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Delayed Diagnosis of Dislocation of All Four Ulnar Carpometacarpal Joints. Surgical Treatment Strategy and Challenges.

Background  Carpometacarpal dislocations are rare injuries whose diagnosis is often missed initially. These injuries can be treated conservatively, as long as an anatomical closed reduction is achieved. However, in most cases, open reduction followed by internal or external fixation is necessary to reach a stable anatomical reduction. Case Description  A 32-year-old male was referred to our institution due to excess swelling of his right hand, 2 months after a motorcycle crash he sustained. During our imaging workup, a dorsal carpometacarpal dislocation of all four ulnar metacarpals was found accompanied by a fracture of the base of the fifth metacarpal. An open reduction was achieved using Kirschner wires and a small plate for arthrodesis of the fifth carpometacarpal joint. The postoperative follow-up on the 3rd, 6th, and 12th month was uncomplicated. The range of motion and grip strength was satisfactory on the 3rd month and almost full on the 6th month compared to the unaffected side. Literature Review  Carpometacarpal dislocations are rare hand injuries. They are often the result of a high-energy injury and their diagnosis is usually delayed or missed. The main reasons are the excessive pain and swelling of the hand which make the initial clinical examination difficult and the overlapping of the metacarpals on the X-ray, which make the radiological diagnosis challenging. Case Relevance  A delayed diagnosis needs urgent open surgical treatment to achieve an anatomical reduction due to the interposition of soft tissue, bony fragments, and newly formed callus. Diagnosis and treatment of these injuries demands a high clinical suspicion from the traumatologist. The role of computed tomography scan is invaluable and open reduction is the mainstay of treatment for the cases that are diagnosed late.

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