2nd to 5th Carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture: a case report and literature review

2nd to 5th Carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture: a case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report 2nd to 5th Carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture: a case report and literature review Dong Pan, Renqi Liu, Mengneng Zhou, Xvhui Chen, Yanghua Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6726639/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Multiple carpometacarpal joint dislocations are among the rarer injuries with a limited number of associated case reports. Currently, most clinical reports focus on single joint dislocations, while reports of multiple carpometacarpal dislocations with rupture of the extensor carpi radialis longus tendon stop are rare. Case presentation: In this article, we report a case of a 35-year-old male patient, who sustained dislocations of the 2nd to 5th carpometacarpal joints of his left hand due to a car accident. He underwent incisional reduction and internal fixation, during which a rupture of the extensor carpi radialis longus tendon stop was detected and repaired. Postoperatively, the joint was successfully maintained in its original position without subluxation, and rehabilitation exercises were initiated gradually after pain relief the day following surgery. At the last follow-up visit two months post-surgery, the patient exhibited good flexion and extension function of the finger joints. Discussion and conclusion: Multiple dislocations of the carpometacarpal joints are often accompanied by avulsion fractures of the carpal bones and the bases of the metacarpal bones. The base of the second metacarpal bone, which serves as the attachment point for the radial extensor carpi radialis longus tendon, can be fractured by the pulling force. This type of injury is associated with significant hand swelling, increasing the risk of underdiagnosis and misdiagnosis. The purpose of this article is to share a case of 2nd to 5th carpometacarpal joint dislocation with extensor carpi radialis longus tendon stop rupture to provide a reference for clinical management. Multiple carpometacarpal joint dislocations extensor carpi radialis longus tendon rare case report Figures Figure 1 Background Multiple carpometacarpal dislocations are usually caused by high-intensity external forces on the wrist. Due to the strong capsular-ligamentous structure of the carpometacarpal joint and its intrinsic stability, this type of injury is rare, accounting for only 1% of all acute wrist injuries [ 1 ] . Concomitant rupture of the extensor carpi radialis longus tendon stop is even rarer. The tendon attaches to a rough indentation dorsal to the base of the second metacarpal bone, forming a “cap” structure on the dorsal aspect of the second metacarpophalangeal joint, providing additional stability against dorsal subluxation [ 2 ] . High-intensity external injuries causing multiple carpometacarpal joint dislocations can easily lead to tearing of the extensor carpi radialis longus tendon stop. This type of injury is often underdiagnosed in clinical settings. The biomechanical mechanism of these dislocations combined with tendon rupture is not clear. In this paper, we report a case of 2nd to 5th carpometacarpal joint dislocation with extensor carpi radialis longus tendon stop rupture. Case presentation A 35-year-old male patient was admitted to the hospital by the emergency department two hours after a car accident, presenting with swelling and pain in his left hand. Physical examination revealed a "step-like" deformity in the palm of the left hand, with obvious swelling, tenderness, palpable abnormal movement and Snapping sound, and limited active/passive flexion and extension of the 2nd to 5th fingers. X-ray and CT showed dislocation of the 2nd to 5th metacarpocarpal joints on the left side, and avulsion fracture of the capitulum and the bases of the 2nd and 3rd metacarpal bones (see Figure 1A-D). The left upper limb was immobilized in a plaster cast, and the dislocations were treated with incisional reduction and internal fixation surgery after five days of swelling reduction. Intraoperative exploration revealed a rupture of the radial extensor carpi radialis longus tendon stop, and the extensor carpi radialis longus tendon stop was then repaired (see Figure 1E-F). Surgical procedure: The surgery was performed under brachial plexus nerve block anesthesia, with the patient in the supine position and the affected limb fixed in abduction. The 3rd and 4th metacarpophalangeal joints were treated first, and a longitudinal incision was made on the dorsal side of the metacarpophalangeal joint between the 3rd and 4th metacarpophalangeal joints to incise the skin and subcutaneous tissues. The extensor tendon space was then bluntly separated to fully expose the joints. Intraoperatively, complete dislocation of the 3rd and 4th metacarpophalangeal joints, avulsion fracture of the capitellum and the base of the 2nd and 3rd metacarpal bones, and complete rupture and retraction of the dorsal carpometacarpal ligament were identified. Following anatomical repositioning of the joint, temporary fixation with Kirschner's pin was performed, and C-arm fluoroscopy confirmed that the articular surfaces were well-matched, followed by final fixation with two nickel-titanium memory alloy