TRAUMA SURGERY
Surgical reconstruction using suture anchor for dislocationof the carpometacarpal joint of the thumb: a case report
Genki Okita • Satoshi Anayama • Nobutaka Sato •
Hirotaka Haro
Received: 17 March 2010 / Published online: 25 May 2010
� Springer-Verlag 2010
Abstract Dislocation of the carpometacarpal joint of the
thumb is a rare injury. This is the first report in the liter-
ature performing ligamentous reconstruction using suture
anchors in a case of severe joint instability after manipu-
lative reduction for dislocation of the first carpometacarpal
joint. Our surgical procedure successfully resulted in a
stable pain-free thumb 1 year postoperatively.
Keywords Carpometacarpal joint � Dislocation �Suture anchor � Thumb
Abbreviations
AOL Anterior oblique ligament
CMC Carpometacarpal
DRL Dorsoradial ligament
Introduction
Dislocation of the carpometacarpal (CMC) joint of the
thumb is an uncommon injury. There are three main
treatments for the injury: casting, pinning and ligamentous
reconstruction [1]. However, the proper treatment strategy
remains controversial. There are some reports describing
reconstruction with suture anchors for rupture of ligaments
and tendon (for example, digital collateral ligament and
finger extensor tendon) with good results [2]. In this case,
we have obtained a satisfactory result by performing
reconstruction using suture anchors for severe joint insta-
bility after manipulative reduction.
Case report
A 39-year-old motorcyclist was involved in a high-speed
head-on collision with an oncoming car. Three days after
injury, the patient attended a nearby clinic with pain at the
base of the right thumb, and was diagnosed with disloca-
tion of the first CMC joint. The dislocated joint was
manipulated and reduced easily in the clinic, but could not
be maintained in the reduced position prompting referral of
the patient to our clinic.
Physical examination revealed a bony prominence on
the first CMC joint. The patient additionally complained of
pain with activity of the thumb (Fig. 1). Radiographs
showed an isolated radial–dorsal dislocation of the joint
with no evidence of fracture (Fig. 2). Manipulation and
reduction was done, but failed to relocate the joint due to
severe joint instability.
Eight days after injury, open reduction was performed
using axillary nerve block. The first CMC joint was
approached through an anterior curvilinear incision along
the lateral margin of the first metacarpal. On the volar
aspect, there was avulsion of the anterior oblique ligament
(AOL), which was separated from the periosteum of the first
metacarpal bone. On the dorsal aspect, there was avulsion
of the dorsoradial ligament (DRL), which similarly was
separated from the periosteum of the trapezium, in addition
to capsule disruption. We sutured each of the ligaments and
the lateral capsule to its original position with micro suture
anchors (Mitek Products, Massachusetts, USA), and con-
firmed the joint was reduced and stabilized (Figs. 3, 4).
G. Okita � S. Anayama � N. Sato � H. Haro (&)
Department of Orthopaedic Surgery, Faculty of Medicine,
University of Yamanashi, 1110 Shimokato, Chuo,
Yamanashi 409-3898, Japan
e-mail: [emailprotected]
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Arch Orthop Trauma Surg (2011) 131:225–228
DOI 10.1007/s00402-010-1122-3
A plaster cast was applied with the thumb in the neutral
position. After 4 weeks, the cast was removed, and then
active and passive motion was instituted. At the 1-year
follow-up visit, radiological examination showed excellent
positioning of the thumb and no evidence of post-traumatic
arthritic changes. The patient complained of no pain,
instability or functional disadvantage.
Fig. 1 Physical examination revealed a bony prominence on the first
CMC jointFig. 2 Preoperative radiograph revealed a dislocated first CMC joint
Fig. 3 AOL, DRL and capsular
tear, which have been repaired
using suture anchor technique
Fig. 4 Postoperative
radiograph revealed the CMC
joint to be reduced and suture
anchors inserted in the
metacarpal bone and trapezium
226 Arch Orthop Trauma Surg (2011) 131:225–228
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Discussion
The first CMC joint is a saddle joint with perpendicular
transverse axes as both articular surfaces are concave.
