Unrecognized dislocations generally require an open reduction and pin
fixation, instead of a closed reduction. Delayed reduction of the joint
may also result in significant articular damage, necessitating an
arthrodesis. Redislocation of a dorsal DIP joint dislocation can occur
if hyperextension is not prevented for at least 3 weeks.
DIP Joint Ligament Injuries
Unless they accompany a dislocation, nearly all ligament
injuries of the DIP joint are partial tears or sprains at the DIP joint
level and thus can be treated nonoperatively. Temporary splinting for a
few days for comfort should be followed by an early, vigorous active
motion program.
PROXIMAL INTERPHALANGEAL JOINT
Assessment and Indications for Treatment
Proximal interphalangeal joint dislocations and
subluxations are frequently associated with an injury to the volar
plate, collateral ligament, extensor tendon (central slip), and joint
articular surface (Table 39.2). Assess these
structures and take true AP and lateral radiographs of the digit,
particularly of the PIP joint. Stress views to assess collateral
ligament injuries may be helpful. Open dislocations require adequate
debridement and antibiotics.
Table 39.2. Algorithm for Assessment of Proximal Interphalangeal (PIP) Joint Injuries
Proximal interphalangeal joint injuries, especially dislocations, are among the most common hand injuries (23,38,42,98,104),
ranging from a simple hyperextension injury, as seen in sporting
injuries, to a severely comminuted fracture. The more common injuries
occur secondary to a hyperextension force (dorsal subluxation or
dislocation,

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volar
plate rupture), longitudinal compression and hyperextension force
(dorsal fracture–dislocation), lateral deviation force (collateral
ligament injuries), and combined rotatory and longitudinal compression
force (rotatory dislocations).

PIP Joint Dorsal Dislocations
There are several dorsal PIP joint dislocation classification systems (14,28,38,48,84,86,120).
However, generally three types can be categorized depending on the
degree of hyperextension force applied to the joint and any associated
fractures (28,38).
  • Type I is a hyperextension injury to the joint with subluxation but not dislocation.
  • Type II is a dorsal dislocation.
  • Type III is a shear fracture of the volar base of the middle phalanx, producing a fracture–dislocation (Fig. 39.10).
    Type I injuries are associated with avulsion of the volar plate, and a
    partial horizontal split occurs between the volar and dorsal portions
    of the collateral ligaments. Type II injuries are associated with a
    complete avulsion injury of the volar plate and a greater longitudinal
    tear of the collateral ligaments (12,18,28,38).
    Figure 39.10. Three types of dorsal PIP joint hyperextension injury (see text for description of injuries).
The acute dorsal injury without fracture can usually be
reduced by closed means. A digital block is often unnecessary. The
volar plate, by necessity, is ruptured, usually from the middle
phalanx, but the collateral ligaments rarely are ruptured completely
from their attachments (10,12).
Perform reduction with longitudinal traction and direct pressure on the
dorsal base of the middle phalanx, displacing it distally and palmarly.
Confirm congruous reduction of the joint with postreduction
radiographs. Assess both active and passive stability of the joint
after reduction. With type I and II dorsal dislocations, the joint is
usually stable after reduction (56,126).
Type III injuries are discussed in the following section. Use a resting
splint with the finger flexed to 20° to 30° for 7–10 days. Do not
splint the digit in flexion for an extended period of time, and begin
early active motion with protection against hyperextension.
Alternatively, use an orthoplast figure-eight splint, preventing joint
hyperextension (79). Protect the injured digit,
especially during sporting activities, by taping it to the adjacent
uninjured digit. Reassure the patient that persistent swelling and slow
resolution of stiffness is to be expected.
Treat open PIP joint dislocations with irrigation, debridement, and antibiotics (71,129).
Chronic dorsal dislocations are uncommon, as are irreducible dorsal dislocations (36,43,62,71,101),
and require open reduction. An attempt at gentle closed reduction under
adequate anesthesia is permissible but is best done in the operating
room; if it is unsuccessful, the joint then can be approached
surgically.
Open Reduction of a Chronic, Irreducible, Dorsal PIP Joint Dislocation
  • Make a straight or slightly curvilinear dorsal longitudinal incision.
  • Divide the central slip of the extensor
    mechanism in the midline but do not dissect distal to the base of the
    middle phalanx, as the attachments of the central slip to the middle
    phalanx and triangular ligament must remain intact.
  • If the volar plate is interposed, split
    the interval between it and each accessory collateral ligament.
    Mobilize the volar plate and perform a trial reduction of the joint.
  • If this fails, release the origins of the
    collateral ligaments from the proximal phalanx by sharp subperiosteal
    dissection. This should allow reduction if the joint is hyperextended
    and the volar plate is pushed palmarward.
  • After reduction, test the joint for
    instability. If instability is present, transfix the joint with smooth
    0.035–0.045 K-wire for 3 weeks.
  • If the joint is fairly stable, close the
    extensor split and the skin separately with nonabsorbable sutures. Take
    postreduction radiographs to confirm congruous reduction of the joint.
  • Immobilize the hand in a cast dressing
    with the PIP joints flexed no more than 10°. After 5–7 days, begin
    active flexion for an additional 2–4 weeks, using a dorsal
    extension-block splint to prevent hyperextension of the joint.
Complications
The most common complication following a dorsal PIP joint dislocation is stiffness secondary to prolonged splinting (146). Prolonged splinting of the joint in flexion can produce a joint flexion contracture, due to contracture of

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the volar plate (also referred to as a pseudoboutonnieére deformity) (90,91).
A significant contracture can be treated with dynamic splinting, serial
casting, or, eventually, surgical release of the contracture (25,38,80,88,140).

In contrast to prolonged splinting of the PIP joint, if
joint hyperextension is not prevented for at least 3 weeks, either
redislocation of the joint or a chronic swan-neck deformity may occur (104).
A true lateral radiograph will help guard against persistent
subluxation. With a chronic swan-neck deformity, painful snapping of
the lateral bands over the phalangeal heads or inability to initiate
joint flexion may occur. Treatment includes primary reattachment of the
volar plate or sublimis tenodesis (see the section below on volar plate ruptures) (1,7,12,22,38,72,78,91,109,110,132,136,144,195).
PIP Joint Palmar Dislocations
Palmar PIP dislocations are rare and result from a longitudinal and rotatory force directed on a partially flexed PIP joint (39,127).
The injury results in volar displacement of the middle phalanx relative
to the proximal phalanx. There is a disruption of the extensor
mechanism (central slip), creating a boutonnieére injury. One proximal
phalangeal condyle may herniate between the central slip and the
lateral band, producing a rotatory or irreducible PIP joint dislocation
(see Rotatory Dislocations). There may be an injury to a collateral
ligament and the volar plate (Fig. 39.11) (33,37).
Figure 39.11. A: Lateral radiograph of volar proximal interphalangeal dislocation. B: Diagram showing how the boutonnieére develops as the head of the proximal phalanx herniates through the extensor mechanism.
Usually, closed treatment will successfully reduce these dislocations:
  • Reduce a palmar PIP joint dislocation with gentle traction on the middle phalanx with the MP and PIP joints flexed (134,146).
    Wrist extension may relax the extensor mechanism. In general, full
    passive extension of the joint is obtainable and postreduction
    radiographs should confirm congruous reduction of the joint.
  • After reduction, test active PIP joint
    extension to determine the status of the central slip. With disruption
    of the central slip, the PIP joint should be splinted in extension for
    4–6 weeks, either with smooth K-wire transfixing the joint or simply
    with an external splint.
  • The DIP and MP joints should be permitted
    to move so that the extensor mechanism is less likely to become
    adherent. If the dislocation is irreducible or chronic (34,106,110,111), surgery is necessary.
Open Reduction of a Chronic Palmar PIP Joint Dislocation
  • Make a straight dorsal or slightly curvilinear incision.
  • Mobilize the lateral bands so that the head of the proximal phalanx is no longer caught between them.
  • Reduce the joint, and transfix it in extension with smooth 0.035–0.045 K-wire.
  • Reattach the central slip to the base of
    the middle phalanx with nonabsorbable sutures to remaining periosteum,
    through bone holes, or with miniature suture anchors. Repair the
    interval between each lateral band and the central slip with
    nonabsorbable sutures. Postreduction radiographs should confirm
    congruous reduction of the joint.
  • Remove the pin after 6 weeks, having allowed active motion at the MP and DIP joints during that time.
Complications
The results of open reduction of a chronic palmar PIP
joint dislocation tend to be poor, emphasizing the need for early
recognition of the injury (28,34,38,41,106,110,146).
If any or too early PIP flexion is allowed during the immobilization
period, a boutonnieére deformity will result. Treatment of the
boutonnieére deformity varies depending on the duration of the
deformity (35,89).
PIP Joint Rotary (Irreducible) Dislocations
Irreducible rotary dislocation of the PIP joint, a
complex volar-lateral dislocation, is an uncommon injury in which the
middle phalanx is displaced laterally and palmarly (8,21,24,30,36,39,59,61,63,65,69,93,98,100,102,106,110,111,122,127,135,143). The injury occurs secondary to a combined rotatory and compressive force applied to

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the PIP joint. Clinically, the PIP joint is swollen and tender. The
digit may be deviated and flexed. In contrast to the palmar PIP joint
dislocation, for which passive extension is possible after reduction,
there is resistance to active and passive flexion and especially to
passive extension.

