double dislocations of the thumb joints have only been reported on four previous occasions , in all cases reported to date , the joints have dislocated dorsally .
we present the case of a 26-year - old male patient with simultaneous volar dislocations of the carpometacarpal and metacarpophalangeal joints of the thumb .
there was delayed operative treatment of this injury with ligament reconstruction and stabilization of the metacarpophalangeal joint .
this rare case provides a mechanism to this type of injury , highlights the importance of initial , and repeated clinical and radiographic review , highlights the soft tissue component to this injury , and demonstrates how even delayed treatment can result in a good functional outcome .
the thumb joints are vital to the co - ordinated , multidirectional and precise movements of the hand .
the thumb is positioned in a perpendicular plane to the other fingers , with the saddle - shaped carpometacarpal ( cmc ) joint providing six different planes of movement .
the metacarpophalangeal ( mcp ) joint of the thumb is more like an interphalangeal articulation with movements restricted to one plane .
dislocations of joints in the hand are relatively common ; however multiple dislocations of the thumb joints have been rarely described [ 1 - 6 ] .
these dislocations involve high - energy axial loading injuries to the thumb , and can also be associated with fractures and ligament disruption .
stiffness and pain after injuries to these joints can result in significant impact on activities of daily living .
there have been four other reports of double dislocations of the thumb in the literature .
our report of simultaneous volar dislocations of both of these joints is the first to be described .
a 26-year - old right - handed male horse - trainer injured his right hand while riding , as he raised his arm to protect himself from a low branch .
he presented to the accident and emergency department with a painful and obviously deformed right thumb .
this was a closed isolated injury , and he had no neurological or vascular deficit of the affected thumb .
there was also a fracture of the volar aspect of the base of the first metacarpal , which appeared to be an avulsion - type ( fig .
1 ) . ap and lateral radiographs of the initial injury under local anaesthesia block , the two dislocations were reduced with longitudinal traction , and the thumb was immobilized in a bennett s cast . upon review in fracture clinic
one week later , the position of the cmc joint was excellent , but there was slight radial translation at the mcp joint ( fig .
the patient declined operative intervention at this stage , and was maintained in his thumb cast .
the patient failed to attend subsequent clinic appointments , but was reviewed again four weeks after the injury . unfortunately in the interim , the patient had attended a minor injuries department and had his cast changed ( without a new x - ray ) after soiling it while at work . at this stage
the cmc joint was again well reduced , but there was approximately 30 degrees of radial angulation of the proximal phalanx at the mcp joint ( fig .
a dorsal approach was taken over the mcp joint in order to examine both collateral ligaments .
the radial collateral ligament was intact but the ulnar collateral ligament was completely ruptured , with disruption of the capsule extending around to the dorsal aspect of the joint .
the ulnar collateral was repaired by tying the ligamentous attachments from the metacarpal , to mitek ( de puy mitek , warsaw , in , usa ) sutures anchored into the proximal phalanx . finally the mcp joint was temporarily immobilized with a kirschner ( k ) wire ( fig .
ap and lateral radiographs one week post - operatively post - operatively the patient continued to work with horses , despite advice to the contrary .
the kirschner wire was removed three weeks post - operatively due to a superficial pin site infection , which was successfully treated with systemic oral antibiotics ( amoxicillin / clavulanic acid ) .
the patient was working and able to perform most of his manual tasks , although he complained of weakened grip strength .
he was found to have considerable stiffness at the 1st mcp joint , with range of movement limited from 0 to 30 degrees at 12 months the patient was pain free without restriction of function , and although he could fully extend his mcp joint , he could only flex to 50 degrees only ( compared to 90 degrees on the contralateral side ) .
double dislocations of thumb joints are rare , there are only six previous reports of concurrent dislocations of the cmc and mcp of the thumb , and of these only one report also includes an associated fracture at the base of the thumb .
interestingly , in the other case reports , both the cmc and mcp dislocated dorsally .
the accepted mechanism of this injury is a longitudinally directed force with hyperextension at the mcp , and slight flexion at the cmc joint .
when questioned he described gripping the reins with hands together , and then raising both arms above his head for protection just prior to impact .
this would cause his wrists to be flexed and radially deviated , with thumb metacarpals extended , and phalanges flexed .
