THUMB MP JOINT DISLOCATION

DOCTOR CARMES
HAND CENTER
CLINIQUE DES EAUX CLAIRES
GUADELOUPE
 1- DORSAL THUMB DISLOCATION

Rare

To reduce this dislocation, the maneuver is particular.

An inadequate maneuver increases the severity of
the injury and makes surgical treatment mandatory.
 MECHANISM OF THE INJURY
Hyperextension with a part of
rotation
The head is going to pass
between the FPL and the thenar
muscles
The volar plate and the
sesamoid bones may lock into the
joint.

The collateral ligaments are

usually intacts (because they are
tense in flexion).
 CLINICAL PRESENTATION

Clinical diagnosis is usually easy:

Pain, functional limitation,

More or less severe deformity of

the thumb

X-rays confirm the diagnosis

But their analysis is delicate

Two types of lesions are described

1) SIMPLE DORSAL DISLOCATION

Pain

Functional limitation

Thumb in hyper-extension

X-rays: sesamoids are still

in contact with the
metacarpal head
2) COMPLEX DORSAL DISLOCATION

Pain

Functional limitation

Thumb is no more
extended but parallel to
the metacarpal. The MP
joint deformity is minimal

X-rays: Sesamoids are

posterior to the
metacarpal head
 X-RAYS

Confirm the diagnosis

Visualize possible associated

fractures

Different anatomical types

have been described but they
are of limited use
TAKE HOME MESSAGE

If you fail to do the correct maneuver,

you will change a simple dislocation to a
complex one, most often now irreducible

It only exists one maneuver of reduction

which needs adequate pain relief

After reducing the dislocation, you must

test the joint under fluoroscopy, another
good reason for adequate sedation
 REDUCTION WITH THE
MANEUVER OF FARABEUF

Was invented by Louis Farabeuf

(1841-1910), French surgeon who described
the anatomical lesions, the reduction
maneuver and the instrument he used.
 MANEUVER OF FARABEUF

Under local or regional

anesthesia +/- MEOPA
(Kalinox*)

Do not pull in the axis of the

thumb risk of incarceration of
the metacarpal head between
the FPL and thenar muscles,
while the sesamoids and volar
plate go dorsally over the
metacarpal head
 MANEUVER OF FARABEUF

Explain the patient how you

will perform the reduction

Increase the deformity

Then push the phalanx

distally while pressing the
base of P1 over the
metacarpal to reduce en
bloc the phalanx with the
sesamoids, the volar
plate and the FPL

Close reduction of this dislocation is easier if the insertions of the thenar muscles on the sesamoids are intact as
they serve as a guide for the solar plate to get back into its initial position (Weeks 1981)
 No traction in the thumb axis
sesamoids will interpose into the
joint
TESTING AFTER REDUCTION IS MADE
IN THE TWO PLANES
In the frontal plane

If there is a severe lesion

of one of the collateral
ligament (mostly MCL):
surgery is needed
 Then testing under fluoroscopy to better
understand the anatomical lesions and the
potential evolution to chronic volar instability
IN DORSAL DISLOCATION W/O FRACTURE

Which are the injured structures ?

Volar plate

3: metacarpal-sesamoid lgt
4: phalangeal-sesamoid lgt
5: Sesamoid

FPB (radial) or Adductor (ulnar)

 RUPTURE OF THE METACARPAL-SESAMOID
LIGAMENT

The most frequent injury (80%)

Close reduction is stable

In extension sesamoids stay close to the phalanx

Immobilisation 3-4 weeks with a gauntlet opening the

1st web
 IF

Rupture of the
Rupture of the phalangeal-
active sling
sesamoid ligament

Fracture of a sesamoid

Rupture of FPB tendon

Evaluation of the
necessity for surgery
RUPTURE OF THE PHALANGEAL-
SESAMOID LIGAMENT
Sesamoids do not follow the base
of the phalanx in extension
 FRACTURE OF A SESAMOID BONE

Difficult to see !

The name sesamoid comes from the greek, it is the flat and oval sesame plant
seed, an Indian plant used by the physicians as a purgative
 TWO TYPES OF SESAMOID FRACTURE

First description in 1915

Type 1: without volar plate rupture - stable with no

necessity for surgery

Type 2: with volar plate rupture (also described by

Stener) - unstable, needs surgical treatment.

3 clinical signs:
- Injury in hyper-extension,
- Palmar ecchymosis along the FPL tendon, at the level of
the MP joint, extending to the thenar eminence,
- Pain during pressure of the fractured sesamoid.
RUPTURE OF FPB TENDON

Hematoma, proximal pain,

pain increased by resisted
MP flexion if seen late

US can help for diagnosis

 2- PALMAR DISLOCATION OF THE THUMB MP

The EPL tendon is no more palpable, there

is a radial or ulnar displacement of the
tendon (EPL, EPB) with a paradoxal flexion
of the MP with an IP extension when the MP
is extended

Most often (15/17 cases) open reduction is

needed as the dorsal capsule and extensor
tendons tend to interpose.

Beware of an associated collateral ligament

injury which should be repaired surgically
 CONCLUSION

Rare injuries

Severe, complex injuries should be treated

surgically

A meticulous clinical examination with a complete

ligamentous testing is the key for choosing the
optimal treatment
 Hand center
Guadeloupe

MARIA
hurricane

Thank you