loopers and repair of the dorsal carpometacarpal ligament with a 2.0-mm-diameter anchor nail. Subsequently, the 5th carpometacarpal joint was treated and cross-fixed with 2 Kirschner's pins after repositioning by traction compression technique. The 2nd carpometacarpal joint was then addressed. Another longitudinal incision was made on the dorsal side of the palm between the 2nd carpometacarpal joints, with incision of the skin and subcutaneous tissues, blunt separation of the extensor tendon gap, and visualization of the operative field, It revealed that the 2nd carpometacarpal joint dislocation was accompanied by a complete rupture of the dorsal carpometacarpal ligament with a second metacarpal base avulsion fracture and a rupture of the extensor carpi radialis longus at the stopping point of the tendon, which was then retracted. After repositioning, the joint was temporarily immobilized with a Kirschner pin, fixed with a memory alloy ring hugger, and the extensor carpi radialis longus tendon stop was reconstructed with an anchor nail with a diameter of 2.0 mm, along with the repair of the dorsal carpometacarpal ligament.. Intraoperative C-arm fluoroscopy confirmed satisfactory repositioning of the joints and proper placement of the internal fixation (see Figure 1G-H). The incision was closed layer by layer. Progressive rehabilitation commenced the day after surgery. At the 2-month postoperative follow-up, the DASH (Disabilities of the Arm, Shoulder, and Hand) evaluation scale score was 3.33 (see Appendix). The patient's finger joint flexion and extension mobility returned to normal, and her hand grip strength and wrist function recovered well (see Figures 1I-J). Discussion The mechanism of injury in multiple carpometacarpal dislocations is usually closely related to high-impact trauma. The articular surfaces of the 2nd to 5th carpometacarpal joints are planar micromotor joints, interconnected by multiple ligaments, including interosseous ligaments and dorsal metacarpal lateral ligaments, providing stability and resulting in relatively low joint mobility. Dislocation of the carpometacarpal joint is typically accompanied by avulsion fractures of the base of the metacarpal and carpal bones due to these stable ligaments and muscle attachment structures [ 3 ] . However, simultaneous dislocation of the 2nd to 5th carpometacarpal joints combined with rupture of the long extensor carpi radialis tendon stop is rare in clinical practice. According to some scholars [ 4 – 5 ] , multiple dislocations of the carpometacarpal joints with rupture of the extensor carpi radialis longus tendon stop can only occur when the hand is subjected to strong force in two opposite directions simultaneously, resulting in complete tearing and injury of the ligaments around the carpometacarpal joints. The mechanism of injury in this patient was a car accident impact with the hand acting as a support. The palm and elbow joints were subjected to simultaneous violence in opposite directions, with distal violence transmitted longitudinally via the 2nd to 5th metacarpal bones and proximally via the ulnar radius. This concentrated violence on the carpometacarpal joints led to hyperflexion of the wrists and contraction of the extensor carpi radialis longus tendon, causing dislocations of the carpometacarpal joints and ruptures of the radial extensor carpi radialis longus tendon stop. Therefore, there should be a high degree of suspicion for such hand injuries when evaluating x-ray of high-energy trauma. A systematic evaluation of the carpometacarpal joint is necessary. In addition, the hand is evident swelling after injury. And severe swelling tends to mask the deformity caused by dislocation of the carpometacarpal joint, increasing the risk of underdiagnosis and misdiagnosis. Therefore, in addition to routine frontal and lateral radiographs of the wrist, CT scans should be performed to clarify the type and extent of carpometacarpal joint dislocation [ 6 ] . Although there is a paucity of literature on multiple carpometacarpal joint dislocations with long extensor carpi radialis longus tendon stop rupture, some relevant clinical studies exist. Suwannaphisit et al. [ 7 ] and Al - Batta et al. [ 8 ] reported rare cases of multiple 2nd − 5th carpometacarpal joint dislocations due to automobile accidental injuries; and Jorgensen et al. [ 9 ] described a rare case in a 17-year-old patient with a basal fracture of the third metacarpal with dislocation of the 3–5 carpometacarpal joints, the patient regained normal functionality of the hand after surgical reconstruction. Najefi et al. [ 10 ] and Shyamsundar [ 11 ] shared cases of basal avulsion fracture of the 2nd metacarpal due to avulsion of the extensor carpi radialis longus tendon. In all of these cases, the providers provided adequate clinical assessment and intervention to the patients in the early stages of the disease and combined with physiotherapy in the later stages of the disease, which effectively improved the prognosis of the clinical treatment. This contrasts with a previous report of a patient who suffered disability and loss of function in the same time interval [ 12 ] . This shows that early diagnosis and treatment are crucial for multiple carpometacarpal joint dislocations with extensor carpi radialis longus tendon stop rupture. To the best of our knowledge, such mixed injuries have not been described in detail in clinical