the authors feel that a longitudinally directed force with the thumb in this position would account for this unique injury . in all of the previous reports ,
the cmc joint was unstable and required operative stabilization ; with k - wires in four cases , and ligament reconstruction ( eaton s procedure ) in two cases [ 1 - 6 ] . in two of these case reports ,
the radial collateral ligament of the mcp joint was unstable , and in another the ulnar collateral ligament was unstable .
all of these ligaments required repair , with additional k - wire fixation in one of these cases [ 2 - 6 ] . in their report of concurrent cmc and mcp joint dislocations , drosos et al
categorize mcp joint dislocations as simple ( reducible with a closed technique ) and complex ( irreducible with closed technique , requiring open reduction ) .
it has been postulated that the energy required to produce double dislocations causes more ligamentous damage , and hence greater instability that either injury on its own .
four weeks after the injury , the cmc joint of our patient was still in a good position , and although the lateral view of the mcp showed no subluxation / dislocation , the antero - posterior view of the mcp joint showed further radial angulation .
even though there was slight translation at the mcp joint at the one - week review , we were forced to opt for conservative management because the patient declined operative intervention .
certainly we did no harm by delayed operative fixation until three weeks later . in the case described by ibrahim and noor ,
the patient had both cmc and mcp joints dislocated for five weeks before operative repair was performed ; the cmc joint was stabilized with a sole k - wire , and at the mcp joint a k - wire plus radial collateral ligament repair .
farzan et al , report a case of a volar dislocated cmc which presented 3 months after the initial injury , due to pain and an inability to pinch and perform opposition .
this required open reduction , reconstruction with eaton s procedure , k - wire stabilization , and a thumb spica for six weeks . at four month
follow up thumb opposition was possible and pain - free , pinch and grip were near normal compared to the contra - lateral side , and the global reduction in thumb movement was only 10 degrees .
this injury can be treated non - operatively if assessed accurately at presentation , with close follow up .
marcotte and trzeciak , described a case of cmc and mcp dislocations , which were stable after closed reduction , with only slight laxity of the ulnar collateral ligament .
although the option of surgical stabilization was discussed , the joints remained anatomically reduced for the 5 weeks the patient remained in a cast .
the patient continued to have clinical and radiological follow up monthly , for 3 months to confirm the joints remained reduced . at 2 year
follow up , the thumb was pain free , stable , with a good range of movement and no evidence of arthritis . in our report , the patient was followed up for one year , similar follow up to the other reports .
moore et al followed up their patient for 9 years , with no evidence of arthritis or instability .
however , gerard et al , did report degenerative changes in the cmc and mcp joints in a patient with double dislocations .
given the severity of this injury , it is certainly conceivable that these patients would develop symptomatic degenerative changes in the long term .
our literature review suggests there are many options for the treating this injury : operative or conservative treatment ; treating both joints as separate injuries or together ; and ligamentous repair and/or k - wire fixation .
the key to these decisions seems to rest at the initial clinic review after successful reduction .
if instability can be assessed here and operative or nonoperative decisions made , then management can be tailored accordingly .
furthermore these injuries need weekly radiographic follow up if conservative treatment is opted for , so that any further subluxation or dislocation is highlighted early .
although the patient opted for initial conservative management , and even with delayed operative stabilization of one joint , the patient had a good functional outcome .
double dislocation of cmc and mcp joints of the thumb is rare entity ; however it behaves similar to isolated injuries .
 introduction : multiple dislocations of joints in the hand are rare . 
 double dislocations of the thumb joints have only been reported on four previous occasions , in all cases reported to date , the joints have dislocated dorsally.case report : we present the case of a 26-year - old male patient with simultaneous volar dislocations of the carpometacarpal and metacarpophalangeal joints of the thumb . 
 there was delayed operative treatment of this injury with ligament reconstruction and stabilization of the metacarpophalangeal joint.conclusions:this rare case provides a mechanism to this type of injury , highlights the importance of initial , and repeated clinical and radiographic review , highlights the soft tissue component to this injury , and demonstrates how even delayed treatment can result in a good functional outcome . 
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Case Report:
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Introduction
Case History
Discussion
Conclusion