Due to the difficulty of performing a closed reduction and maintaining the reduction in the event of a successful closed reduction, a surgical approach to this injury
is advisable. An attempt at a closed reduction can be performed in the operating room, thus allowing greater relaxation to the patient. In the event of a successful closed reduction, K-wire fixation of the dislocation should be performed to stabilize the reduction. (Figs. 55-5 and 55-6). A 0.45-inch K wire is placed on a power drill and penetrates the skin at the level of the proximal metacarpal flare of the involved joint. It is important to insert the wire dorsally to avoid injury to the deep motor branch of the ulnar nerve. The pins are bent and put past the skin when reduction and stability are achieved. The wrist is immobilized for 6 weeks in a cast and the pins are removed at 6 to 8 weeks.
Figure 55—6. (A) Note fourth CMC joint held in place by other pinned digits. (B) Lateral demonstrating the percutaneous pinning of multiple CMC joints using distal metacarpal entry points.
In the event of failure of obtaining a successful closed reduction, an open reduction should be performed. The joints can be approached via a transverse incision along Langer's lines at the level of the carpometacarpal joint. Reduction of the third carpometacarpal joint is the key to the reduction of the remaining joints as this joint functions as the keystone of the transverse and longitudinal arches of the hand. K-wire fixation of the reduced joints produces a joint that will remain stable during the course of immobilization. Internal fixation with pins, screws, or plates can be performed to maintain stability. High-energy injuries often require internal fixation as they are often associated with fractures.
In the event of multiple dislocations, K-wire fixation of all dislocated joints need not be performed. The second and third carpometacarpal joints should be stabilized, as they are the keystones of the hand, and the fifth carpometacarpal joint should be stabilized to avoid subluxation and ulnar deviation. The fourth carpometacarpal joint need not be pinned if its adjacent joints have been pinned, as the strong inter-metacarpal ligaments are not disrupted and will contribute to stability.
After reduction and pinning of the carpometacarpal dislocation, the hand should be splinted for pain management and soft tissue rest. After a week, gentle active and passive range-of-motion exercises of the fingers and wrist can be performed. The K wires can be removed after 6 to 12 weeks. Patients with concomitant fractures require the longer length of time before K-wire removal. After removal of the K wires, progressive active and passive range-of-motion and strengthening exercise should be performed.
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