practice yet. The main reason is the stable joint-capsular complex structure of the carpometacarpal joint. Due to the limited number of reported cases, clinicians are not well aware of this type of injury. Therefore, there is no consensus on treatment [ 13 ] . Common treatments include closed reduction cast fixation, percutaneous internal fixation, and open reduction and internal fixation. It has been reported that patients can have near-normal hand function after conservative treatment with cast immobilization [ 14 – 16 ] . However, conservative treatment is often accompanied by a high complication rate due to the high likelihood of subluxation. And a dislocated carpometacarpal joint can lead to severe hand disability [ 17 ] , a ruptured radial long extensor carpi radialis brevis tendon can also result in decreased wrist strength and mobility, and even trigger secondary instability or redisplacement [ 18 ] . Therefore, early intervention is crucial for restoring pinch and grip strength in patients. Based on this, surgical treatment with open reduction and internal fixation should be chosen as early as possible to achieve normal hand function. For open fracture dislocation, joint instability after failure of closed reduction, intra-articular injury, displaced avulsion fracture accompanied by carpal or metacarpal fracture or involving the radial extensor carpi radialis tendon (as in this case) are all indications for surgical treatment [ 19 ] . Intraoperatively, in addition to trying to protect the blood vessels, nerves, and tendons of the dorsal part of the metacarpal, attention should also be paid to protecting and repairing the ligamentous structures around the carpometacarpal joint, in order to reduce the probability of postoperative re-dislocation of the carpometacarpal joint and carpal bone necrosis. After reduction, flexible and multidirectional fixation of the dislocated carpometacarpal joint can be achieved with high fixation strength by longitudinal, transverse and oblique cross Kirschner pin and plate fixation. In this case, we applied a nickel-titanium memory alloy ring hugger for fixation, which showed significant advantages in the treatment of carpometacarpal joint dislocation. Its unique shape memory property can generate continuous dynamic compression at body temperature, providing a three-dimensional fixation effect, which can maintain anatomical repositioning and promote fracture healing at the same time. Compared with traditional Kirschner pin fixation, this technique is easier to operate, shortens the operation time by nearly 30%, and avoids complications related to pin tract infection. Clinical studies [ 20 ] have shown that patients immobilized with a nickel-titanium memory alloy ring hugger can start functional exercise early, the average grip strength recovery time is 2–4 weeks shorter than the traditional method, and the final functional recovery is more satisfactory, which is one of the preferred options for the treatment of carpometacarpal joint dislocation. Conclusions Multiple carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture is an extremely rare injury. There are relatively few clinically reported cases, and clinicians' knowledge of this type of injury is relatively weak, which can easily lead to serious hand dysfunction due to misdiagnosis and underdiagnosis. Therefore, careful radiologic evaluation, meticulous and stable repositioning maneuvers, as well as attention to the repair of surrounding tendons and ligaments, are required. In this case, the patient achieved a favorable outcome through imaging and effective clinical treatment. Declarations Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Acknowledgements Not applicable. Funding Not applicable. Author information Authors and Affiliations: Jiangnan Hospital Affiliated to Zhejiang Chinese Medical University (Hangzhou Xiaoshan Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, China. Dong Pan, Renqi Liu, Mengneng Zhou ,Xvhui Chen& Yanghua Tang Contributions: P. D was instrumental in the collection and analysis of data, as well as the writing of the manuscript. L.R.Q provided valuable assistance in data collection and analysis, ensuring thoroughness and accuracy. Z.M.N participated in data analysis. C.X.H contributed by collecting patient data and assisting in the literature review process. corresponding author, T.Y.H was responsible for the overall study design, formulating the research ideas, and the critical review and revision of the manuscript, ensuring the study’s integrity and coherence. P. D.and L.R.Q contributed equally to this work and should be considered co-first authors. Corresponding author: Correspondence to Yanghua Tang. Ethics declarations Ethics approval and consent to participate: The patient’s informed consent has been obtained, and our hospital’s ethics committee has confirmed it. Consent for publication: Written informed consent was obtained from the patient for the publication of their personal and clinical details along with any identifying images included in this study. Competing interests: The authors declare no competing interests. Clinical trial number Not applicable. References Kim JS, Hussain K, Higginbotham DO,et al. Management of thumb carpometacarpal joint dislocations: A systematic review[J]. J Orthop. 