No abstract

Level III.

Fracture dislocation of the carpometacarpal joints on the ulnar side of the hand is an uncommon injury. These are high-energy injuries seen in motorcyclists and boxers. The mechanism of injury involves violent, forceful dorsiflexion of the wrist combined with longitudinal impact on the closed hand. This article reports a case of fracture of the base of the middle finger with dislocation of the ring and little finger carpometacarpal joints. On first examination, a diagnosis of isolated, minimally-displaced, middle-metacarpal base fracture was made and deemed suitable for nonoperative management. The hand was splinted in a plaster-of-Paris slab. Later, a true lateral radiograph showed the exact nature of the injury. The fracture was successfully treated with closed reduction under general anesthesia and transfixation using Kirschner wires. Functional results were excellent with return to work at 10 weeks and excellent grip strength at 14 weeks. This injury may be missed in an acute setting in a busy accident and emergency unit. Swelling around the wrist with shortening of the knuckle should alert the clinician towards the possibility of such an injury. On routine anteroposterior view, overlap of joint surfaces, loss of parallelism, and asymmetry at the carpometacarpal joints should raise suspicion of the possibility of a subtle carpometacarpal injury. This article highlights the importance of a high index of suspicion, a true lateral radiograph, and careful evaluation of radiographs in diagnosing these injuries. Intensive postoperative physiotherapy is vital to achieving a satisfactory outcome.

A 16-year-old boy was running a 100 m sprint. About 40 m from the starting line, he felt a sharp snap in his right groin with moderate sudden pain. As he decelerated, there was similar snap with sudden pain in the left groin. He collapsed to the ground with moderate pain over both the groins. He was unable to get up from the ground and had to be carried off on a stretcher.On arrival in the emergency department by ambulance about an hour from the time of injury, the pain was still localised to both the groins and had somewhat subsided with analgesics. On examination, he was of moderate build with good muscular tone. His height was 178 cm and weight 72 kg. He had no obvious bruising or swelling. There was no deformity of the lower limbs, with both being held in neutral rotation. He was tender anteriorly over the hip and the anterior aspect of the iliac crest on both sides. Both hips were held in about 208 of flexion with the knees flexed to about 308. He was unable to straighten his leg. Rotational movements were not possible. Distal sensation and circulation were normal.A radiograph of the pelvis was performed which showed bilateral avulsion of the anterior superior iliac spine (ASIS) with almost symmetrical caudal displacement of the avulsed bony fragment on both the sides by about 2 cm (Figs. 1-3). This was confirmed on MRI scan.Full bone profile laboratory tests, full blood count, full biochemistry tests as well as growth and thyroid hormone levels were all normal.He was treated with analgesia and full bed rest in a semi-flexed hip position in 45-908 flexion for the first 2 weeks. A check X-ray at 2 weeks showed initial signs of callus formation and he was started on a course of gradual physiotherapy with increasing hip extension gaining full weight bearing training by 4 weeks and full ROM at 6 weeks (Figs. 4 and 5). He was kept on crutches until he regained full ROM in both hips at 4 weeks, and he returned to full sports activities and was free from pain by 10 weeks after the injury. Radiographs at 3 months showed both fractures were fully healed (Figs. 6-8).