Chronic with arthritic changes CMC arthrodesis

scaphoid, capitate, and second metacarpal bones. It is wedge-shaped; the dorsal facet is twice the size of the palmar facet, which causes fractures and dislocations to displace dorsally when the second metacarpal is driven into extreme flexion [7,9,93]. In addition to the orientation, the palmar ligaments are stronger than its dorsal attachments, and therefore the bone is susceptible to displacement dorsally. The trapezoid is perfused by separate circulations on the volar and dorsal surfaces, where 70% of the blood supply is delivered dorsally. When there is dorsal displacement, the vasculature may be ruptured, predisposing the trapezoid to avascular necrosis [93].

Fracture dislocations are the result of high-energy forces that create multiple injuries. Therefore the metacarpals, as well as the carpal bones, require a thorough inspection during treatment planning. Isolated injuries are caused by extreme palmar flexion by the second metacarpal leading to fracture or dorsal dislocation. Clinically, there is point tenderness at the dorsal trapezoid as well as pain exacerbation with manipulation of the second metacarpal bone. Plain radiographs often do not suffice, and a CT scan is required to make a definitive diagnosis. PA and oblique views may show an empty space with proximal migration of the second metacarpal or dorsal displacement of the trapezoid, respectively [7-9,93,94].

Nondisplaced fractures should be managed nonoperatively with a short-arm thumb spica cast for 4 to 6 weeks. Displaced fractures should be treated with closed reduction internal fixation versus ORIF. Closed reduction may be achieved by distraction of the thumb and second meta-carpal as well as palmarly directed pressure over the dorsal aspect of the trapezoid [93,94]. If closed reduction fails, ORIF is performed through a dorsal incision. Carpometacarpal arthrodesis is reserved for chronic mal- or nonunion with arthritic changes. Box 7 provides diagnosis and treatment guidelines.


Carpal fractures are uncommon but potentially devastating injuries. Physical examination and standard plain radiographs may reveal only subtle findings. Knowledge of expected fracture patterns and use of special radiographic views or CT scans should aid in making the diagnosis. Nondisplaced fractures should be treated nonoperatively. For intra-articular carpal bone fractures, virtually any amount of displacement is unacceptable and requires reduction and fixation. Depending on the bone, differing blood supply anatomy may play a role in the prognosis of nonunion and risk of AVN. Chronic cases of carpal nonunion, AVN, and arthritis my require salvage procedures of proximal row carpectomy, partial or complete wrist arthrodesis, or arthroplasty.


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Hand Clin 22 (2006) 517-528

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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