2021,25:59-63. Cattelan M, Meier R. Abrissfraktur der Extensor-carpi-radialis-longus-Sehne von der Basis des Metakarpale II: Eine seltene Verletzung [Bony avulsion of the extensor carpi radialis longus tendon from the base of the second metacarpal: A rare injury][J]. Unfallchirurg. 2015,118(9):812-816. Cates RA, Rhee PC, Kakar S. Multiple Volar Carpometacarpal Dislocations: Case Report/Review of the Literature[J]. J Wrist Surg. 2016,5(3):236-240. Alexander C, Abzug JM, Johnson AJ,et al. Motorcyclist's thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes[J]. J Hand Surg Eur. 2016,41(7):707–709. Annappa R, Kotian P, Ja P,et al. Ligamentous reconstruction of traumatic dislocation of thumb carpometacarpal joint: case report and review of literature[J]. J Orthop Case Rep. 2015,5(4):79–81. Fa-Binefa M, Almenara M, Mata-Muñoz JM, et al. Retrospective interobserver agreement on diagnoses of 4th and 5th carpometacarpal fracture-dislocation and hamate fracture in plain X-ray - Is CT essential after ulnar carpometacarpal pain?[J]. Skeletal Radiol. 2023,52(12):2427-2433. Suwannaphisit S, Suwanno P, Fongsri W, et al. Multiple carpometacarpal joint fracture-dislocation from the second to fifth: A case report. Ann Med Surg (Lond)[J]. 2022,76:103596. Al-Battat MY, Al Hassan MA, Al Qahtani SM. Carpometacarpal dislocation second to fifth with associated hamate fracture: A case report of rare injury[J]. Int J Surg Case Rep. 2023,108:108417. Jorgensen C, Christos SC. Carpometacarpal Dislocation with Third Metacarpal Fracture[J]. Clin Pract Cases Emerg Med. 2021,5(4):488-490. Najefi A, Jeyaseelan L, Patel A,et al. Avulsion Fractures at the Base of the 2(nd) Metacarpal Due to the Extensor Carpi Radialis Longus Tendon: A Case Report and Review of the Literature[J]. Arch Trauma Res. 2016,5(1):e32872. Shyamsundar S. Avulsion fracture of the extensor carpi radialis longus tendon: case report and literature review[J]. Hand Surg. 2012,17(2):247-249. Kumar S, Arora A, Jain AK,et al. Volar dislocation of multiple carpometacarpal joints: report of four cases[J]. J. Orthop. Trauma. 1998,12(7):523–526. Storken G., Bogie R., Jansen EJ. Acute ulnar carpometacarpal dislocations. Can it be treated conservatively? A review of four cases[J]. Hand (N Y) 2011,6:420–423. Horneff JG 3rd, Park MJ, Steinberg DR. Acute closed dislocation of the second through fourth carpometacarpal joints: satisfactory treatment with closed reduction and immobilization[J]. Hand (N Y). 2013,8(2):227-231. Giacomo L, Khan A, Shahid I,et al. Carpometacarpal joint concurrent dislocation of four long finger: results of a non-operative management[J]. EC Orthops. 2016,4(6):688–693. Jumeau H, Lechien P, Dupriez F. Conservative Treatment of Carpometacarpal Dislocation of the Three Last Fingers[J]. Case Rep Emerg Med. 2016,2016:4962021. Court T, Hussain K, Kim JS,et al. Systematic Review of Ligament Reconstruction of Traumatic Isolated Thumb Carpometacarpal Joint Dislocation[J]. J Am Acad Orthop Surg Glob Res Rev. 2022,6(12):e22.00103. Robert N, Zbili D, Bellity J,et al. Avulsion fracture of the extensor carpi radialis longus carpal insertion due to a basketball injury: case report and literature review[J]. Chir Main. 2014,33(6):410-412. Büren C, Gehrmann S, Kaufmann R,et al. Management algorithm for index through small finger carpometacarpal fracture dislocations[J]. Eur J Trauma Emerg Surg. 2016,42(1):37-42. Xu S, Zhu J, Yu Q,et al. Surgical treatment of sternum comminuted fracture with memory alloy embracing fixator[J]. J Thorac Dis. 2021,13(4):2194-2202. Additional Declarations No competing interests reported. Supplementary Files DASH.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6726639","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":468095174,"identity":"b67add1f-dcbc-45b8-8f33-80deb995c8dc","order_by":0,"name":"Dong Pan","email":"","orcid":"","institution":"Jiangnan Hospital Affiliated to Zhejiang Chinese Medical University (Hangzhou Xiaoshan Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, 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joints had been satisfactorily reset and the internal fixation was in good position . \u003cstrong\u003eI and J\u003c/strong\u003e Two months of postoperative follow-up x-ray showed good joint position and stable internal fixation .）\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6726639/v1/6163375e405abdaf3a5fe079.png"},{"id":85286745,"identity":"e0320075-0b32-4a38-9bd9-20ced9528bd4","added_by":"auto","created_at":"2025-06-24 09:17:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1420054,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6726639/v1/20111f9c-a400-459b-b74a-1c23df0e7e75.pdf"},{"id":84422635,"identity":"3e1c5d6c-15c2-4234-9252-8aadd07fd268","added_by":"auto","created_at":"2025-06-11 18:40:14","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":430138,"visible":true,"origin":"","legend":"","description":"","filename":"DASH.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6726639/v1/b6d568d62b4f24529c931b17.