On the injured side of the joint, the collateral
ligament is ruptured and the condyle of the proximal phalanx usually
penetrates through a longitudinal rent between the lateral band and the
central slip (Fig. 39.12). The lateral band is looped through the joint around the condyle, preventing reduction.
Figure 39.12. A longitudinal rent in the extensor mechanism produced by the condyle of the proximal phalanx (above probe) splits the central slip (held by forceps) from the lateral band (below probe). The band then loops around the condyle and through the joint, preventing reduction.
Radiographically, the lateral and palmar dislocation can
be improved by closed reduction, but there will be a persistent
subluxation and widening of the joint space on the side of injury (Fig. 39.13).
Due to the rotatory nature of the injury, on a true lateral radiograph
of the digit, one phalanx may appear slightly rotated relative to the
other. This persistent subluxation of the joint usually must be treated
surgically. Attempt closed reduction following digital block
anesthesia, with gentle longitudinal traction and finger rotation (20,28,38,134).
Flex the MP and PIP joints to relax the lateral bands, and extend the
wrist to relax the extensor mechanism. Confirm congruous reduction with
radiographs and test for active motion and active and passive
stability. With incomplete active PIP joint extension, splint the joint
in full extension for 3–6 weeks.
Figure 39.13. AP radiograph showing persistent subluxation or widening on one side of the PIP joint.
Open Reduction of a Rotatory (Irreducible) PIP Joint Dislocation
  • Make a mid-axial or dorsal curvilinear
    incision angled toward the injured side of the PIP joint. The condyle
    protruding between the central slip and the lateral band will be seen
    at once (Fig. 39.14).
    Figure 39.14. Clinical photograph corresponding to Figure 39.12.
  • Remove the lateral band from the joint with a blunt instrument. The joint will promptly reduce.
  • Repair the collateral ligament if
    disruption of the collateral ligament results in persistent joint
    instability or subluxation. If the lateral band is not badly damaged,
    repair the longitudinal rent in the interval between the lateral band
    and the central slip. If the lateral band is severely damaged, excise
    it.

    • P.1277


  • The remaining intact central slip and lateral band are sufficient to provide full extension of the finger (100). Intraoperative postreduction radiographs should confirm congruous reduction of the joint.
  • After 5–7 days of immobilization in a
    cast dressing, start active motion, with the finger strapped to the
    adjacent finger to protect against reinjury. Protect the finger for 4–6
    weeks.
Complications
Complications from treating rotatory PIP joint
dislocations are usually due to failure to diagnose the dislocation,
causing a delay in treatment that results in a fixed flexion deformity (146).
Incomplete joint reduction results from incomplete removal of the
lateral band. Joint instability results from inadequate collateral
ligament repair. Failure to adequately reduce the joint will result in
a fixed flexion deformity. Late treatment consists of volar plate and
collateral ligament release, excision of the lateral band, and
reduction of the joint (106).
PIP Joint Fracture–Dislocations
Fracture–dislocation of the PIP joint is probably the
most difficult fracture–dislocation to treat in the hand. As the middle
phalanx displaces proximally and dorsally, the head of the proximal
phalanx is driven into the palmar lip of the base of the middle
phalanx. A comminuted depressed fracture usually results and can
involve 70% or more of the articular surface. These injuries can be
divided into stable and unstable fracture–dislocations (28,38).
In stable fracture–dislocations, the volar lip fracture usually
involves less than 40% of the articular surface. The dorsal portions of
the collateral ligaments remain attached to the middle phalanx. With
unstable fracture–dislocations the volar lip fracture involves more
than 40% of the articular surface. The collateral ligaments usually
remain attached to the volar lip fracture. Dorsal joint subluxation,
which is difficult to reduce and to maintain by closed means, tends to
occur with PIP joint extension.
Whenever possible, treat this injury closed with the dorsal extension-block splinting technique (26,41,92,131).
Dorsal subluxation associated with volar lip middle phalangeal
fractures can occasionally be reduced with PIP joint flexion. Always
try this technique first, since it yields the best results if
applicable (Fig. 39.15). The key to its
usefulness is restoration of the joint alignment, not reduction of the
fracture. If the fracture reduces also, this is a bonus.
Figure 39.15. Fracture–dislocation of the PIP joint. B:
Joint reduced by flexion of the finger to 60° or more. The fracture
reduction (anatomic here) is a bonus but is not necessary for a good
result. C: Healed fracture–dislocation with good joint congruity.
Dorsal Extension-Block Splinting
  • Use a padded hand-based aluminum splint
    or combine an aluminum splint with a short arm cast. With the latter
    technique, a padded aluminum splint loop is taped to a short arm cast
    over the top of the finger being tested (Fig. 39.16).
    Figure 39.16. Extension-block splint.
  • The MP joint is splinted in flexion and the proximal

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    phalanx is taped to the splint. Taping of the proximal portion of the
    digit ensures that finger flexion occurs at the PIP and not at the MP
    joint.

  • Fashion the splint so that the PIP joint
    is flexed approximately 10° to 15° short of the unstable, dorsally
    subluxed position, which is generally between 30° to 40° of PIP joint
    flexion.
  • A true lateral radiograph of the digit will confirm that the joint subluxation is corrected.
  • Adjust the splint weekly by reducing the
    degree of PIP joint flexion by 25%, or approximately 10°. Take
    radiographs weekly to ensure that dorsal joint subluxation has not
    recurred.
  • If joint alignment cannot be restored by
    closed means, extension-block splinting should be abandoned and an
    alternative procedure used. These measures include extension-block
    pinning (135,138), skeletal tractionor dynamic skeletal traction (2,3,17,22,55,97,105,115,119,121), dynamic hinged external fixation (48,49,66,74), open reduction and internal fixation (33,40,60,61,81,86,91,128,141,144,147,148 and 149), and vo-lar plate arthroplasty (11,29,31,60,61,87).
Extension-Block Pinning
  • Place a smooth K-wire in the proximal
    phalangeal head and shaft from a distal to proximal direction at an
    angle, with the PIP joint partially flexed, which places it dorsal to
    the middle phalanx, and with the dorsal fracture–subluxation reduced.
  • The wire prevents dorsal subluxation of the middle phalanx as seen on a lateral radiograph.
Dynamic Skeletal Traction
Readers are advised to read the original articles for a detailed description of the skeletal traction techniques (2,3,17,55,97,105,119,121).
Force-Couple Splint
  • Use a small needle to identify the joint line (Fig. 39.17A).
    Figure 39.17.
    Force-couple splint. See text for a description of each step in the
    technique. Agee JM. Unstable Fracture Dislocation of the Proximal
    Interphalangeal Joint: Treatment with the Force Couple Splint. Clin Orthop 1987;214:101.
  • Insert smooth K-wires transversely into the middle phalangeal base (Fig. 39.17B) and into the center of the proximal phalangeal head (Fig. 39.17C), parallel to the PIP joint articular surface.
  • Place a threaded K-wire in a dorsal to volar direction in the proximal half of the middle phalanx (Fig. 39.17D) and through the dorsal and volar cortices, being careful not to penetrate the flexor tendon.
  • On both sides of the finger, bend the distal K-wire proximally at 90° and pass it proximal and palmar to the proximal wire (Fig. 39.17E).
    Make a second 90° bend in the distal wire, 5–10 mm proximal to the
    proximal wire, and direct the wire dorsally or vertically (Fig. 39.17F). Bend a hook into the ends of the K-wire to retain a rubber band.
  • On both sides of the finger, bend the proximal K-wire at 90° in a palmar direction (Fig. 39.17G). Bend the proximal wire outside of the distal wire.
  • Connect the vertically oriented, threaded
    K-wire and the vertical arms of the distal K-wire with a rubber band,
    producing linkage, or a force couple (Fig. 39.17H).
  • Place adhesive tape around the ends of the proximal K-wire to prevent the two ends of the wire from spreading apart (Fig. 39.17I).
  • The force couple allows joint range of
    motion and is used to palmarly displace the middle phalanx and dorsally
    displace the proximal phalanx and thereby reduce dorsal subluxation of
    the PIP joint fracture–dislocation (2,3) (Fig. 39.17J).
Rubber Band Traction with an External Outrigger Device
  • Place a transosseous wire horizontally
    into the distal head of the middle phalanx and bend the wire distally
    on both sides of the finger at 90° angles.
  • Place a loop into the ends of the wire
    and connect with rubber bands, the ends of the wire to a sliding
    U-shaped thermoplastic component.
  • The U-shaped component is looped over a circular 3- or 6-inch-diameter hand/forearm outrigger hoop splint.
  • The rubber band provides traction across the PIP joint. Use of the outrigger splint allows active finger flexion and extension (119,121) (Fig. 39.18).
    Figure 39.18.
    Outrigger splint. From Schenk RR. The Dynamic Traction Method.
    Combining Movement and Traction for Intra-Articular Fractures of the
    Phalanges. Hand Clinic 1994;10:187.
Dynamic Hinged External Fixation
  • Under fluoroscopic guidance or open
    visualization, place a K-wire horizontally into the proximal phalangeal
    head center axis of rotation.
  • Place the centering hole of a hinged
    external fixator [e.g., the Compass PIP Hinge (Smith and Nephew
    Richards, Memphis, TN)] over the central axis pin (Fig. 39.19).
    Figure 39.19. Placement of the hinged external fixator. From Jones BF, Stern PJ. Interphalangeal Joint Arthrodesis. Hand Clinic 1994;10:267.
  • Place smooth K-wires initially through
    the proximal and then through the distal pin blocks in the mid-axial
    line of the digit. Hold the middle phalanx reduced during K-wire
    placement in the distal pin block.
  • Apply joint distraction or passive joint motion, as needed, using a built-in distraction screw or worm gear mechanism (Fig. 39.20).
    Figure 39.20. Application of joint distraction. From Jones BF, Stern PJ. Interphalangeal Joint Arthrodesis. Hand Clinic 1994;10:267.
Volar Plate Arthroplasty
Open reduction and internal fixation
of the palmar lip fracture is a demanding and often frustrating
technique. If the fragment is sufficiently large and the fracture
fairly fresh, however, internal fixation may provide reasonably good
joint motion. Methods of fixation include K-wires, screw fixation, and
intraosseous wiring.
Volar plate arthroplasty
as described by Eaton and Malerich (31),
is an alternative that can be used for acute as well as chronic
injuries. Advancement of the volar plate attempts to restore the
impacted volar articular surface.

