2, 3 CMC Joint Injuries: A Case Series and Review of the Evaluation, Diagnosis and Treatment
Zachary C. Hanson, M.D., Wellstar Atlanta Medical Center, Atlanta, GA and Gary M. Lourie, MD, The Hand and Upper Extremity Center of Georgia, Atlanta, GA
Acute injury to the second and third carpometacarpal (CMC) joints are uncommon injuries that are frequently missed on initial evaluation. Missed diagnosis and delayed treatment leads to significant rates of chronic pain and functional debilitation, while early identification and treatment dramatically increases the likelihood of a successful outcome. In this study we review the presentation, diagnosis, and treatment of 2, 3 CMC joint injuries and present a series of patients with these injuries to examine the delay in diagnosis, common mechanisms of injury, physical examination findings and treatment outcomes.
Methods & Materials
We retrospectively reviewed 40 patients diagnosed with 2nd and 3rd CMC joint injuries over a 15-year period at a specialty hand surgery clinic by a single, fellowship-trained hand surgeon. Patient charts were reviewed and injury mechanism, time to diagnosis, examination findings, treatment, long-term sequelae and treatment outcomes were reviewed.
38 patients (95%) were diagnosed on a delayed basis while only 2 (5%) were diagnosed within 2 weeks of injury; average time to diagnosis was 168 days. 16 (40%) occurred due to a motor-vehicle accident; another 16 (40%) were from sports injuries and 4 (10%) due to a direct blow (e.g., thrown punch, fall onto a closed fist). 63% of injuries involved the dominant hand. 60% were misdiagnosed prior to presentation, with "wrist sprain" being most common (30%). 14 (35%) were referred for "chronic wrist pain", with no formal diagnosis. On exam, 100% of patients had 2, 3 CMC joint point tenderness and reduced grip strength. Traditional provocative maneuvers (i.e. metacarpal shuck test and torque tests) were positive in less than 50% of patients, while the Kleinmann compression test was positive in 35 (87.5%). All patients received an initial trial of conservative treatment, 19 (47.5%) of which eventually required surgical intervention with temporizing k-wire stabilization or CMC arthrodesis. The 2 patients with acute CMC joint injuries required surgical stabilization, with complete resolution of pain and return to baseline level of activity by 6 months post-operatively.
Missed 2, 3 CMC joint injuries and delayed treatment is associated with significant rates of chronic pain and functional limitations. Patients diagnosed early and treated appropriately generally have a very good prognosis for pain relief and return to baseline function. A high clinical suspicion based on the history, physical exam and imaging is important to appropriately treat these patients and minimize pain and long-term morbidity.
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