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cstrong\u003e2nd to 5th Carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture: a case report\u003c/strong\u003e \u003cstrong\u003eand literature review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eMultiple carpometacarpal dislocations are usually caused by high-intensity external forces on the wrist. Due to the strong capsular-ligamentous structure of the carpometacarpal joint and its intrinsic stability, this type of injury is rare, accounting for only 1% of all acute wrist injuries\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Concomitant rupture of the extensor carpi radialis longus tendon stop is even rarer. The tendon attaches to a rough indentation dorsal to the base of the second metacarpal bone, forming a \u0026ldquo;cap\u0026rdquo; structure on the dorsal aspect of the second metacarpophalangeal joint, providing additional stability against dorsal subluxation\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. High-intensity external injuries causing multiple carpometacarpal joint dislocations can easily lead to tearing of the extensor carpi radialis longus tendon stop. This type of injury is often underdiagnosed in clinical settings. The biomechanical mechanism of these dislocations combined with tendon rupture is not clear. In this paper, we report a case of 2nd to 5th carpometacarpal joint dislocation with extensor carpi radialis longus tendon stop rupture.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 35-year-old male patient was admitted to the hospital by the emergency department two hours after a car accident, presenting with swelling and pain in his left hand. Physical examination revealed a \u0026quot;step-like\u0026quot; deformity in the palm of the left hand, with obvious swelling, tenderness, \u0026nbsp;palpable abnormal movement and Snapping sound, and limited active/passive flexion and extension of the 2nd to 5th fingers. X-ray and CT showed dislocation of the 2nd to 5th metacarpocarpal joints on the left side, and avulsion fracture of the capitulum and the bases of the 2nd and 3rd metacarpal bones (see Figure 1A-D). The left upper limb was immobilized in a plaster cast, and the dislocations were treated with incisional reduction and internal fixation surgery after five days of swelling reduction. Intraoperative exploration revealed a rupture of the radial extensor carpi radialis longus tendon stop, and the extensor carpi radialis longus tendon stop was then repaired (see Figure 1E-F).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgery was performed under brachial plexus nerve block anesthesia, with the patient in the supine position and the affected limb fixed in abduction. The 3rd and 4th metacarpophalangeal joints were treated first, and a longitudinal incision was made on the dorsal side of the metacarpophalangeal joint between the 3rd and 4th metacarpophalangeal joints to incise the skin and subcutaneous tissues. The extensor tendon space was then bluntly separated to fully expose the joints. Intraoperatively, complete dislocation of the 3rd and 4th metacarpophalangeal joints, avulsion fracture of the capitellum and the base of the 2nd and 3rd metacarpal bones, and complete rupture and retraction of the dorsal carpometacarpal ligament were identified. Following anatomical repositioning of the joint, temporary fixation with Kirschner\u0026apos;s pin was performed, and C-arm fluoroscopy confirmed that the articular surfaces were well-matched, followed by final fixation with two nickel-titanium memory alloy loopers and repair of the dorsal carpometacarpal ligament with a 2.0-mm-diameter anchor nail. Subsequently, the 5th carpometacarpal joint was treated and cross-fixed with 2 Kirschner\u0026apos;s pins after repositioning by traction compression technique. The 2nd carpometacarpal joint was then addressed. Another longitudinal incision was made on the dorsal side of the palm between the 2nd carpometacarpal joints, with incision of the skin and subcutaneous tissues, blunt separation of the extensor tendon gap, and visualization of the operative field, It revealed that the 2nd carpometacarpal joint dislocation was accompanied by a complete rupture of the dorsal carpometacarpal ligament with a second metacarpal base avulsion fracture and a rupture of the extensor carpi radialis longus at the stopping point of the tendon, which was then retracted. After repositioning, the joint was temporarily immobilized with a Kirschner pin, fixed with a memory alloy ring hugger, and the extensor carpi radialis longus tendon stop was reconstructed with an anchor nail with a diameter of 2.0 mm, along with the repair of the dorsal carpometacarpal ligament.. Intraoperative C-arm fluoroscopy confirmed satisfactory repositioning of the joints and proper placement of the internal fixation (see Figure 1G-H). The incision was closed layer by layer. Progressive rehabilitation commenced the day after surgery. At the 2-month postoperative follow-up, the DASH (Disabilities of the Arm, Shoulder, and Hand) evaluation scale score was 3.33 (see Appendix). The patient\u0026apos;s finger joint flexion and extension mobility returned to normal, and her hand grip strength and wrist function recovered well (see Figures 1I-J).