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P.1280


  • Make a palmar zigzag incision over the PIP joint.
  • Elevate the flexor sheath from the distal edge of the A2 to the proximal edge of the A4 pulley, protecting the digital arteries and nerves at all times.
  • Retract the flexor tendons without damaging the vincula.
  • Mobilize the volar plate and accessory
    collateral ligaments with the attached palmar lip fragment from the
    middle phalanx, leaving it attached proximally.
  • Excise the remaining collateral ligaments
    connecting the proximal and middle phalanges (especially in chronic
    cases), and then open the joint by hyperextending it (like a shotgun) (Fig. 39.21).
    Figure 39.21. PIP joint exposed by opening like a shotgun. From the bottom:
    Fracture fragment with attached volar plate, head of proximal phalanx,
    base of middle phalanx with defect from compression fracture.
  • Debride small or loose fragments. If the
    fragment attached to the volar plate is large, fix it with fine smooth
    K-wire(s), screws, or an interosseous wire to the middle phalanx, being
    careful to establish a smooth articular surface and a congruous joint
    reduction.
  • Confirm congruous reduction of the joint with postreduction radiographs.
  • More commonly, the volar plate fragment
    cannot be used. Dissect it free subperiosteally from the volar plate,
    retaining all possible length of the plate. Mobilize the volar plate as
    much as possible, leaving its proximal attachment intact, by freeing
    any restraining bands in the recess.
  • Create a transverse trough in the middle
    phalangeal defect at the dorsalmost part of the cancellous defect, near
    the palmar margin of the remaining dorsal articular cartilage. The
    trough must be perpendicular to the long axis of the middle phalanx.
    Place drill holes at the lateral margins of the trough.
  • Place a criss-cross, nonabsorbable suture
    (2-0 or 3-0 Prolene) in the distal volar plate, and pass the ends
    through the drill holes. To prevent tethering of the distal

    P.1281



    extensor mechanism, flex the DIP joint 30° when passing the sutures dorsally.

  • Reduce the PIP joint, and pull the volar plate into the trough with the joint flexed no more than 30° (Fig. 39.22). Tie the suture over a protected button dorsally.
    Figure 39.22. A:
    View from palmar side of volar plate arthroplasty as sutures lead the
    distal edge of the volar plate into the trough at the base of the
    middle phalanx. B: Lateral view of volar plate arthroplasty, secured with the joint flexed.
  • Confirm congruous reduction of the joint
    with intraoperative postreduction radiographs. Suture any remaining
    collateral ligament to the lateral margin of the volar plate.
  • Transfix the joint with a smooth 0.035–0.045 K-wire with the joint in 20° to 30° of flexion.
  • Immobilize the hand in a cast dressing.
    Remove the wire at 2 weeks, and encourage active flexion with use of an
    extension-block splint. Begin active extension at 4 weeks and extension
    splinting at 5 weeks if full extension is lacking. Motion may continue
    to improve for several months.
Complications
Dorsal PIP joint fracture–dislocation complications are
usually due to failure to treat the initial injury adequately or
secondary to loss of reduction of the joint. Persistent joint
dislocation can occur with closed treatment when the joint hinges
instead of reducing congruously, or redislocation occurs with too rapid
mobilization of the joint into extension. Redislocation can also result
from inadequate reduction at surgery, or from failure of the pullout
suture or of internal fixation. Angulation of the joint can occur
secondary to asymmetrical impaction of the volar lip fragment or with
oblique placement of the volar plate bone trough. Flexion contracture
occurs with prolonged immobilization. Posttraumatic arthritis results
from articular damage.
Treatment of complications includes joint contracture
release, repeat open reduction and internal fixation, opening-wedge
osteotomy and bone grafting, volar plate arthroplasty, and joint
arthrodesis (27,28,31,38,64,140,146,149).
PIP Joint Lateral Dislocations—Collateral Ligament Injuries
Acute Collateral Ligament Ruptures
Collateral ligament injuries are usually caused by an abduction or adduction force with the PIP joint in extension (91). The radial collateral ligament tends to be more commonly injured than the ulnar collateral ligament (42).
Clinically, tenderness occurs over the site of injury, and joint laxity
to lateral stress may be present. Most PIP joint collateral ligament
injuries are incomplete and need only to be protected by strapping to
an adjacent digit for 3–6 weeks (41,96).
However, lateral dislocations of the PIP joint can result in complete,
but uncommon, rupture of a collateral ligament and at least a portion
of the volar plate (28,38). Angulation greater than 20° with lateral stress testing indicates a complete collateral ligament injury (34,68,95) (Fig. 39.9A).
Treatment of complete collateral ligament injuries is
controversial. After closed reduction, assess stability of the joint by
active motion and confirm joint congruency on radiographs. Acutely, use
a temporary splint for comfort, followed by strapping to an adjacent
digit for 3–4 weeks, encouraging full active motion. Repair of the
collateral ligament has been described (4,13,16,41,60,61 and 62,91,94,113,116),
but joint stiffness is a problem. The index radial collateral ligament
is probably the only ligament that needs early surgery (41,62,94).

P.1282


Open Repair of Acute Collateral Ligament Ruptures
  • Make a radial mid-axial incision.
  • Divide the transverse retinacular ligament, reflect it, and retract the radial lateral band dorsally.
  • Identify and repair the torn collateral
    ligament. The stump usually is still attached at the middle phalanx and
    is repaired with nonabsorbable sutures.
  • If no residual stump is present, roughen
    the bone and drill parallel holes obliquely across the phalanx. Pass a
    nonabsorbable suture, using a modified Bunnell suture technique,
    through the torn edge of the ligament. Pass the two suture ends through
    the holes in the bone and out through the skin. Tie the suture over a
    protected button with the joint reduced and the ligament pulled taut.
    Miniature suture anchors can be used instead of a transosseous pullout
    suture technique (Fig. 39.23).
    Figure 39.23. Miniature suture anchors can be used instead of a pullout suture technique to repair the collateral ligament.
  • Repair the accompanying partial tear of the volar plate as well.
  • Repair the retinacular ligament, close the skin, and confirm congruous reduction of the joint with radiographs.
  • Splint the digit in no more than 20° of
    PIP joint flexion for 5–7 days and then start active motion with
    adjacent finger-strapping for an additional 2–3 weeks.
Chronic Collateral Ligament Ruptures
Chronic collateral ligament injuries are rarely
sufficiently symptomatic to require reconstruction. Often, there are
degenerative changes in the joint, and ligament reconstruction cannot
be expected to alleviate symptoms due to arthritis. Once again, if
reconstruction of a chronic PIP collateral ligament rupture is
necessary, it is on the radial side of the index finger.
Reconstruction of the collateral ligament can be done by
shortening or imbricating the remaining ligament or by augmenting the
repair, usually with a slip of the superficialis (78,91,104,113).
Open Repair of Chronic Collateral Ligament Ruptures
  • Make a surgical approach similar to that made for the acute collateral ligament injury.
  • Identify the ligament and dissect it
    free. Imbricate it in its midportion, or shorten it and suture it with
    a nonabsorbable suture at the proper length.
  • If further reinforcement is needed,
    separate the radial slip of the superficialis, leaving it attached
    distally detaching it proximally. Pass the tendon through a drill hole
    in the head of the proximal phalanx with a pullout suture and tie the
    suture over a protected button on the ulnar side of the proximal
    phalanx.
  • Alternately, pass the superficialis
    through two holes drilled on the radial aspect of the proximal
    phalangeal head and suture the tendon to itself. Spread out the tendon
    dorsally and suture its radial (now dorsal) edge to the remaining
    fibers of the collateral ligament.
  • Close the wound as previously described.
    After 10 days of immobilization in no more than 20° of flexion,
    encourage the patient to actively exercise with strapping to the
    adjacent long finger for an additional 4–5 weeks.
Complications
Complications in the treatment of lateral PIP joint
dislocations usually occur from inadequate initial treatment, and they
are frequently an expected outcome of the injury, even with adequate
treatment. Pain, instability, loss of motion, and arthrosis can occur
from incomplete joint reduction, lateral translocation, or uneven
forces within the joint secondary to excessive scarring (146).
Late reconstruction cannot be expected to produce a
perfectly stable joint. Potential problems of ligament reconstruction
include joint stiffness or persistent laxity.
PIP Joint Volar Plate Ruptures (Swan-Neck or Hyperextension Deformity)
Volar plate ruptures of the PIP joint can result from a
dorsal PIP joint dislocation or hyperextension injury (type 1 dorsal
PIP joint dislocation). The volar plate usually detaches distally from
the middle phalanx, with or without a piece of bone. If the volar plate
ruptures distally with a small fragment of bone (as seen on the lateral
radiograph), the joint is inevitably congruous. This injury must be
differentiated from the serious PIP joint fracture–dislocation. Treat
the minor volar plate fracture as any other volar plate injury, with
protection against hyperextension by either a temporary dorsal-block
digital splint or by strapping to an adjacent finger for 3 weeks.
Encourage full flexion.
Chronic volar plate ruptures can result in a swan-neck
deformity with dorsal subluxation of the lateral bands. Painful flexion
of the PIP joint can occur as the lateral bands sublux palmarly over
the proximal phalangeal condyles. Distinguish this swan-neck deformity
from the type of swan-neck deformity secondary to an extensor terminal
tendon disruption (mallet finger). With volar plate insufficiency, the
patient will be able to actively extend the DIP

P.1283


joint
with the PIP joint held in full extension. Nonoperative treatment
includes use of a orthoplast or silver (double-ring) splint to help
prevent PIP joint hyperextension (Fig. 39.24). Symptomatic volar plate ruptures (Fig. 39.25)
can be helped by surgical correction. Options include late reattachment
or shortening of the volar plate, with or without some form of volar
reinforcement (1,7,12,22,72,78,91,104,109,132,136,144).

Figure 39.24.
Silver ring (or double-ring) splint used for swan-neck deformity to
prevent hyperextension at the PIP joint. The splint can be padded if it
irritates the dorsum of the digit.
Figure 39.25. Chronic volar plate rupture in a basketball player; it subluxated each time he caught the ball.
Open Repair of Chronic Volar Plate Ruptures
  • Make a palmar zigzag incision and release the flexor sheath between the A2 and 4 pulleys.
  • Protect the digital vessels and nerves
    while retracting the flexor tendons to expose the volar plate. If it
    has been ruptured in midsubstance and repair is possible, suture the
    edges directly.
  • More often, it will be detached distally (Fig. 39.26A).
    In that case, roughen the base of the middle phalanx and create a
    transverse trough. Place a nonabsorbable suture in the distal end of
    the volar plate with a modified Bunnell suture technique. Place drill
    holes at the lateral margins of the trough in a distal but somewhat
    lateral direction so that the extensor mechanism will not be injured or
    trapped by the passing of the pullout suture. Pass the ends of the
    suture from the volar plate through the drill holes, and tie them over
    a protected button. To prevent tethering of the distal extensor
    mechanism, flex the DIP joint 30° when passing the sutures dorsally. As
    the suture is tied, flex the PIP joint. Apply gentle traction on the
    suture so the distal end of the volar plate is pulled snugly into the
    trough (Fig. 39.26B).
    Figure 39.26. A: Volar plate rupture usually occurs distal from the base of the middle phalanx. B:
    The distal margin of the volar plate is pulled snugly into a trough in
    the middle phalanx and secured through drill holes in the bone.
  • If there is not enough of the volar plate
    left to advance or repair, a volar reinforcement procedure can be used.
    With this technique, isolate either slip of the superficialis. Leave it
    attached distally and detach it proximally under the A2 pulley.
  • Place a drill hole transversely in the
    neck of the proximal phalanx. Draw the proximal end of the detached
    superficialis slip into the hole, using a pullout nonabsorbable suture,
    and tie it over a protected button (Fig. 39.27).

