Delayed Open Reduction and Fixation of an Isolated Trapezium Dislocation.

We report a case of a 49-year-old patient with an isolated dorsal radial dislocation of the right trapezium that occurred in a context of polytrauma. At first, the lesion went unnoticed. The diagnosis was made 1 month later because of persistent pain in the thumb. An open reduction of the dislocation was carried out, and osteosynthesis using scaphoid-trapezium and trapeziotrapezoid pinning was conducted under fluoroscopic control. The patient was immobilized for 3 months after surgery. After 4 years, the mobility of the thumb was complete and painless.

Dislocations of the trapezium are rare injuries, and isolated dislocations without fracture are even rarer. They occur in the aftermath of high-energy traumas such as road accidents or as a result of crushing. Two therapeutic options have been described for the treatment: (1) treatment of the trapezium by reduction of the dislocation (it can be conducted by closed or open approach with Kirschner wire fixation), and (2) treatment by trapeziectomy.

The surgical treatment of trapezium dislocations is sometimes delayed because of misdiagnosis., The clinical results are mostly satisfactory. The complications usually described include pain, decrease in joint motion, or decrease in the strength of the thumb.3, 4

The choice of treatment should take several parameters into account, particularly the integrity of the peritrapezium articulatory surfaces, the presumed state of vascularization of the trapezium, and any delay in treatment. Long-term complications to be avoided are posttraumatic arthritis and osteonecrosis. In the literature, treatment by reduction and osteosynthesis has only been conducted in cases diagnosed early. Treatment for cases with delayed diagnosis has been trapeziectomy. To our knowledge, the case presented here is the first report of an isolated dislocation of the trapezium treated at a delayed time after the trauma by open reduction and stabilized using Kirschner wires, with a follow-up of more than 4 years.

Case Presentation

The patient was a 49-year-old right-handed gardener who was admitted to the intensive care unit after a motorbike accident involving high velocity and a fall on his right side. The patient had numerous traumas on the left-hand side: open fracture of the femur, open fracture of the distal part of the tibia, open fracture of the humeral diaphysis, and a closed fracture of the 2 bones in his forearm. On the right-hand side, a hemothorax and a fracture of the lateral tibia plateau were observed. Emergency medical treatment and surgery were performed, with stabilization of the vital parameters and control of the orthopedic injuries by external fixation. Open reduction and internal fixations were performed progressively after the general and local state (muscular and cutaneous) of the fracture sites had improved.

On the fourth day of hospitalization, the patient complained of pain in his right hand. Although a dislocation of the trapezium was visible on the x-rays, they were interpreted as normal (Fig. 1).

Figure 1

Hand radiograph at 4 days showing the anteroposterior and lateral views with trapezium dislocation (white arrow).

After 5 days in the intensive care unit, the patient was transferred to the traumatology and hand surgery unit. A month later, he alerted the surgery team once again to his right hand because he had observed a decrease in the joint motion of his thumb. He had minimal pain.

A clinical examination of the thumb found 55° of palmar abduction, −40° of palmar adduction, a Kapandji score of 9 (the patient was able to touch the fifth metacarpophalangeal joint crease with the tip of his thumb), and 0° of extension of metacarpophalangeal joint. Further x-rays were, therefore, conducted. They confirmed a dorsal radial dislocation of the trapezium. A scan confirmed the absence of associated bone lesions (Fig. 2).

Figure 2

A Anteroposterior and lateral radiographs and B computed tomography scan of the hand at 1 month showing interruption of the first Gilula arc (yellow line).

An attempt at reduction by external maneuver (by gripping the patient’s thumb and applying a distracting force, while simultaneously applying pressure on the radial aspect of the trapezium) was first made in the operating room under general anesthesia and fluoroscopic control. Because the reduction was impossible, it was decided to opt for dorsal surgical approach centered on the trapezium. A straight incision was made over the interval between the extensor pollicis longus and extensor pollicis brevis tendons. Scaphoid-trapezium and metacarpal-trapezium arthrotomies were conducted, and no major chondral damage was observed once the joint debridement was performed. Anatomical reduction of the scaphotrapezial joint was obtained by putting back the trapezium on the scaphoid using a Joseph periosteal elevator to aid in distraction. The trapezium was stabilized using 2 scaphoid-trapezium Kirschner wires of 1.5 mm (0.059 in) and 1 trapeziotrapezoid Kirschner wire of 1.2 mm (0.047 in) (Fig. 3). The hand was immobilized after surgery with a thumb spica cast. The cast was discontinued, and Kirschner wires removed at 3 months. Physiotherapy sessions were initiated. At 4 months after surgery, the hand was painless. At the 4-year follow-up, the patient did not report any pain, the joint motion was 90° of palmar abduction, 20° of palmar adduction, 0° of extension at the metacarpophalangeal joint, opposition reached 9 according to Kapandji’s score, and the strength of the thumb was identical to that on the contralateral side. There were no signs of posttraumatic arthritis or osteonecrosis of the trapezium on the x-rays (Fig. 4). However, the patient did not resume work because of complications related to his tibia and femur fractures (pseudoarthrosis).

Figure 3

Intraoperative images showing A dorsal surgical approach and B fluoroscopic control

Figure 4

Hand radiograph at 4 years showing the anteroposterior and lateral views.