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe mechanism of injury in multiple carpometacarpal dislocations is usually closely related to high-impact trauma. The articular surfaces of the 2nd to 5th carpometacarpal joints are planar micromotor joints, interconnected by multiple ligaments, including interosseous ligaments and dorsal metacarpal lateral ligaments, providing stability and resulting in relatively low joint mobility. Dislocation of the carpometacarpal joint is typically accompanied by avulsion fractures of the base of the metacarpal and carpal bones due to these stable ligaments and muscle attachment structures\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. However, simultaneous dislocation of the 2nd to 5th carpometacarpal joints combined with rupture of the long extensor carpi radialis tendon stop is rare in clinical practice. According to some scholars\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, multiple dislocations of the carpometacarpal joints with rupture of the extensor carpi radialis longus tendon stop can only occur when the hand is subjected to strong force in two opposite directions simultaneously, resulting in complete tearing and injury of the ligaments around the carpometacarpal joints. The mechanism of injury in this patient was a car accident impact with the hand acting as a support. The palm and elbow joints were subjected to simultaneous violence in opposite directions, with distal violence transmitted longitudinally via the 2nd to 5th metacarpal bones and proximally via the ulnar radius. This concentrated violence on the carpometacarpal joints led to hyperflexion of the wrists and contraction of the extensor carpi radialis longus tendon, causing dislocations of the carpometacarpal joints and ruptures of the radial extensor carpi radialis longus tendon stop. Therefore, there should be a high degree of suspicion for such hand injuries when evaluating x-ray of high-energy trauma. A systematic evaluation of the carpometacarpal joint is necessary. In addition, the hand is evident swelling after injury. And severe swelling tends to mask the deformity caused by dislocation of the carpometacarpal joint, increasing the risk of underdiagnosis and misdiagnosis. Therefore, in addition to routine frontal and lateral radiographs of the wrist, CT scans should be performed to clarify the type and extent of carpometacarpal joint dislocation\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Although there is a paucity of literature on multiple carpometacarpal joint dislocations with long extensor carpi radialis longus tendon stop rupture, some relevant clinical studies exist. Suwannaphisit et al.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e and Al - Batta et al.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e reported rare cases of multiple 2nd \u0026minus;\u0026thinsp;5th carpometacarpal joint dislocations due to automobile accidental injuries; and Jorgensen et al.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e described a rare case in a 17-year-old patient with a basal fracture of the third metacarpal with dislocation of the 3\u0026ndash;5 carpometacarpal joints, the patient regained normal functionality of the hand after surgical reconstruction. Najefi et al.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e and Shyamsundar\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e shared cases of basal avulsion fracture of the 2nd metacarpal due to avulsion of the extensor carpi radialis longus tendon. In all of these cases, the providers provided adequate clinical assessment and intervention to the patients in the early stages of the disease and combined with physiotherapy in the later stages of the disease, which effectively improved the prognosis of the clinical treatment. This contrasts with a previous report of a patient who suffered disability and loss of function in the same time interval\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. This shows that early diagnosis and treatment are crucial for multiple carpometacarpal joint dislocations with extensor carpi radialis longus tendon stop rupture.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, such mixed injuries have not been described in detail in clinical practice yet. The main reason is the stable joint-capsular complex structure of the carpometacarpal joint. Due to the limited number of reported cases, clinicians are not well aware of this type of injury. Therefore, there is no consensus on treatment\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Common treatments include closed reduction cast fixation, percutaneous internal fixation, and open reduction and internal fixation. It has been reported that patients can have near-normal hand function after conservative treatment with cast immobilization\u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. However, conservative treatment is often accompanied by a high complication rate due to the high likelihood of subluxation. And a dislocated carpometacarpal joint can lead to severe hand disability\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, a ruptured radial long extensor carpi radialis brevis tendon can also result in decreased wrist strength and mobility, and even trigger secondary instability or redisplacement\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Therefore, early intervention is crucial for restoring pinch and grip strength in patients. Based on this, surgical treatment with open reduction and internal fixation should be chosen as early as possible to achieve normal hand function. For open fracture dislocation, joint instability after failure of closed reduction, intra-articular injury, displaced avulsion fracture accompanied by carpal or metacarpal fracture or involving the radial extensor carpi radialis tendon (as in this case) are all indications for surgical treatment\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Intraoperatively, in addition to trying to protect the blood vessels, nerves, and tendons of the dorsal part of the metacarpal, attention