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    Take care to ensure that the superficialis slip is taut when the PIP joint is in 10° to 15° of flexion.

    Figure 39.27. One superficialis slip is fixed to the proximal phalanx, creating a tenodesis of the PIP joint.
  • Temporarily fix the joint with a
    0.035–0.045 smooth K-wire for 3 weeks, and then protect it with a
    dorsal-block splint for an additional 4 weeks.
Complications
The complications associated with treating volar plate
ruptures are the same as for dorsal PIP joint dislocations. Operative
repair for chronic volar plate ruptures, as for any ligament repairs or
reconstructions, can lead to some loss of motion and chronic
thickening. A flexion deformity is common.
METACARPOPHALANGEAL JOINT
Assessment and Indications for Treatment
Metacarpophalangeal joint injuries are frequently
associated with an injury to the volar plate, collateral ligament, and
joint articular surface, which require adequate assessment and AP,
lateral, and oblique radiographs of the hand (Table 39.3).
A Brewerton view or oblique view of the metacarpal heads may be helpful
to identify small fractures (see the section above on General Principles of Treatment) (171,185,189,206). Open dislocations require adequate debridement and antibiotics.
Table 39.3. Algorithm for Assessment of Metacarpophalangeal (MP) Joint Injuries
Injuries to the ligaments and dislocations of the MP
joints are uncommon. Most of these occur with the fingers in some
extension when the collateral ligaments are more lax. This provides
some margin for protection so that complete ligament rupture is
unusual. The most common mechanism of injury is hyperextension or ulnar
deviation of the joint. The most commonly involved joint is the index
finger, followed by the thumb and little finger. Central digit
dislocations are usually associated with dislocation of either the
adjacent index or little finger (42,151,153,154,156,170,177,180,182,187,188,195,200,202,211,212,216).
Metacarpophalangeal joint injuries are classified as
dislocations or collateral ligament injuries. The dislocations are
based on the direction of the dislocation (dorsal versus volar) and
whether they are easily reducible (simple) or irreducible without
surgical intervention (complex).
Dorsal MP Joint Dislocations
With a hyperextension injury to the MP joint, the
membranous portion of the volar plate usually ruptures off the
metacarpal neck. Dorsal MP dislocations can be classified as simple
(subluxation) or complex dislocations (165,172,174).
Simple MP joint dislocations are easily treated by closed reduction.
Take care not to converta simple dislocation into a complex dislocation
(165,172,176,190,383).
With simple MP joint dislocations, the proximal phalanx is
hyperextended on the metacarpal head, but some contact remains between
the MP joint articular surfaces. The proximal edge of the volar plate
lies palmarward over the metacarpal head. Therefore, the base of the
proximal phalanx should be pushed distally and palmarly. If
hyperextension with traction is mistakenly used, the volar plate can
slip dorsally over the metacarpal head and prevent reduction.
Interposition of the volar plate between the metacarpal
head and the base of the proximal phalanx makes this complex
dislocation irreducible (183). The lumbrical
medially and the flexor tendon laterally around the metacarpal neck
prevent reduction of the dislocation by longitudinal traction only (Fig. 39.28) (175).
With a complex dislocation of the little finger, the structures
preventing reduction include the abductor and flexor digiti minimi
ulnarly and the lumbrical and flexor tendon radially (154).
Figure 39.28.
The factors producing a complex dorsal MP joint dislocation (see text
for details). (From Kaplan EB. Dorsal Dislocation of the
Metacarpophalangeal Joint of the Index Finger. J Bone Joint Surg 1957;39A:1081, with permission.)
Clinically, the joint is slightly hyperextended, with
the phalanx appearing parallel to the metacarpal with a tendency for
the digit to overlap its neighbor (Fig. 39.29).
On the palmar surface, the skin is puckered or dimpled.
Radiographically, the joint space is widened, the joint surfaces are
offset, and the sesamoid appears to lie within the joint (Fig. 39.30) (163,175,201,208).
Figure 39.29. Complex MP dislocation with the finger parallel to the metacarpal.
Figure 39.30. The phalanx is offset at the MP joint, lying parallel to the metacarpal in a complex dislocation.
  • Attempt a single effort at a closed
    reduction under a good anesthetic in the operating room with the wrist
    flexed to relax the flexor tendons.
  • Apply pressure dorsally and distally to
    the base of the proximal phalanx while attempting to slide the proximal
    phalanx over the metacarpal head.
  • Confirm reduction clinically and
    radiographically. Assess active and passive joint stability, splint the
    hand with the MP joints flexed for a few days for comfort, and start
    early active motion with an extension-block splint. If a closed joint
    reduction fails, perform an open reduction.
Open Reduction of Complex Dorsal MP Joint Dislocations
Both the dorsal (158,160,177,183,187,199,201,204) and the palmar approaches (16,19,60,61,152,153,155,156 and 157,163,167,168 and 169,173,174,179,183,190,191,198,208,209 and 210,214,217) have strong advocates.
Dorsal Approach
  • Make a straight or slightly curvilinear dorsal incision over the joint.

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  • Longitudinally release the extensor
    tendon or the sagittal band (usually on the ulnar side) and perform a
    dorsal midline capsulotomy.
  • Identify and carefully incise
    longitudinally the volar plate in the midline; avoid damaging the
    metacarpal head articular surface. Flex the wrist to relax the flexor
    tendon and reduce the joint.
  • If needed, push the separate halves of the volar plate over and around the metacarpal head.
  • After the joint is reduced, separately
    repair the capsule, the extensor tendon or sagittal band, and the skin.
    Intraoperative postreduction radiographs should confirm congruous
    reduction of the joint.
  • As with a closed reduction, splint the
    hand with the MP joints flexed for a few days and then begin active
    motion with an extension-block splint.
Palmar Approach
  • Make an incision that connects the
    mid-axial line with the transverse mid-palmar crease. Take great care
    to avoid injury of the digital artery and nerve (especially the
    radial), which are pressed against the deep surface of the skin by the
    metacarpal head. Retract the nerves and arteries gently.
  • Incise the A1 pulley and retract the flexor tendons and lumbrical. The metacarpal head now dominates the field (Fig. 39.31A).
    Figure 39.31. A:
    When the skin is opened before reduction, the metacarpal head dominates
    the field. The flexor tendons lie ulnarly, the lumbrical and digital
    nerve radially, and the volar plate dorsally, blocking reduction. B: The volar plate (held by the forceps) has been extricated and the joint reduced.
  • Carefully make a longitudinal incision
    between the sides of the volar plate and the deep transverse metacarpal
    ligament. Insert a sturdy but narrow-angled dental probe or skin hook
    around the volar plate to extricate it from between the phalangeal base
    and the metacarpal head. The joint will snap into the reduced position (Fig. 39.31B).
  • Because the volar plate is still attached to the phalanx, no repair is needed.
  • Repair the skin incision and splint the
    hand with the MP joints flexed for a few days. Then start active
    motion, preventing MP joint hyperextension with a dorsal-block splint
    for 3–4 weeks.
Complications
Complications in treating dorsal MP joint dislocations
may result either from a delay in treatment or from overly aggressive
treatment. Damage to the articular surfaces can occur with repeated
attempts at a closed reduction or secondary to a forceful open
reduction. Traction and hyperextension of the digit can possibly
convert a simple MP joint dislocation into a complex dislocation.
Loss of joint motion and degenerative arthritis may
occur with delayed reduction. A combined volar and dorsal approach and
collateral ligament release may be needed to openly reduce a
longstanding dislocation (165,173,174,178,186,198,213).
Injury to the neurovascular bundles can occur in the palmar approach
with an inappropriate skin incision. Redislocation can occur if
hyperextension is not prevented, and loss of joint motion can occur
with prolonged immobilization.
Palmar MP Joint Dislocations
Palmar MP joint dislocations are rare (159,161,184,190,193,194,203,215,383). Avulsion of either the dorsal capsule

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from the metacarpal proximally or the volar plate from the proximal phalanx, or collateral ligament avulsion, can occur (159,197,203,215).
Interposition of these structures between the metacarpal head and
proximal phalanx can occur, producing a complex dislocation (174). If an attempt at a closed reduction under adequate anesthesia is unsuccessful, an open reduction is warranted.