Discussion

Dislocations of the trapezium are rare; only 16 cases have been reported in the literature since the 1950s. They can either be isolated or associated with fractures of other bones in the hand and the wrist. They are mostly secondary to high velocity trauma (motorbike accidents) or trauma involving crushing of the hand. The stability of the trapezium and of the metacarpal-trapezium joint is controlled by a complex network of 16 ligaments., Clinically, a dislocation of the trapezium is usually diagnosed when a functional loss is reported in the thumb, such as pain or a decrease in range of motion, mandating a complete x-ray assessment of the hand. Diagnosis is made on the observation of an interruption of the first Gilula arc on the trapezium. Optimal surgical treatment is urgently required. In the literature, 14 (87.5%) cases have been reported with treatment within 7 days following the trauma, and 2 (12.5%) cases have been reported with treatment after more than 3 weeks (Table).1, 2, 3, 4 Early treatments have consisted of a closed reduction of the dislocation with or without stabilizing Kirschner wires or open reduction with Kirschner wires. In 2 cases, a trapeziectomy was carried out early on because of a major damage to the metacarpal-trapezium joint, or the trapezium was found to be completely detached from soft tissues, which could have rapidly led to osteonecrosis., Trapeziectomies have also been conducted in cases of delayed treatment (more than 21 days), including 1 for failure in an initial open reduction. In the literature, clinical results have been satisfactory for all treatment types (no pain and complete thumb range of motion). However, the small number of cases reported, the different types of injuries and associated lesions and their treatment, and an often insufficiently long period of follow-up do not allow any recommendations to be drawn concerning the best therapeutic strategy.

Table

Review of Cases of Dislocations of the Trapezium Since 1950

Treatment Delay		Publication (Case)	Type of Treatment	Sequelae	Follow-Up
Early treatment	1 d	Brewood	Closed reduction and percutaneous fixation	No	7 wk
		Clarke and Raphael	Open reduction and fixation	Scaphotrapeziotrapezoid arthritis	20 mo
		Kenyon et al	Closed reduction and percutaneous fixation	No	8 wk
		Mckie et al	Closed reduction	No	Approximately 3 mo
		Sherlock3 (case 1)	Open reduction and fixation	Stiffness of the thumb with a decrease in opposition	12 mo
		Sherlock et al (case 2)3	Open reduction and fixation	Lateral subluxation of the trapezium, trapeziotrapezoid sclerosis	6 mo
		Siegel and Hertzberg	Open reduction and fixation	Reduction in articulatory amplitudes (interphalangeal flexion, adduction, and opposition of the thumb), adherence of the flexor pollicis longus	34 mo
		Vente and de Ruiter	Closed reduction	No	13 mo
		Wintman et al	Closed reduction and intracutaneous fixations	Occasional mechanical pain during hard labor	1 y
		Seimon	Open reduction and fixations	Decrease in opposition and abduction, destruction of the carpometacarpal articulation	16 mo
		Peterson2 (case 1)	Trapeziectomy	No	4 mo
	2 d	Ichikawa and Inoue	Closed reduction and percutaneous fixation	No	2 y
	3 d	Goldberg et al4	Trapeziectomy	Decrease in thumb opposition and abduction and interphalangeal flexion compared with the contralateral side, shortening of the thumb by 1cm	8 mo
	5 d	Boe	Open reduction and fixation	No	2.5 y
Delayed treatment	21 d	Harris et al1	Trapeziectomy	No	3 mo
	1 mo	Case presented	Open reduction and fixation	No	4 y
	14 wk	Peterson2 (case 2)	Trapeziectomy	No	1 mo

This case is, to our knowledge, the first report of an isolated dislocation of the trapezium with delayed treatment (1 month) by reduction and Kirschner wire fixation and with a long-term follow-up (4 years). This therapeutic option was chosen despite the delay in treatment because the patient was a young manual worker. Additionally, the state of the articulatory surfaces observed perioperatively on the trapezium was satisfactory. Furthermore, the vascularization of the trapezium looked preserved as soft tissue attachments persisted, and the trapezium was not damaged 1 month after dislocation. The aim was to preserve the bone structure and to avoid any complications from trapeziectomy, particularly a loss of strength in the long term, and scaphotrapezoid arthritis. Furthermore, if posttraumatic arthritis results, the preservation of the trapezium enables a carpometacarpal implant to be inserted or a late trapeziectomy to be performed. A correct analysis of the hand x-ray of our patient in the intensive care unit would have enabled an early diagnosis to be made by applying the criteria defined by Harris et al. This would have enabled more rapid treatment, with a probable reduction of the dislocation by external maneuver, thus decreasing the risk of iatrogenic devascularization of the trapezium as a result of surgery. In cases of polytrauma, certain lesions of the extremities can go unnoticed if the x-ray analysis is not meticulous and methodical, as attention is given to more crucial vital parameters and osteoarticulatory damage. Once the diagnosis of dislocation of the trapezium was established on the basis of the second x-rays, we completed a scan of the hand to look for any associated lesions.

Reduction associated with the fixation of an isolated dislocation of the trapezium is a viable therapeutic alternative, even in subacute cases when articular cartilage is preserved, and it can lead to anatomical and functional restoration of thumb function.