JBJS | Successful Manual Reduction of Locked Metacarpophalangeal Joints in Fingers*

The Journal of Bone & Joint Surgery, Volume 82, Issue 3

Articles | March 01, 2000

Successful Manual Reduction of Locked Metacarpophalangeal Joints in Fingers*

MASAHARU YAGI, M.D.†; KENSUKE YAMANAKA, M.D.‡; KENJI YOSHIDA, M.D.†; NAOTO SATO, M.D.†; AKIO INOUE, M.D.†, KURUME, JAPAN

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Investigation performed at the Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume

The Journal of Bone & Joint Surgery. 2000; 82:366-71

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Abstract

Background: Many studies on the etiology and operative treatment of locked metacarpophalangeal joints in fingers have been reported, but there have been few investigations on manual reduction. The rate of success of manual reduction in previous reports has been low, and no consensus has been reached with regard to the best method of manual reduction. On the basis of our experience with operative treatment, we devised a safe method of manual reduction.

Methods: Between January 1987 and December 1995, we reduced a locked metacarpophalangeal joint in twelve female patients; every locked finger was successfully reduced, and complications such as fracture did not occur during manual reduction. The average duration of follow-up was five years and nine months (range, three years and two months to nine years and three months).

Results: Six patients had no recurrence of the locking. Four of the six remaining patients had one or two incidents of locking, had no alteration in the activities of daily living, and did not want operative treatment. The two remaining patients reported that they had incidents of locking several times a day, and they requested operative treatment as they were afraid of additional recurrences. One patient had an open reduction fifteen months after the initial episode of locking, and the other patient elected not to have an operation for personal reasons.

Conclusions: We believe that our method of manual reduction should be used to treat a locked metacarpophalangeal joint in a finger and that operative treatment should be limited to patients in whom manual reduction is unsuccessful or the reduction is unstable.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Since a locked metacarpophalangeal joint was first reported by Langenskiöld⁹, in 1949, many investigators have described the etiology of this condition. An abnormal shape of the metacarpal head⁴, a tear of the volar plate¹⁸, impingement of an enlarged sesamoid³, and entrapment of the first dorsal interosseus tendon by an exostosis on the metacarpal head² have all been implicated in the etiology. However, most cases of locking have been related to catching of the volar plate or the accessory collateral ligament on either an osteophyte or an osseous prominence on the condyle of the metacarpal^1,5,7,16 (Fig. 1).

In many reported cases of locking, manual reduction was impossible^1,5,7,12,15. Because of the risk of fracture during reduction⁷, most patients have been managed operatively. A consensus has not been reached on the best method of manual reduction, possibly because this entity is relatively rare.

During operative reductions performed before 1987, we devised a safe and successful method of closed reduction. Since then, we have used this closed method of reduction in all of our patients.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedic Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan.

‡Department of Orthopedic Surgery, Kurume University Medical Center, 155-1 Kokubu-machi, Kurume 839-0863, Japan.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedic Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan.

‡Department of Orthopedic Surgery, Kurume University Medical Center, 155-1 Kokubu-machi, Kurume 839-0863, Japan.

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FIG1:: Fig. 1 Diagram of the mechanism of locking, showing the radial aspect of the metacarpophalangeal joint of the left index finger with the volar plate (VP), the accessory collateral ligament (A), and the collateral ligament (C).

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FIG2:: Fig. 2 Diagrams showing the technique of manual reduction. Step 1: the arrow shows the direction of force that is applied to flex the metacarpophalangeal joint. Step 2: the metacarpophalangeal joint is pushed into radial deviation (Black 2 on White Circle). Step 3: the joint is moved in external rotation (Black 3 on White Circle). Step 4: the metacarpophalangeal joint is gradually extended while a position of radial deviation and external rotation is maintained. If reduction is not obtained after repetition of this procedure several times, the finger is moved in the opposite direction (into ulnar deviation [White 2 on Black Circle] and internal rotation [White 3 on Black Circle]).

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FIG3:: Fig. 3 Diagram showing the anatomical appearance of the joint during step 1 of the reduction. A = accessory collateral ligament, C = collateral ligament, and VP = volar plate.