MP Joint Collateral Ligament Injuries
Collateral ligament injuries of the MP joint often are
missed. Since the collateral ligaments of the MP joint are at their
longest or most taut in full flexion, testing for collateral ligament
stability must be performed with the joint flexed maximally. The
mechanism of injury usually consists of forced ulnar deviation of the
digits. The injury seems to occur mostly in the ulnar three fingers and
to the radial side (166,172).
Clinically, tenderness is present over the injured ligament, and stress
testing (passive radial/ulnar deviation) with the MP joint flexed
produces pain. Obtain radiographs, including oblique and Brewerton
views (171,185,189,206,213), to identify avulsion fractures. Stress views with the MP joint in full flexion may help confirm a ligament tear (213). Arthrography has been used to identify the location of the collateral ligament injury (164,181). The collateral ligament is avulsed off the metacarpal head most commonly but can also be torn distally or in midsubstance (195,196,213).
Initial treatment usually consists of immobilization
with the MP joints flexed 30° to 50° for 3 weeks, followed by taping
the finger to the adjacent digit for an additional 3 weeks (167,172,174). Surgery is advocated for gross instability of the joint (60,61,164,181,205,217),
an associated displaced avulsion fracture (displaced 2 or 3 mm), or a
displaced or rotated avulsion fracture involving 20% or more of the
articular surface (174). With persistent joint instability, late reconstruction has been advocated (164,166,178).
Operative Repair of MP Joint Collateral Ligament Injuries
Acute Collateral Ligament Ruptures
  • Make a longitudinal incision in the dorsum of the web space on the affected side of the digit.
  • Incise and retract the transverse fibers
    of the extensor hood. Incise the joint capsule dorsal to the collateral
    ligament parallel to its dorsal margin. Dissect and mobilize the
    ligament.
  • If there is an attached avulsion fracture
    of adequate size attached to the ligament, reduce and fix the bone
    fragment with one or two smooth 0.035 K-wires (Fig. 39.32).
    Figure 39.32. A: A displaced articular fracture usually is attached to the collateral ligament. B: K-wire fixation of the displaced fracture often must be done by placing the wire in the phalanx first.
  • If the fragment is too small, place a pullout suture around it. Place a drill hole obliquely connecting the

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    cortex on the opposite side of the phalanx to the site of the intended
    ligament attachment. Place the pullout suture through this hole and
    over a protected button.

  • Close the transverse fibers of the hood
    and skin in layers and check for congruous reduction of the joint and
    adequate alignment of the fracture fragment with radiographs.
  • Immobilize the hand with the MP joints
    flexed to 45° for 3 weeks and protected by taping the finger to the
    adjacent digit for another 3 weeks.
Chronic Collateral Ligament Ruptures
When chronic, these ligament tears often are only
minimally symptomatic. If they prove disabling, surgical treatment can
be difficult. The same approach as previously described is used.
Carefully tease out the collateral ligament, and mobilize it to its
maximum length. Repair the ligament to the phalanx by the pullout
suture technique. Perform closure as previously described.
Complications
Complications in treating MP joint collateral ligament
ruptures are usually due to undertreatment of the injury. They include
residual pain, joint swelling, instability (index finger with pinch),
and deviated digit (abducted little finger) (166,179,186,213).
Repairing or reconstructing the collateral ligament too
tightly (i.e., collateral ligament repair with the joint held in
extension) will result in a loss of joint motion.
CARPOMETACARPAL JOINT
Assessment and Indications for Treatment
Carpometacarpal joint dislocations are frequently
associated with intraarticular fractures, so adequate assessment of the
articular surfaces is needed with true AP, lateral, and oblique
pronated radiographs of the hand (Table 39.4).
Occasionally, tomography or a CT scan may be helpful to identify small
fractures. Open dislocations require adequate debridement and
antibiotics.
Table 39.4. Algorithm for Assessment of Carpometacarpal (CMC) Joint Injuries
Dislocations and Ligamentous Injuries
Dislocations and ligamentous injuries of the CMC joints
are virtually synonymous and will be considered together. Due to the
inherent stability of the CMC joints, which are further strengthened by
strong surrounding ligaments, pure CMC joint dislocations are uncommon;
fracture–dislocations of the CMC joints are much more common.
The most common site for subluxation or dislocation is at the base of the fifth metacarpal (221). The fifth and fourth metacarpals may dislocate together, or all four may do so (251). Often, an intraarticular fracture is associated with dislocation of the CMC joint (60,61,221,224,227,228,230,231,243,251,252 and 253,256,259,260,261 and 262,266,270,271 and 272,281).
Isolated dorsal CMC dislocations or fracture–dislocations generally
occur when a longitudinal compressive force is applied to the dorsal
aspect of the metacarpal head. This force produces a longitudinal
compressive and flexion moment to the metacarpal. Occasionally, volar
CMC dislocations can occur (218,224,228,257,265,267,277).
Multiple CMC dislocations or dislocations of the index and long CMC
joints generally occur when larger forces produce the injury. These
injuries are frequently associated with metacarpal shaft fractures and
soft-tissue injuries (219,222,227,230,231,235,237,238,242 and 243,245,246,247,248 and 249,251,252 and 253,254,257,264,268,269,273,274,275 and 276,278,279 and 280).
Careful evaluation of AP, lateral, and oblique radiographs reveals the injury (240).
A 30° pronated lateral view, which places the fourth and fifth CMC
joints in profile, will help in diagnosing dislocations or
fracture–dislocations of these joints (221,232,233,250). Tomography or CT scan can be used to further delineate the injury or help diagnose occult fractures (250).
For dislocations without fracture, treatment options
include a closed reduction, closed reduction and percutaneous K-wire
fixation, and open reduction internal fixation of the dislocation (229,236,239,244). Closed reduction is usually possible.
  • With adequate analgesia, apply
    longitudinal traction to the involved digit(s). Apply pressure over the
    dorsal base of the dislocated metacarpal in a distal and volar
    direction, then extend the metacarpal to help reduce the dislocated
    joint. Occasionally, closed reduction will fail because of interposed
    soft tissues or chondral fragments.
  • If the reduction is successful,
    immobilize the hand with the wrist extended, the MP joints flexed, and
    the IP joints extended for 3–4 weeks.
  • The CMC joint(s) must be frequently
    evaluated for redislocation. Because of the possibility of
    redislocation, closed reduction with percutaneous pinning is preferable
    (227,228 and 229,235,236,238,247,259,271).
  • Transfix the metacarpal to the
    appropriate carpal or an adjacent stable metacarpal. Small associated
    fractures with some articular incongruity are unimportant (270).
If redislocation occurs, closed reduction fails, or a
substantial intraarticular fracture is present and remains
significantly displaced after a closed reduction, do an open reduction.
Chronic dislocations usually require open reduction and internal
fixation. Extensive dissection with excision of scar tissue may be
necessary to achieve reduction. If symptomatic posttraumatic arthrosis
is present, a resection or resection–interposition arthroplasty is
useful, and an arthrodesis remains an option (220,221,223,225,226,229,234,236,241,245,246,254,255,258,260).
Open Reduction of a CMC Dislocation
Acute CMC Dislocation
  • Make a dorsal longitudinal or oblique incision over the affected joint. Protect the dorsal sensory nerve branches and veins.

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  • Retract the extensor tendons and
    visualize the injured joint. Retract the ruptured ligaments and debride
    any small loose fragments about the joint. Gently reduce the joint.
  • Reduce any intraarticular fractures and
    transfix them with one or two smooth 0.035–0.045 K-wires. If no
    fracture is present, reduce the dislocation and secure it with a
    0.035–0.045 smooth wire placed obliquely from the metacarpal across the
    joint into the appropriate carpal bone or to an adjacent stable
    metacarpal.
  • Ligament repair is unnecessary, although capsular closure can be performed. Confirm reduction of the joint with radiographs.
  • Close the skin and splint the hand for
    3–4 weeks, allowing full finger motion after the first few days. Remove
    the pins at 6 weeks.
Chronic CMC Dislocation
  • Use the same approach as described for an open reduction of an acute dislocation.
  • Incise and reflect the scarred ligaments
    by subperiosteal dissection. Perform an open reduction of the joint if
    the joint surfaces are preserved. Confirm proper position with
    radiographs.
  • If arthrosis is present, resect the
    proximal 1 cm of the base of the metacarpal. A tendon anchovy or a
    portion of the joint capsule may be interposed in the area of the
    resected metacarpal. Repair the dorsal ligaments and close the skin.
    Use K-wire fixation if the joint is unstable. Splint the hand for 3–4
    weeks, but permit early finger motion.
If a CMC arthrodesis is used instead of arthroplasty,
take care to preserve the transverse metacarpal arch by fusing the
fourth and fifth metacarpals in some flexion.
Complications
A delay in diagnosis or treatment of CMC dislocations may result in chronic CMC dislocation and subsequent arthrosis (281).
Undertreatment may result in a redislocation of the CMC joint following
closed reduction alone or secondary to premature removal of fixation
wires.
Injury of sensory nerves is common, so care in
protecting them is imperative. Improper pinning of metacarpals to
adjacent metacarpals can lead to a “pancake” hand from flattening of
the transverse metacarpal arch. Posttraumatic arthritis can occur with
poor surgical alignment of the carpometacarpal or intermetacarpal
joints.
THUMB
ANATOMY
The anatomy of the joints of the thumb is somewhat
different from that of the other digits. Like the finger MP joint, the
thumb MP joint is a condyloid joint allowing for flexion–extension and
abduction–adduction. The amount of thumb MP joint flexion varies
widely, ranging from 5° to 115° (356). Variable amounts of MP joint hyperextension can also occur, ranging up to 45° (average 8°) (285). The amount of MP joint abduction–adduction is less in the thumb than in the fingers (0° to 20°, average 10°) (296).
A slight difference in the shape between the proximal phalangeal
condyles produces a slight amount of pronation of the thumb with MP
flexion (285,308,373).
Like the finger PIP joint, the thumb MP joint is
supported by strong collateral and accessory collateral ligaments as
well as a volar plate. The adductor pollicis inserts into the ulnar
sesamoid located within the volar plate, as well as the proximal
phalanx. The abductor pollicis brevis and flexor pollicis brevis insert
into the radial sesamoid, also located within the volar plate.
Additionally, the adductor and abductor pollicis brevis tendons have an
insertion or expansion into the extensor aponeurosis (328,370,371,376).
Further support to the MP joint is provided by extensor pollicis longus
and brevis tendons associated with the dorsal MP joint capsule and the
flexor pollicis longus tendon, overlying the volar plate and sesamoids,
volarly. Stability is therefore provided by both static and dynamic
restraints.
The trapeziometacarpal joint consists of two saddle surfaces in apposition (Fig. 39.33) (287,389,391,392,393 and 394,406).
The longitudinal axes of each joint surface are oriented perpendicular
to one another, allowing flexion–extension, abduction–adduction, and
some pronation–supination (389,390,395).
An elongated volar lip of the thumb metacarpal provides an attachment
site for the volar metacarpal ligament to the tubercle of the
trapezium. Although it has a relatively loose capsular support,
thickenings in the joint capsule help provide joint stability. Four
ligaments have been frequently cited as the main stabilizers of the CMC
joint: the volar or anterior oblique (palmar trapeziometacarpal)
ligament, the dorsal (posterior) oblique ligament, the dorsoradial
ligament, and the intermetacarpal ligament (386,387,389,392,399,402,404,406,408,409,411). Tubercles on both the metacarpal and trapezium serve as attachment sites for these ligaments (Fig. 39.33).
Figure 39.33. A: Trapeziometacarpal joint seen from the volar side. T, trapezium; M, base of first metacarpal; 1, FCR tunnel; 2, radiovolar tubercle and ridge; 3, dorsoradial tubercle; 4, dorsoulnar tubercle; 5, volar metacarpal beak; 6, volar tubercle. B: Articular facets of the trapezium (T) and first metacarpal (M). 1, dorsal ligament; 2, FCR tunnel; 3, volar radial tubercle; 4, dorsoradial tubercle; 5, dorsoulnar tubercle; 6, volar metacarpal beak; 7, dorsal beak; 8, radial or lateral tubercle; 8, ulnar or medial tubercle. (From Zancolli EA, Cozzi EP. Atlas of Surgical Anatomy of the Hand. New York: Churchill-Livingstone, 1992, with permission.)
THUMB METACARPOPHALANGEAL JOINT
Assessment and Indications for Treatment
The assessment and indications for treatment are similar
to those of the MP joint of the fingers. Thumb MP joint injuries are
frequently associated with collateral ligament and volar plate
injuries, as well as an occasional intraarticular fracture.
Injuries to the ligaments and dislocations of the thumb MP joint are common and consist of dislocations, collateral