should also be paid to protecting and repairing the ligamentous structures around the carpometacarpal joint, in order to reduce the probability of postoperative re-dislocation of the carpometacarpal joint and carpal bone necrosis. After reduction, flexible and multidirectional fixation of the dislocated carpometacarpal joint can be achieved with high fixation strength by longitudinal, transverse and oblique cross Kirschner pin and plate fixation. In this case, we applied a nickel-titanium memory alloy ring hugger for fixation, which showed significant advantages in the treatment of carpometacarpal joint dislocation. Its unique shape memory property can generate continuous dynamic compression at body temperature, providing a three-dimensional fixation effect, which can maintain anatomical repositioning and promote fracture healing at the same time. Compared with traditional Kirschner pin fixation, this technique is easier to operate, shortens the operation time by nearly 30%, and avoids complications related to pin tract infection. Clinical studies\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e have shown that patients immobilized with a nickel-titanium memory alloy ring hugger can start functional exercise early, the average grip strength recovery time is 2\u0026ndash;4 weeks shorter than the traditional method, and the final functional recovery is more satisfactory, which is one of the preferred options for the treatment of carpometacarpal joint dislocation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMultiple carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture is an extremely rare injury. There are relatively few clinically reported cases, and clinicians' knowledge of this type of injury is relatively weak, which can easily lead to serious hand dysfunction due to misdiagnosis and underdiagnosis. Therefore, careful radiologic evaluation, meticulous and stable repositioning maneuvers, as well as attention to the repair of surrounding tendons and ligaments, are required. In this case, the patient achieved a favorable outcome through imaging and effective clinical treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations:\u003c/strong\u003e Jiangnan Hospital Affiliated to Zhejiang Chinese Medical University (Hangzhou Xiaoshan Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, China.\u003c/p\u003e\n\u003cp\u003eDong Pan,\u0026nbsp;Renqi Liu,\u0026nbsp;Mengneng Zhou\u0026nbsp;,Xvhui Chen\u0026amp;\u0026nbsp;Yanghua Tang\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions:\u0026nbsp;\u003c/strong\u003eP. D was instrumental in the collection and analysis of data, as well as the writing of the manuscript. L.R.Q provided valuable assistance in data collection and analysis, ensuring thoroughness and accuracy. Z.M.N participated in data analysis. C.X.H contributed by collecting patient data and assisting in the literature review process. corresponding author, T.Y.H was responsible for the overall study design, formulating the research ideas, and the critical review and revision of the manuscript, ensuring the study\u0026rsquo;s integrity and coherence.\u003c/p\u003e\n\u003cp\u003eP. D.and L.R.Q contributed equally to this work and should be considered co-first authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author:\u003c/strong\u003e Correspondence to Yanghua Tang.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe patient\u0026rsquo;s informed consent has been obtained, and our hospital\u0026rsquo;s ethics committee has confirmed it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for the publication of their personal and clinical details along with any identifying images included in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKim JS, Hussain K, Higginbotham DO,et al. Management of thumb carpometacarpal joint dislocations: A systematic review[J]. J Orthop. 2021,25:59-63.\u003c/li\u003e\n\u003cli\u003eCattelan M, Meier R. Abrissfraktur der Extensor-carpi-radialis-longus-Sehne von der Basis des Metakarpale II: Eine seltene Verletzung [Bony avulsion of the extensor carpi radialis longus tendon from the base of the second metacarpal: A rare injury][J]. Unfallchirurg. 2015,118(9):812-816.\u003c/li\u003e\n\u003cli\u003eCates RA, Rhee PC, Kakar S. Multiple Volar Carpometacarpal Dislocations: Case Report/Review of the Literature[J]. J Wrist Surg. 2016,5(3):236-240. \u003c/li\u003e\n\u003cli\u003eAlexander C, Abzug JM, Johnson AJ,et al. Motorcyclist\u0026apos;s thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes[J]. J Hand Surg Eur. 2016,41(7):707\u0026ndash;709.\u003c/li\u003e\n\u003cli\u003eAnnappa R, Kotian P, Ja P,et al. Ligamentous reconstruction of traumatic dislocation of thumb carpometacarpal joint: case report and review of literature[J]. J Orthop Case Rep. 2015,5(4):79\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eFa-Binefa M, Almenara M, Mata-Mu\u0026ntilde;oz JM, et al. Retrospective interobserver agreement on diagnoses of 4th and 5th carpometacarpal fracture-dislocation and hamate fracture in plain X-ray - Is CT essential after ulnar carpometacarpal pain?[J]. Skeletal Radiol. 2023,52(12):2427-2433.\u003c/li\u003e\n\u003cli\u003eSuwannaphisit S, Suwanno P, Fongsri W, et al. Multiple carpometacarpal joint fracture-dislocation from the second to fifth: A case report. Ann Med Surg (Lond)[J]. 