Review Question - QID 217949

This patient has a subacute (>2 weeks) fracture dislocation of his fourth and fifth metacarpals with additional dorsal hamate fracture. Due to the delayed presentation, closed reduction attempts are unlikely to be successful and lead to suboptimal long-term outcomes.

Carpometacarpal joint (CMCJ) fracture-dislocations of the hand most commonly occur in the 5th digit secondary to axial load injuries (i.e. punching a wall). Many of these are isolated injuries without any concomitant fractures, however, may also involve the 4th digit. In the acute setting, the vast majority of these injuries can be treated with closed reduction and splint application with appropriate dorsal molding to prevent repeat dislocating events. Weekly follow-up with repeated radiographs to ensure continued reduction and joint continuity is paramount in nonoperative management. Like with any fracture, the chance of obtaining a closed reduction becomes more difficult with delayed presentations. When patients present in the subacute (>2 weeks) period with continued dislocation, there is often a block to reduction secondary to interposed scar tissue requiring operative open reduction with scar tissue removal and internal fixation.

Zhang and colleagues reviewed the effect of timing on the treatment and outcome of combined fourth and fifth CMCJ fracture-dislocations. In their prospective case series, they found that all 20 acute (<3 days from injury) CMCJ fracture-dislocations were successfully treated with closed reduction and splinting with the restoration of grip strength, ROM, function, and return to work at 1-year follow-up. The patients presenting with delayed diagnosis (>2 weeks) treated with conservative management had a long-term deformity, complaints of chronic pain, limited ROM, and decreased grip strength compared to those treated with ORIF. The authors concluded that acute CMCJ fracture dislocations be treated with closed reduction while delayed presentation should be treated with ORIF.

Catalano and colleagues reviewed the management of carpal fractures other than the scaphoid. They discuss that 4th and 5th CMCJ fracture-dislocations may be inherently unstable due to coronal plane hamate body fractures. They stress the importance of restoring the articular congruity for the hamate CMCJ articulation, as the increased mobility of the fourth and fifth CMCJ is highly prone to post-traumatic arthritis. They recommend early operative intervention with closed reduction and k-wire fixation versus open reduction internal fixation in these cases.

Figure A and B show AP and lateral imaging of left-hand 4th and 5th CMCJ fracture-dislocations. There is an appreciable dorsal hamate avulsion fracture on the lateral imaging as well.

Answer 1. Non-steroidal anti-inflammatory medications with routine follow-up would be inappropriate in the setting of continued dislocation of the 4th and 5th CMCJs.
Answer 2: Initiation of occupational therapy for range of motion and strengthening exercises will likely lead to worse long-term outcomes given the continued dislocation of the 4th and 5th CMCJs.
Answer 3. Reapplication of splint in situ with additional 3 weeks of immobilization would be inappropriate with continued dislocation of the 4th and 5th CMCJs.
Answer 4. Closed reduction with fiberglass cast application in a 3-week-old injury is a lofty goal and would not likely lead to a successful reduction. The resultant worse outcomes could be mitigated with operative open scar tissue removal, reduction, and fixation.