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ligament injuries, and volar plate ruptures. The dislocations are based
on the direction of dislocation of the phalanx (dorsal versus volar)
and whether they are easily reducible (simple versus complex).

Thumb MP Joint Dislocations
Dislocations of the MP joint usually are dorsal, resulting from hyperextension, and can be treated closed (296,299,308,309).
The dislocation results in a complete tear of the volar plate
proximally and usually of a portion of the collateral ligaments (377). Dorsal subluxation of the MP joint can occur with less severe hyperextension injuries (324). Volar MP dislocations are not as common (313,322,344,348,349,383).
Clinically and radiographically, hyperextension of the MP joint is
noted. Widening of the joint space is suggestive of soft-tissue
interposition. Interposition of the sesamoids between the metacarpal
head and the base of the proximal phalanx is highly suggestive of a
complex MP joint dislocation.
  • Perform closed reduction of the
    dislocated joint under adequate analgesia with the wrist and IP joint
    flexed to relax the flexor tendon.
  • Avoid longitudinal traction and
    hyperextension of the thumb MP joint, and push the base of the proximal
    phalanx distally and palmarly.
  • Confirm congruous reduction of the joint
    on radiographs and test for active and passive joint stability. Test
    for collateral ligament stability and treat accordingly (see sections
    below on collateral ligament ruptures).
  • Occasionally, dorsal dislocations may
    prove to be irreducible because of interposition of the volar plate or
    other structures (e.g., sesamoid, flexor pollicis longus) between the
    base of the proximal phalanx and the head of the metacarpal (296,301,310,312,323,329,341,343,354). When this situation is present, do an open reduction. Volar (323,341), dorsal (160,301), and lateral (354) approaches to the MP joint have been advocated.
Open Reduction of an Irreducible Thumb MP Joint Dislocation
  • Make a chevron-shaped incision on the
    radial aspect of the joint, bringing the apex of the incision somewhat
    palmarly. Take care to not injure the digital nerves, especially the
    radial.
  • Partially release the proximal flexor tendon pulley and retract the flexor pollicis longus.
  • Make a longitudinal incision between the
    radial collateral ligament and the edge of the volar plate. Place a
    stiff-angled probe or a skin hook behind the volar plate, extricate it
    from the joint, and allow the joint to reduce.
  • Repair the ligament, if needed, either directly or using pullout suture technique.
  • Close the skin. Confirm congruous
    reduction of the joint with radiographs. After initial immobilization
    for comfort for a few days, begin motion using an extension-block
    splint for 3–4 weeks.

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Thumb MP Joint Ulnar Collateral Ligament Ruptures
Ulnar collateral ligament ruptures of the MP joint, also
referred to as gamekeeper’s thumb and skier’s thumb, are common
injuries (289,295,296,304,305,325,343,345,346,351,368,371,385).
The mechanism of injury includes forceful abduction or radial deviation
of the thumb proximal phalanx. Other injured structures may include the
volar plate, the dorsal MP joint capsule, and the adductor aponeurosis,
or there may be an avulsion fracture of the proximal phalanx (289,293,296,297,304,305 and 306,322,327,329,333,340,343,347,357,362,371,376,378,379).
A Stener lesion (376) occurs
when there is interposition of the adductor aponeurosis between a
completely avulsed ulnar collateral ligament (avulsed from the proximal
phalanx) and the proximal phalanx ligament insertion site, or between
two ends of a midsubstance ligament tear (Fig. 39.34).
Interposition of the adductor aponeurosis interferes with healing of
the ulnar collateral ligament. Complete ligament avulsion is needed to
produce a Stener lesion; therefore, differentiating the complete from
partial ligament avulsion injury is necessary to diagnose a Stener
lesion. The reported incidence of a Stener lesion occurring with an
acute ulnar collateral ligament rupture varies with different series,
but it ranges from 14% to 83% (311).
Figure 39.34.
The ulnar aspect of the metacarpophalangeal joint of the right thumb.
After distal rupture, the ulnar collateral ligament has been folded
right over. The torn end sticks out proximal to the adductor
aponeurosis (shown divided in the lower picture).
(From Stener B. Displacement of the Ruptured Ulnar Collateral Ligament
of the Metacarpophalangeal Joint of the Thumb. A Clinical and Anatomic
Study. J Bone Joint Surg 1962;44B:869, with permission.)
There is painful swelling of the MP joint with localized
tenderness over the region of the ulnar collateral ligament, with
instability when gently applying radial stress to the thumb MP joint (289,295,296,304,311,356,371,376). If there is no end point of resistance and angular deformation is more than 30° compared to the uninjured thumb (Fig. 39.35), a complete ulnar collateral ligament rupture is likely (289,304,318,355,356,372).
Perform the test with the MP joint in full extension and at 30° of
flexion. Palpation of the end of the ruptured collateral ligament is
difficult, but it confirms a complete ligament rupture (282).
Local or nerve-block anesthesia may be helpful in testing the
collateral ligament if there is significantpain or muscle spasm (289,304,311,329,340,347,356,357,368).
Figure 39.35.
Complete instability to radial stress of the MP joint of the thumb.
(From Neviaser RJ, Wilson JN, Lievano A. Rupture of the Ulnar
Collateral Ligament of the Thumb—Correction by Dynamic Repair. J Bone Joint Surg 1971;53A:1357, with permission.)
Take radiographs to identify an avulsion fracture. In questionable cases, stress radiographs can be helpful (61,289,298,311,338,355) (Fig. 39.36).
These tests should not be done in the presence of a significant
articular fracture but can be of value with a small avulsion fracture.
The fracture is not always attached to the ligament (Fig. 39.37), so the position of the fracture fragment does not always identify the location of the ruptured ligament end (320,338).
Figure 39.36. Comparative stress radiographs showing instability of the left thumb.
Figure 39.37. Stress radiograph in which “avulsion” fracture follows phalanx, suggesting it is not attached to the ligament.
Arthrography, magnetic resonance imaging, and ultrasonography have been used to identify ulnar collateral ligament injuries (289,292,303,316,317,319,321,336,352,353,364,365,375), but in the majority of cases, the diagnosis can be made with the clinical examination and stress radiographs.

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Acute Thumb MP Joint Ulnar Collateral Ligament Injury
Treat partial ruptures with immobilization in a thumb spica cast for 4 weeks (311). Alternatively, in a compliant patient, an orthoplast splint can be used (374).
When an acute complete rupture is present, operative
repair provides the greatest security that a stable joint will result.
Theoretically, a complete ligament rupture without a Stener lesion can
be treated nonoperatively (296,360,376).
Because this lesion frequently cannot be determined by physical
examination, stress or plain radiographs, or arthrography, surgical
repair is usually recommended (30,60,61,296,304,306,310,322,329,337,340,343,344 and 345,349,352,355,371,376,379,382).
The ulnar collateral ligament can be directly repaired (midsubstance
tears) or reattached to bone by pullout suture technique, mini-suture
anchor, or absorbable tack, and by K-wires or tension-band wiring for
small avulsion fractures (286,288,308,326,332,363,366,381).
Repair of an Acute Thumb MP Joint Ulnar Collateral Ligament Injury
  • Make a chevron-shaped or curvilinear
    incision on the ulnar side of the MP joint. Take care not to extend the
    incision across the web space, which produces a contracting scar.
    Carefully elevate the skin flaps, protecting the branches of the dorsal
    radial sensory nerve. The torn ligament is usually seen at the proximal
    edge of the adductor aponeurosis.
  • Divide the adductor pollicis aponeurosis
    just ulnar to its insertion into the extensor tendon and reflect it for
    later repair. Remove loose bone fragments from the MP joint.
  • Note the level of injury to the ulnar
    collateral ligament. The ligament is typically avulsed distally from
    its insertion into the proximal phalanx. A midsubstance ligament tear
    may be directly repaired. Usually, the ulnar collateral ligament needs
    to be mobilized. Place a 4-0 nonabsorbable suture in its distal end
    using a modified Bunnell suture technique.
  • Roughen the base of the proximal phalanx where the ligament is to be attached. Place one or two drill holes

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    obliquely and through the opposite cortex. Place the ends of the
    sutures through the drill hole(s) and through the skin. Reduce the MP
    joint and tie the suture over a protected button. Alternatively, repair
    the ligament using miniature suture anchors placed within the bone
    trough (Fig. 39.23).

