The operative findings and pathological anatomy in nine patients with complex metacarpophalangeal dislocations correlated well with dissections in fresh cadaver hands. The single most important element preventing reduction is interposition of the volar plate between the base of the proximal phalanx and the head of the metacarpal. Of importance is an understanding of the three sets of transverse ligaments and their relationship to the volar plate: (1) the natatory ligament, (2) the superficial transverse metacarpal ligament, and (3) the deep transverse metacarpal ligament. Early active motion was encouraged, commencing immediately following open reduction, and resulted in a full range. In one patient, ten days of immobilization caused residual restriction of motion.