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FIG4:: Fig. 4 Diagrams of the anatomical appearance of the joint during step 3 of the manual reduction technique, showing the metacarpophalangeal joint in external rotation (a) and internal rotation (b). The solid circle indicates the direction of movement of the pocket of the ligament. U = ulnar side, R = radial side, A = accessory collateral ligament, C = collateral ligament, and VP = volar plate.

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FIG5:: Fig. 5 Radiographs of the metacarpal head in two patients, showing one (Case 9) in which the tip of the condyle had a sharp edge (a) and one (Case 7) in which it had a dull edge (b).

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TABLE I: DATA ON THE PATIENTS

*After treatment for recurrence, one patient (Case 9) decided not to have an operation and remained under observation and another (Case 12) had an open reduction fifteen months after the initial episode of locking.

Case	Age (yrs.)	Involved Finger	Cause of Injury	Duration from Injury to Treatment at Previous Clinic (days)	Unsuccessful Treatment at Previous Clinic	Index Procedure			Recurrence
Duration from Injury to Manual Reduction (days)	Radiographic Appearance at Tip of Condyle	Duration of Follow-up (mos.)	Frequency of Episodes	Duration from First Examination to Initial Recurrence (mos.)	Treatment
1	65	Right index	Writing	1	Manipulation	4	Dull	111	Once only	1	Manual reduction
2	27	Right index	Grasping a pillow	0	Manipulation	2	Dull	86	None
3	64	Left long	Grasping an object	—	None	1	Sharp	86	None
4	45	Left index	Sewing a bag	—	None	4	Dull	83	Once only	4	Manual reduction
5	16	Right little	Grasping an object	1	Manipulation	6	Dull	78	None
6	37	Right index	Unfolding a carton	0	Manipulation	4	Dull	72	Once only	33	Manual reduction
7	56	Right index	Dragging a cushion	—	None	1	Dull	68	None
8	56	Left index	Holding a telephone receiver	—	None	2	Dull	58	None
9*	36	Left index	Holding a shopping bag	1	Manipulation	6	Sharp	53	Frequent	1	Manual reduction
10	30	Left index	Holding a fish	1	Manipulation	6	Dull	52	Twice only	2	Manual reduction
11	34	Left index	Grasping an object	1	Manipulation	5	Dull	38	None
12*	75	Right index	Grasping an object	—	None	8	Sharp	41	Frequent	2	Manual reduction

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TABLE I: DATA ON THE PATIENTS

Case	Age (yrs.)	Involved Finger	Cause of Injury	Duration from Injury to Treatment at Previous Clinic (days)	Unsuccessful Treatment at Previous Clinic	Index Procedure			Recurrence
Duration from Injury to Manual Reduction (days)	Radiographic Appearance at Tip of Condyle	Duration of Follow-up (mos.)	Frequency of Episodes	Duration from First Examination to Initial Recurrence (mos.)	Treatment
1	65	Right index	Writing	1	Manipulation	4	Dull	111	Once only	1	Manual reduction
2	27	Right index	Grasping a pillow	0	Manipulation	2	Dull	86	None
3	64	Left long	Grasping an object	—	None	1	Sharp	86	None
4	45	Left index	Sewing a bag	—	None	4	Dull	83	Once only	4	Manual reduction
5	16	Right little	Grasping an object	1	Manipulation	6	Dull	78	None
6	37	Right index	Unfolding a carton	0	Manipulation	4	Dull	72	Once only	33	Manual reduction
7	56	Right index	Dragging a cushion	—	None	1	Dull	68	None
8	56	Left index	Holding a telephone receiver	—	None	2	Dull	58	None
9*	36	Left index	Holding a shopping bag	1	Manipulation	6	Sharp	53	Frequent	1	Manual reduction
10	30	Left index	Holding a fish	1	Manipulation	6	Dull	52	Twice only	2	Manual reduction
11	34	Left index	Grasping an object	1	Manipulation	5	Dull	38	None
12*	75	Right index	Grasping an object	—	None	8	Sharp	41	Frequent	2	Manual reduction

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Twelve female patients who had a locked metacarpophalangeal joint were first seen between January 1987 and December 1995 (Table I). The average age was forty-five years (range, sixteen to seventy-five years). The index finger was locked in ten patients; the long finger, in one; and the little finger, in one. Seven of the twelve patients had had an unsuccessful closed reduction at other clinics before consulting with us. The patients sought our opinion between one and eight days after the initial injury. They had full active flexion of the finger without pain, and active and passive extension was limited to 30 degrees. Our method of manual reduction was attempted for all of the patients.