  • Repair any rent in the dorsal capsule.
    Place a suture in the volar ulnar corner of the volar plate–collateral
    ligament complex to repair any tears in this region.
  • If a small avulsed bone fragment is
    present, excise the fragment and repair the ligament; or, if the
    fragment is sufficiently large, repair it using K-wires or pullout
    suture technique.
  • Repair the adductor aponeurosis to the extensor mechanism and close the skin.
  • A K-wire can be used to transfix the MP joint, but it is usually not needed.
  • Immobilize the thumb in a spica cast for
    4 weeks and then begin protected motion in a removable custom splint
    for another 2–3 weeks. IP joint motion can be started earlier. Avoid
    forceful stressing of the ligament repair for 3 months.
Chronic Thumb MP Joint Ulnar Collateral Ligament Instability
When chronic MP joint instability is present, it usually results in weakness of thumb function (342).
Treatment options include reefing or imbrication of the scarred
collateral ligament or reattaching a remnant of scarred tissue to the
proximal phalanx (60,61,346,348,357,379), dynamic tendon transfers (283,310,311,327,340,351,367,368), static tendon transfers (305,334,357,379), free tendon grafting (284,290,305,308,309,339,344,355,369,371,379), or MP fusion (304,333,337,343,352,357,371). Joint arthrodesis is generally recommended if posttraumatic arthritis is present (296,304,314,317,345,352) (see Chapter 72).
If the joint is not arthritic, the following reconstructive procedures
are valuable. There are, however, many other techniques using tendon
grafts (284,308,335,339,350,371,379).
Repair of a Chronic Thumb Ulnar Collateral Ligament Injury
Adductor Pollicis Advancement for Chronic Thumb Ulnar Collateral Ligament Injury (Neviaser Technique)
  • Use the approach for the acute collateral ligament injury. Protect the digital nerves dorsally and palmarly (Fig. 39.38).
    Figure 39.38.
    Adductor pollicis advancement technique for chronic thumb ulnar
    collateral ligament injury. Capsuloligamentous complex is reefed, and
    the tendon of the adductor pollicis is advanced and inserted into a
    drill hole in the mid-axial region of the proximal phalanx.
  • Isolate and detach the major tendon of
    insertion of the adductor pollicis. Leave enough tendinous tissue to
    accept a pullout suture.
  • Mobilize a broad, proximally based,
    U-shaped flap on the metacarpal. Drill a bicortical hole in the ulnar
    mid-axial line of the proximal phalanx, 10–12 mm distal to the joint.
    Enlarge the opening on the ulnar side of the proximal phalanx to accept
    the adductor tendon.
  • With the joint reduced, imbricate or
    advance the flap of scarred collateral ligament and suture it to the
    residual soft tissue at the phalangeal base with a nonabsorbable suture.
  • Place a nonabsorbable modified Bunnell
    suture in the adductor tendon and pass it through the proximal phalanx
    to exit percutaneously on the radial side. With the thumb adducted, tie
    the suture over a protected button, making sure the adductor tendon is
    pulled well into the ulnar hole of the phalanx.
  • Repair the aponeurosis and skin
    separately and immobilize the thumb in a spica cast for 4 weeks. Then
    begin protected motion in a removable custom splint for another 2–3
    weeks. Remove the button and pullout suture at 5–6 weeks. Avoid
    forceful stressing of the ligament reconstruction for 3 months (351).
Free Tendon Graft for Chronic Thumb Ulnar Collateral Ligament Injury (Smith Technique)
  • Use the approach for the acute collateral ligament injury (Fig. 39.39).
    Figure 39.39.
    Free tendon graft technique for chronic thumb ulnar collateral ligament
    injury. See text for details. (From Smith RJ. Posttraumatic Instability
    of the Metacarpophalangeal Joint of the Thumb. J Bone Joint Surg 1977;59A:14, with permission.)
  • Drill a hole transversely, in a radial to
    ulnar direction, along the base of the proximal phalanx just distal to
    the articular surface.
  • Place the hole volar to the axis of joint
    motion. Place a suture in the end of the free tendon graft and pass it
    through the proximal phalanx to exit percutaneously on the radial side,
    pulling the tendon through the ulnar hole. Tie the suture over a
    protected button.
  • Alternatively, create two holes on the
    ulnar side of the base of the proximal phalanx, one dorsally and one
    volar to the axis of motion. Connect the holes within

    P.1296



    the medullary canal and enlarge them so that a free tendon graft (palmaris or long toe extensor) can be placed through them.

  • Pull the remaining portion of the free
    tendon graft to the metacarpal head. Make parallel longitudinal
    incisions in the remnant of the collateral ligament. Secure the tendon
    graft, with nonabsorbable sutures, to the metacarpal head by weaving
    the graft through the ligament.
  • Alternatively, place two holes in the
    ulnar side of the metacarpal head, one dorsal and one volar. Pass the
    tendon graft between the two holes and through an intramedullary
    tunnel. Pass the remaining portion of the tendon graft distally back on
    itself, parallel and volar to the other limb of the tendon graft.
    Suture the two limbs of the tendon graft to one another. Repair and
    imbricate, if needed, the adductor aponeurosis to the extensor
    mechanism and then close the skin (371).
Extensor Pollicis Brevis Tendon Transfer for Chronic Thumb Ulnar Collateral Ligament Injury (Sakellarides Technique)
  • Use the approach for the acute collateral ligament injury (Fig. 39.40).
    Figure 39.40.
    Extensor pollicis brevis tendon transfer technique for chronic thumb
    ulnar collateral ligament injury. See text for details. (From
    Sakellarides HT, DeWeese JW. Instability of the Metacarpophalangeal
    Joint of the Thumb. Reconstruction of the Collateral Ligament Using the
    Extensor Pollicis Brevis. J Bone Joint Surg 1976;58A:106, with permission.)
  • Transversely incise the scarred collateral ligament and create proximal and distal flaps.
  • Dissect and mobilize the extensor
    pollicis brevis. Detach either half or all of the tendon distal to the
    MP joint, leaving it proximally based.
  • Drill two holes, one dorsally and one
    medially, in the base of the proximal phalanx. Place a nonabsorbable
    modified Bunnell suture in the extensor pollicis brevis tendon and pass
    it through the dorsal hole, exiting medially. Suture the end of the
    tendon to the remaining proximal stump of collateral ligament. If no
    proximal metacarpal ligament stump is available, use a pullout suture
    technique. Repair and imbricate any remaining portion of the collateral
    ligament.
  • Repair the adductor aponeurosis to the extensor mechanism and close the skin. Stabilize the MP joint with a K-wire, if needed (368).
Complications
A delay in diagnosis or treatment of thumb MP joint
ulnar collateral ligament injuries can result in chronic MP joint
instability with pain, loss of pinch strength, and, with time,
arthrosis (335,382).
With surgical repair or reconstruction, sensory nerve
injury and web space contractures can occur. A loose ligament repair
may leave a lax joint. Loss of joint motion is common following
ligament repair or reconstruction. Residual pain can persist from
unappreciated joint arthritis.
Thumb MP Joint Radial Collateral Ligament Ruptures
Injury to the radial collateral ligament of the MP joint is less common than its ulnar counterpart (294,331,333,346,371)

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and is usually caused by forceful adduction, ulnar deviation, or
torsion of the thumb proximal phalanx. The radial collateral ligament
can be avulsed from either the base of the proximal phalanx or the
metacarpal head, or it can be attenuated in its midportion (294,300,371).
The dorsal joint capsule may also be torn. The thumb often lies in
ulnar deviation and slight pronation, a finding confirmed by
radiographs (Fig. 39.41). Without a radial
collateral ligament to provide stability, the proximal phalanx is
deviated ulnarly by the strong pull of the adductor pollicis. The
patient will have localized tenderness over the area of injury. The
metacarpal head may be prominent dorsoradially. Check with passive
ulnar stress of the MP joint with the joint in extension and at 30° of
flexion. Instability of greater than 30° as compared to the opposite
thumb, without a firm end point, is indicative of a complete tear of
the radial collateral ligament. Stress views of the MP joint may also
be helpful to determine the integrity of the ligament.

Figure 39.41. Radial collateral ligament rupture leaves the phalanx subluxated ulnarly by the strong pull of the adductor pollicis.
Treat partial radial collateral ligament injuries in a thumb spica cast with the thumb in a reduced position for 4 weeks.
Unfortunately, these injuries usually are not recognized
until found in the chronic state. As with the ulnar collateral
ligament, treatment options include direct ligament repair (304,343,371),
reefing or imbrication of the scarred collateral ligament or
reattaching a remnant of scarred tissue to the proximal phalanx (294,310), dynamic tendon transfers (294,310,350,351), free tendon grafting (291,307,371),
or MP fusion. If there is posttraumatic arthritis, do an arthrodesis.
If the joint is not arthritic, use the following reconstruction (350,351).
Repair of a Tear of the Thumb Radial Collateral Ligament
Acute Thumb MP Joint Radial Collateral Ligament Injury
  • Make a chevron incision on the radial side of the MP joint, protecting the dorsal radial sensory nerve.
  • Divide the abductor pollicis brevis
    aponeurosis just radial to its insertion into the extensor tendon, and
    reflect it for later repair. Repair the ligament either in midsubstance
    or to either the proximal phalanx or metacarpal head, depending on the
    area of injury. If the ends of the torn ligament are identifiable,
    divide the capsule and ligament transversely and imbricate them. Repair
    any capsular and extensor mechanism tears.
  • Close the skin separately. Stabilize the
    joint with a K-wire fixation if there is residual joint instability.
    Postoperative treatment is similar to that for ulnar collateral
    ligament tears.
Chronic Thumb MP Joint Radial Collateral Ligament Injury
  • Use the approach for the acute collateral
    ligament injury. Detach the tendon of the abductor pollicis brevis with
    sufficient length to hold a suture.
  • Create a proximally based, U-shaped flap of scarred radial collateral ligament mass.
  • Drill a bicortical hole about 10–12 mm distal to the joint. Enlarge the radial hole with a curet.
  • Imbricate or reef the ligament flap with
    the joint reduced. Pass a nonabsorbable suture through the abductor
    pollicis brevis tendon using a modified Bunnell suture technique. Pass
    both ends of the suture through the drill hole in the proximal phalanx
    and out through the skin on the ulnar side. Tie the suture over a
    protected button, making sure the tendon fits snugly in the radial hole
    (Fig. 39.42).
    Figure 39.42.
    Capsuloligamentous complex is reefed, and the tendon of the abductor
    pollicis brevis is advanced to a drill hole on the radial side of the
    phalanx in the mid-axial plane.
  • Close the skin. Immobilize the thumb in a
    spica cast for 4 weeks and then begin protected motion in a removable
    custom splint for another 2–3 weeks. Remove the button and pullout
    suture at 5–6 weeks. Avoid forceful stress on the ligament repair for 3
    months.
Complications
Complications in treating thumb MP joint radial
collateral ligament injuries are the same as those listed under ulnar
collateral ligament tears described earlier.

