Does Irreducibility Always Mean a Complex Metacarpophalangeal Dislocation: Single-Institution Analysis of 33 Cases in Pediatric Population
Valeriy Shubinets, MD1,2; Rohil Shekher, BS2; David L. Colen, MD2; Ines C Lin, MD, FACS1,2; Robert Carrigan, MD1; Apurva S Shah, MD MBA1; Benjamin Chang, MD1,2
1Children's Hospital of Philadelphia, Philadelphia, PA, 2University of Pennsylvania, Philadelphia, PA
Introduction: Complex metacarpophalangeal (MP) dislocations are defined as irreducible injuries that have failed closed reduction and hence require open surgical release. Despite this well-accepted definition, we have treated several "complex" dislocations by closed reduction in the operating room (OR). This study sought to review our experience in order to better understand the potential management of MP dislocations.
Materials and Methods: A single-institution retrospective chart review was performed for patients less than 18 years of age who underwent closed or open reduction of MP dislocations. Fischer's exact test was applied to examine association (p<0.05 significant).
Results: We identified 33 patients. 82% of patients were male, and mean age was 10 years (range 3-17). Thumb was the most commonly dislocated digit (58%), followed by index (30%) and small finger (12%). On average, each patient had 2 prior unsuccessful attempts at closed reduction, either in the Emergency Department (ED) or outside facility, with 24% having 3-7 prior unsuccessful attempts. 85% of patients (28/33) were taken to the OR for definitive treatment. Of these, 14/28 (50%) were successfully close-reduced shortly after induction of general anesthesia. In one surgeon's experience, 10/12 (83%) OR patients were close-reduced. Neither the number of prior unsuccessful attempts at closed reduction nor the radiographic appearance suggestive of a complex dislocation (i.e., joint widening) correlated with likelihood of success (Fig. 1). Thumb was the most likely digit to be close-reduced compared to index or small finger (p = .04). For open reductions, a dorsal incision was most frequently utilized (64% cases) to remove the entrapped volar plate and free the metacarpal head.
Conclusions: We found in our pediatric population that a near majority of MP dislocations labeled as "complex" can be successfully reduced in closed fashion under general anesthesia. It is not clear whether this is due to more experienced surgeon in the OR or greater sedation. These results suggest that 1) a final closed reduction should be attempted in the OR after induction, even if evidence points to a "complex" dislocation, 2) there may be opportunity for improved teaching of closed reduction maneuvers for MP dislocations, and 3) current definition of simple (reducible) and complex (irreducible) MP dislocations may not truly dictate management via closed or open reductions.
Back to 2019 Abstracts