These concavoconvex contours, by themselves, produce a
degree of intrinsic stability, whereas the ligaments and the
joint capsule play the principal role in stabilization [1].
Thus, the CMC joint injury needs a different treatment
strategy compared with the other digital joints due to
different anatomical structure. There has been a dominant
hypothesis in the literature that the DRL plays the most
important role in stabilizing the joint, which has been
postulated from an anatomical standpoint by Bettinger [3]
and corroborated by Strauch [4], who demonstrated
instability of the joint when the ligaments are sectioned.
Eaton [5] believes that the AOL is the key structure in
maintaining thumb stability. Therefore, Eaton favors
articular reconstruction using a portion of the flexor carpi
radialis tendon. This procedure, which is the most com-
monly used for ligamentous reconstruction, can cover not
only the AOL but also the DRL [6]. In the present case,
these avulsed ligaments were reconstructed using suture
anchors.
The mechanism of injury has been described as the
following three patterns (Fig. 5): (1) the base of the first
and second metacarpals is separated [7], (2) a longitudinal
force is directed along the axis of the first metacarpal with
the trapeziometacarpal joint in full flexion [8] and (3) the
first metacarpal is forced into hyperextension and external
rotation relative to the first CMC joint [9]. In the present
case, the handlebar was likely driven into the first web
space with separation of the base of the first and second
metacarpals with stretching and final rupture of the liga-
ments, resulting in dislocation of the joint.
There are three main treatments for dislocation of the
joint: casting, pinning and ligamentous reconstruction.
Watt [10] has reported a series of 12 joint injuries, in which
seven joints were stable after initial closed reduction on the
day of injury, obtaining good results from treatment with
six cast immobilizations and one pinning. In contrast, five
joints were unstable after closed reduction at 3 days and
3 weeks after the injury. In all of these cases (three casting
immobilizations and two pinnings), unsatisfactory results
were seen with subluxation and instability of the joint.
Nishiguchi [11] describes the treatment of four joints with
pinning: three were performed on the day of injury with
good results, and one was performed 12 days after the
injury and later required ligamentous reconstruction for
pain and instability. Simonian [12] reported 17 joints that
were reduced between 1 and 12 days after the initial injury,
of which joints in four of eight patients who were treated
with pinning later required ligamentous reconstruction for
recurrent subluxation and severe arthritis. Satisfactory
Fig. 5 The mechanism of dislocation of the first CMC joint. a The
base of the first and second metacarpals is separated. b A longitudinal
force is directed along the axis of the first metacarpal with the trapezio-
metacarpal joint in full flexion. c The first metacarpal is forced into
hyperextension and external rotation relative to the first CMC joint
Arch Orthop Trauma Surg (2011) 131:225–228 227
123
results were obtained in the other nine patients who were
treated with initial ligamentous reconstruction.
These results can be summarized as follows: if the joint
is stable after manipulation and reduction, cast immobili-
zation alone is adequate treatment [13]. Alternatively, if the
joint is unstable after reduction, pinning on the day of
injury is sufficient, with ligamentous reconstruction nec-
essary for healing without complication if repair is delayed
for 2 days after the initial injury because even intact liga-
ments are also stretched.
Ligamentous reconstruction is, however, invasive and
difficult; therefore, we believe that suture anchoring of torn
ligaments is adequate therapy if the ligamentous compo-
nents are relatively fresh and are able to hold suture.
In searching the literature, we have not found any reports
of dislocation of the first CMC joint that was treated with
suture anchoring. This is the first report in the literature
demonstrating a satisfactory result by performing recon-
struction using suture anchors for a severely unstable joint
after manipulative reduction for dislocation of the first
CMC joint. In conclusion, we propose the use of suture
anchor technique before ligamentous reconstruction for
dislocation of the first CMC joint.
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