2022,76:103596. \u003c/li\u003e\n\u003cli\u003eAl-Battat MY, Al Hassan MA, Al Qahtani SM. Carpometacarpal dislocation second to fifth with associated hamate fracture: A case report of rare injury[J]. Int J Surg Case Rep. 2023,108:108417.\u003c/li\u003e\n\u003cli\u003eJorgensen C, Christos SC. Carpometacarpal Dislocation with Third Metacarpal Fracture[J]. Clin Pract Cases Emerg Med. 2021,5(4):488-490.\u003c/li\u003e\n\u003cli\u003eNajefi A, Jeyaseelan L, Patel A,et al. Avulsion Fractures at the Base of the 2(nd) Metacarpal Due to the Extensor Carpi Radialis Longus Tendon: A Case Report and Review of the Literature[J]. Arch Trauma Res. 2016,5(1):e32872.\u003c/li\u003e\n\u003cli\u003eShyamsundar S. Avulsion fracture of the extensor carpi radialis longus tendon: case report and literature review[J]. Hand Surg. 2012,17(2):247-249.\u003c/li\u003e\n\u003cli\u003eKumar S, Arora A, Jain AK,et al. Volar dislocation of multiple carpometacarpal joints: report of four cases[J]. J. Orthop. Trauma. 1998,12(7):523\u0026ndash;526.\u003c/li\u003e\n\u003cli\u003eStorken G., Bogie R., Jansen EJ. Acute ulnar carpometacarpal dislocations. Can it be treated conservatively? A review of four cases[J]. Hand (N Y) 2011,6:420\u0026ndash;423.\u003c/li\u003e\n\u003cli\u003eHorneff JG 3rd, Park MJ, Steinberg DR. Acute closed dislocation of the second through fourth carpometacarpal joints: satisfactory treatment with closed reduction and immobilization[J]. Hand (N Y). 2013,8(2):227-231.\u003c/li\u003e\n\u003cli\u003eGiacomo L, Khan A, Shahid I,et al. Carpometacarpal joint concurrent dislocation of four long finger: results of a non-operative management[J]. EC Orthops. 2016,4(6):688\u0026ndash;693.\u003c/li\u003e\n\u003cli\u003eJumeau H, Lechien P, Dupriez F. Conservative Treatment of Carpometacarpal Dislocation of the Three Last Fingers[J]. Case Rep Emerg Med. 2016,2016:4962021.\u003c/li\u003e\n\u003cli\u003eCourt T, Hussain K, Kim JS,et al. Systematic Review of Ligament Reconstruction of Traumatic Isolated Thumb Carpometacarpal Joint Dislocation[J]. J Am Acad Orthop Surg Glob Res Rev. 2022,6(12):e22.00103.\u003c/li\u003e\n\u003cli\u003eRobert N, Zbili D, Bellity J,et al. Avulsion fracture of the extensor carpi radialis longus carpal insertion due to a basketball injury: case report and literature review[J]. Chir Main. 2014,33(6):410-412.\u003c/li\u003e\n\u003cli\u003eB\u0026uuml;ren C, Gehrmann S, Kaufmann R,et al. Management algorithm for index through small finger carpometacarpal fracture dislocations[J]. Eur J Trauma Emerg Surg. 2016,42(1):37-42. \u003c/li\u003e\n\u003cli\u003eXu S, Zhu J, Yu Q,et al. Surgical treatment of sternum comminuted fracture with memory alloy embracing fixator[J]. J Thorac Dis. 2021,13(4):2194-2202. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multiple carpometacarpal joint dislocations, extensor carpi radialis longus tendon, rare case report","lastPublishedDoi":"10.21203/rs.3.rs-6726639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6726639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Multiple carpometacarpal joint dislocations are among the rarer injuries with a limited number of associated case reports. Currently, most clinical reports focus on single joint dislocations, while reports of multiple carpometacarpal dislocations with rupture of the extensor carpi radialis longus tendon stop are rare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e In this article, we report a case of a 35-year-old male patient, who sustained dislocations of the 2nd to 5th carpometacarpal joints of his left hand due to a car accident. He underwent incisional reduction and internal fixation, during which a rupture of the extensor carpi radialis longus tendon stop was detected and repaired. Postoperatively, the joint was successfully maintained in its original position without subluxation, and rehabilitation exercises were initiated gradually after pain relief the day following surgery. At the last follow-up visit two months post-surgery, the patient exhibited good flexion and extension function of the finger joints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and conclusion:\u003c/strong\u003e Multiple dislocations of the carpometacarpal joints are often accompanied by avulsion fractures of the carpal bones and the bases of the metacarpal bones. The base of the second metacarpal bone, which serves as the attachment point for the radial extensor carpi radialis longus tendon, can be fractured by the pulling force. This type of injury is associated with significant hand swelling, increasing the risk of underdiagnosis and misdiagnosis. The purpose of this article is to share a case of 2nd to 5th carpometacarpal joint dislocation with extensor carpi radialis longus tendon stop rupture to provide a reference for clinical management.\u003c/p\u003e","manuscriptTitle":"2nd to 5th Carpometacarpal joint dislocation combined with extensor carpi radialis longus tendon stop rupture: a case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-11 18:40:09","doi":"10.21203/rs.3.rs-6726639/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31a91bdb-4140-4f1b-822a-03b3a426341c","owner":[],"postedDate":"June 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-24T09:09:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-11 18:40:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6726639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6726639","identity":"rs-6726639","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}