Method of Manual Reduction

The method of manual reduction consists of four steps and is performed without anesthesia (Fig. 2). First, it is necessary to identify the site of the accessory collateral ligament—that is, whether it is radial or ulnar—that is holding the joint in a locked position. This is done by locating the site of maximum tenderness, by extending the joint slightly if necessary. The morphology of the metacarpal head is determined on anteroposterior, lateral, and oblique radiographs. The ligament maintaining the locking is usually on the radial side, as the metacarpal head of the index finger is prominent and is easily snared by the ligament.

Step 1: The metacarpophalangeal joint is gradually flexed, which allows the accessory collateral ligament to move proximally through its attachment to the volar plate (Fig. 3).

Step 2: When the metacarpophalangeal joint has been maximally flexed, the joint is pushed into radial deviation. At this stage, in some patients, the joint is reduced with a click. The joint is gradually extended while radial deviation is maintained with the cooperation of the patient.

Step 3: If reduction does not occur, externally twisting the proximal phalanx rotates the metacarpophalangeal joint. When external rotation is performed, the motion of the proximal phalanx is transmitted to the accessory collateral ligament through the volar plate, and the region where the accessory collateral ligament forms a fold at its attachment to the volar plate moves toward the radial side (Fig. 4, a). Flexing the proximal interphalangeal joint and applying force to the fingertip can facilitate this step. At this stage, most joints are reduced.

Step 4: The joint is gradually extended while a position of radial deviation and external rotation is maintained with the cooperation of the patient. Pain or resistance during extension indicates failure of the reduction. The reduction maneuvers should not be forcibly repeated.

When reduction is not obtained after repetition of this procedure several times, we move the finger in the opposite direction (into ulnar deviation and internal rotation). The edge of the ligament moves ulnarly with internal rotation (Fig. 4, b) because the ligament cannot pass over an osseous prominence or osteophyte or because the osseous prominence or osteophyte on the metacarpal head is too large or is caught too tightly. Locking is rarely found on the ulnar side. If reduction still is not achieved, then the metacarpophalangeal joint is moved in opposite directions by alternately placing it, several times, in radial deviation-external rotation and ulnar deviation-internal rotation.

Radiographs are made to confirm the reduction and the absence of a fracture. The metacarpophalangeal joint is stabilized in extension with a metal splint for one week. Full and free motion is allowed thereafter.

Results

Introduction | Materials and Methods | Results | Discussion | References

The osteophyte on the head of the metacarpal had a sharp edge in three patients and a dull edge in the remaining nine patients (Fig. 5). The locked finger was successfully reduced in all twelve patients, and no complications occurred during the reduction.

The average duration of follow-up was five years and nine months (range, three years and two months to nine years and three months). The locking recurred in six patients. Four of the six patients had only one or two episodes of locking and had no difficulty with the activities of daily living. They did not want any additional treatment and were taught how to perform the reduction. The remaining two patients reported that, on occasion, locking occurred several times a day. The patients were afraid of additional recurrences and requested more definitive operative treatment. One patient had an operation fifteen months after the first episode of locking, but the second patient decided not to have an operation for personal reasons and remained under observation.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The few reports on spontaneous reduction^1,12 and successful manipulation of a locked metacarpophalangeal joint^6,10,11,14 are primarily case studies. In most of them, operative treatment usually was performed without an attempt at closed reduction.