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Volar Plate Ruptures
Acute hyperextension injuries of the thumb MP joint are
common and can be diagnosed by eliciting tenderness over the volar
plate and detecting hyperextensibility of this joint (with the IP joint
flexed) compared to the opposite thumb (311,377).
Unlike the finger PIP joints, the volar plate detachment occurs
proximally from the metacarpal. Treat with dorsal-block splinting
(restricting the last 20° of extension) for 4 weeks.
For patients with chronic hyperextensibility at the MP joint, pain and weakness can occur with grasping or pinching (311,361,362).
For patients failing nonoperative measures, the operative options for
chronic MP joint instability include a volar plate capsulodesis (343,384), tenodesis (302,330), dynamic tendon transfer (361), or arthrodesis if arthritic changes are present.
Volar Plate Capsulodesis for a Thumb MP Joint Hyperextension Injury
  • Make a palmar zigzag incision and retract the digital arteries and nerves.
  • Incise the A1 pulley in its
    proximal portion and retract the flexor pollicis longus. Incise the
    intervals between the sides of the volar plate and the accessory
    collateral ligaments. Release the distally based volar plate proximally
    and excise the sesamoids subperiosteally.
  • Using an osteotome or a dental chisel,
    create a transverse trough in the metacarpal neck. Drill a hole through
    each edge of the trough obliquely through the metacarpal. Perform a
    trial reduction of the proximal edge of the volar plate into the
    trough. When the plate is properly seated, passive extension of the MP
    joint should be limited to 15° of flexion. If less flexion is evident,
    trim a portion of the free edge of the volar plate and recheck the
    position of the MP joint.
  • Weave a nonabsorbable suture through the
    free proximal edge of the plate, using a modified Bunnell technique.
    Pass the suture ends through the drill holes and the skin and tie over
    a protected button, thereby drawing the volar plate securely into the
    trough.
  • An alternative, but more difficult,
    method includes creating a synostosis between the sesamoids and
    metacarpal neck to produce a 15° to 20° flexion deformity of the MP
    joint. Transfix the joint with a smooth K-wire to maintain the joint
    position.
  • Suture the accessory collateral ligaments to the edges of the volar plate with 5-0 nonabsorbable suture and close the skin.
  • Use a plaster thumb spica splint for 4
    weeks, allowing IP joint flexion at 1 week. Remove the splint and pin
    at 4 weeks. Begin exercises with an extension-block splint for 2 more
    weeks, followed by removal of the button, suture, and splint.
Complications
Complications in treating thumb MP joint hyperextension injury include joint stiffness with prolonged joint immobilization (278).
Chronic instability can occur if hyperextension is not prevented for a
sufficient amount of time. Degenerative arthritis can occur after
chronic instability has developed (314).
Following surgical correction for chronic instability, a
permanent flexion contracture is common. Recurrent hyperextensibility
is the result of a loose capsulodesis, insecure fixation of the volar
plate to the proximal phalanx, or insufficient immobilization.
Posttraumatic sesamoid arthritis of the MP joint can occur. The radial sesamoid appears to be more frequently involved (380). Acute injuries should be treated with the immobilization of the MP joint, usually in slight flexion (315,359). Chronic injuries, refractory to nonoperative treatment, are usually successfully treated with sesamoid excision (358,380).
Sesamoid excision is performed through a volar approach to the MP joint
volar plate, with enucleation of the sesamoid through a longitudinal
incision in the volar plate (380).
TRAPEZIOMETACARPAL (CARPOMETACARPAL) JOINT
Assessment and Indications for Treatment
Thumb CMC joint dislocations are frequently associated
with intraarticular fractures. To assess, take true AP and lateral
radiographs of the thumb CMC joint (Robert view) (403).
Dorsoradial subluxation of the CMC joint may indicate ligament injury.
Stress radiographs may be helpful in diagnosing instability of the
joint (392,393,395).
The most common dislocation or ligament injury at this joint is the Bennett’s fracture–dislocation (see Chapter 40). Trapeziometacarpal dislocation without fracture is

P.1299



far less common but quite difficult to treat because of persistent instability (243).

Acute Trapeziometacarpal Dislocations
Trapeziometacarpal dislocations without a concomitant
fracture are rare. Most dislocations occur dorsally. The mechanism of
injury is thought to be axial compression with a load on the metacarpal
in flexion (405,411). Disruption of the dorsal ligaments probably occurs to allow the joint to dislocate (398,410,411), but the volar ligament is intact and is subperiosteally stripped off the base of the metacarpal (388,413).
Clinically, a prominence is noted dorsoradially at the base of the
thumb metacarpal with the thumb held is an adducted position, similar
to that seen with a fracture–dislocation at the CMC joint.
Treatment options include a closed reduction or open
reduction, with or without K-wire fixation, and thumb spica cast
immobilization (252,400,401,410,412).
  • Perform a closed reduction under adequate
    analgesia using longitudinal traction, abduction, and extension of the
    thumb. Place direct pressure on the base of the thumb metacarpal base,
    displacing it distally, volarly, and ulnarly.
  • Postreduction radiographs should confirm congruous reduction of the joint.
  • Immobilize in a thumb spica cast with the
    thumb held in abduction and extension and pressure placed on the
    dorsoradial aspect of the metacarpal base. With joint instability or
    radiographic signs of persistent subluxation, add percutaneous
    transarticular K-wire pinning. Remove the wires and cast at 6 weeks and
    begin exercises.
Despite successful reduction of acute dislocations of
the thumb CMC joint, instability and redislocation are common, and
early ligament reconstruction may be necessary. It is important to
monitor the patient radiographically after K-wire removal at frequent
intervals until it is certain that stability has been achieved.
Chronic Trapeziometacarpal Dislocations
For chronic dislocations or for recurrent instability
with posttraumatic arthritis, arthroplasty or arthrodesis is preferred
(see Chapter 71, Chapter 72).
If there is no significant arthritic change, do a ligamentous
reconstruction. The most widely accepted technique uses the flexor
carpi radialis as described by Eaton (390,392,395).
Thumb Trapeziometacarpal Ligamentous Reconstruction (Eaton)
  • Make an incision along the dorsoradial
    margin of the thumb metacarpal and curve it palmarward as it approaches
    the wrist flexor crease, ending over the flexor carpi radialis. Take
    care to protect the sensory nerves (Fig. 39.43 and Fig. 39.44).
    Figure 39.43. Stabilization of the trapeziometacarpal joint by half of the flexor carpi radialis (FCR).
    Figure 39.44. Using the accessory slip of the abductor pollicis longus (APL) to stabilize the trapeziometacarpal joint.
  • Extraperiosteally elevate the thenar
    muscle origin from the trapezium and metacarpal and retract it
    distally. Incise the roof of the flexor carpi radialis tunnel and any
    remaining volar radial CMC joint capsule.
  • Use a drill or gouge to create a tunnel in the metacarpal

    P.1300



    base dorsally between the extensor pollicis longus and brevis and
    exiting at the palmar beak of the metacarpal. Take care not to enter
    the trapeziometacarpal joint.

  • Longitudinally split half of the flexor
    carpi radialis for 6 cm, leaving it distally based. Expose the proximal
    portion of the tendon through transverse incisions over the tendon.
  • Pass the tendon through the bone trough,
    in a volar to dorsal direction, using a suture or wire to guide the
    tendon through the trough. Reduce and pin the joint with a smooth
    K-wire, avoiding the tendon slip.
  • Pull the tendon slip taut and suture it to the dorsal periosteum of the metacarpal.
  • Redirect the tendon slip beneath the
    extensor pollicis brevis and abductor pollicis longus proximally across
    the joint and back under the remaining intact portion of the flexor
    carpi radialis. Turn the tendon slip back to the palmar periosteum of
    the metacarpal, and suture it there. Place additional sutures wherever
    the tendon slip changes direction.
  • Close the skin and immobilize the thumb
    in a thumb spica cast for 4 weeks. Remove the K-wire and protect the
    thumb for an additional 2 weeks with a removable thumb spica splint.
    Start active exercises, but do not expect maximal return of motion for
    up to 4–6 months.
  • An alternative to using the flexor carpi
    radialis tendon is to use one of the slips of the abductor pollicis
    longus. The most common insertion for the commonly present second slip
    is into the trapezium (407). This natural anchor can be used to advantage.
  • Make a longitudinal incision starting
    along the dorsal ulnar side of the proximal third of the first
    metacarpal, curve it palmarward over the trapezium, and continue it
    along the anterior border of the first dorsal compartment.
  • Dissect free an 8 cm distally based slip of the abductor pollicis longus attached to the trapezium.
  • Use a drill or gouge to make a
    dorsal-to-palmar hole in the metacarpal parallel but distal to the
    trapeziometacarpal joint. Pass the slip of abductor pollicis longus
    tendon through the hole using a suture attached to the end of the
    tendon slip.
  • Reduce the joint and tighten the tendon. Loop the tendon back on itself and suture to its trapezial insertion.
  • Reinforce the new “ligament” by spreading
    it out and suturing it to the capsule on each side of the tendon
    wherever it crosses the joint.
  • Pin the joint with a smooth K-wire if
    necessary. Immobilize the thumb in a thumb spica splint or cast for 6
    weeks. When the cast and pin are removed, begin exercises (392).
Complications
Complications in treating thumb trapeziometacarpal
dislocations are usually the result of failing to identify the injury.
Failing to immobilize an incomplete ligament injury can lead to
persistent joint instability, requiring ligament reconstruction (391,392). Failingto recognize a complete dislocation will require an open reduction and ligament reconstruction (391,392,414). Persistent instability may lead to symptomatic joint arthritis requiring arthrodesis or arthroplasty (see Chapter 71, Chapter 72). Persistent subluxation can result if the new ligament is not tightened sufficiently with the joint reduced.
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