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Clinical Case 084: Difficult dislocation

OK Here is a quick case.  One that is a bit outside the norm – not your usual dislocation.

In this case a 14 yo boy presents after falling on the football field.  He landed awkwardly on his hand “popping” his index finger at the knuckle.

On arrival he has an obviously swollen, deformed MCP on the 2nd digit.

A quick X-ray looks like this (click to make the picture bigger!):

Q1:  What is the diagnosis?  Who is it named after?

Q2:  After a quick local block – you pull on the finger – but it aint budging.  Why?

Q3:  What is the most oft described strategy for managing this injury?

Hand MCPdlap

 

handmcdllat

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Comments

  1. I’ve never heard of an eponymous name for these.

    However, these are often impossible to reduce closed, because the metacarpal head can buttonhole between the flexor tendons, or the volar plate can interpose itself into the joint.

    Usually these are treated with open reduction without internal (metalwork) fixation; in a young child like this a couple of stitches into the volar plate and a POSI splint for 4-6 weeks followed by a period of buddy splinting should do the trick.

  2. If it aint going back in then its probably button-holed. i.e. flexor tendon involvement. Guessing named after ?Boutonierrie (French fails me). I always thought had to go for surgery, but keen to hear any tips/tricks!

  3. Something which is terrifying is that an injury as innocuous-seeming as this would, a hundred years ago, have crippled this boy for life. (presumably right-hand dominant, and the quadriga phenomenon would mean that he had markedly lessened grip strength in the other fingers of the hand).

    Crazy question: if you could not operate on this boy (imagine you’re in deepest Africa, and a young hunter has just sustained a hunting injury) what would your management be to maximise his long term outcome?

  4. Jordan Webb says:

    Pretty sure Kaplan first described complex MCPJ dislocations. I think the lumbricals get involved in the entrapment also.

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