Before we began to perform manual reductions in 1987, we managed six patients with open reduction. We evaluated the locked joint carefully to determine the factors preventing a closed reduction. We found a tight band at the site of attachment of the volar plate and the accessory collateral ligament. Slight extension of the metacarpophalangeal joint tightened the band further and caused the metacarpal head to protrude farther volarly. In one patient, additional extension of the joint did not tear the accessory collateral ligament, but the osseous prominence of the metacarpal head was fractured at the point where the accessory collateral ligament was caught over the prominence.

In every involved finger, the accessory collateral ligament that was holding the metacarpal head loosened with flexion of the metacarpophalangeal joint but became taut with extension. Since the pocket-like fold was formed on the inside surface of the accessory collateral ligament, catching was not released with flexion and extension of the joint. After a trial of several methods of manual reduction, we found that when the flexed metacarpophalangeal joint was rotated and radially deviated the ligament fell away from the osseous prominence or osteophyte on the metacarpal head. Extension of the joint combined with radial deviation and external rotation of the finger reduced the metacarpal head. On the basis of our intraoperative findings, we devised a method of closed manual reduction.

Manual reduction has been described in a few reports. Pirotta¹⁰ reported on one patient in whom a locked joint was reduced by infiltration of the joint with 1 percent Xylocaine (lidocaine) and application of traction combined with rotation. In a report on three patients, Guly and Azam⁶ used a digital nerve block and reduced the joint by maintaining traction in the line of the deformity and alternately rotating the finger medially and laterally. Posner et al.¹¹ reported on three patients who had successful reduction of a locked joint with use of an intra-articular injection of a short-acting anesthetic administered dorsally followed by gentle manipulation of the joint by rapid shaking of the finger.

Tanabu and Fukushima¹⁴ reported on six patients in whom a locked metacarpophalangeal joint was successfully reduced by forcible extension of the joint in order to tear the accessory collateral ligament. Tanaka and Uchinishi¹⁵ used the same technique in five patients and reported success in one patient, failure in three, and a fracture in one. We also found that force applied during an open reduction could easily cause a fracture.

Since the report by Langenskiöld⁹, in 1949, seven fractures that occurred during manipulation of a locked joint have been reported^8,9,13,15-17. Therefore, gentle reduction is recommended. Conversely, several authors have stated that they believed that a locked finger should not be manipulated in order to obtain a closed reduction. Harvey⁷ suggested that manipulation of the joint is not indicated because it provides, at best, only temporary relief. Langenskiöld⁹ warned that attempts to unlock the finger with the patient under anesthesia could lead to an intra-articular fracture and subsequent contracture; he suggested excision of the ligament for complete relief, as full mobility could be restored quickly.

On the basis of our results, we do not believe that manual reduction is contraindicated in the treatment of a locked metacarpophalangeal joint. However, surgeons should clearly understand the mechanism of locking when attempting manual reduction. In addition, the method should be performed without the application of undue force. Gentle reduction does not imply a simple decrease of applied force but an understanding of the steps that should be followed to release the accessory collateral ligament. We believe that neither attempting to tear the ligament from its attachments nor expecting to unlock the joint by chance during random movement is a gentle procedure.

Intra-articular anesthesia has been used to perform closed reduction, and Pirotta¹⁰ and Posner et al.¹¹ reported that they found it to be useful. However, we believe that an attempt to reduce a joint manually with use of anesthesia is risky, as the degree of force cannot be assessed accurately. Some investigators have stated that they believed that the accessory collateral ligament could be released easily by injecting an anesthetic into the joint, thereby increasing the intra-articular pressure¹¹. Our method of reduction is not accompanied by severe pain, and we believe that manipulation can become excessively forceful after the patient's perception of pain has been removed. An intra-articular injection of physiological saline solution may have the same effect of distending the joint, but we have no experience with that technique.

Our method of manual reduction, which is based on the mechanism of locking, essentially attempts to unlock an accessory collateral ligament that is caught on a prominent metacarpal head. We were successful in reducing the locked joint in all twelve patients. However, locking recurred in six patients and two of them had an osteophyte with a sharp edge. Except for recurrence, no other complications occurred. We suggest that our method of manual reduction be considered before open reduction is performed.

References

Introduction | Materials and Methods | Results | Discussion | References

Aston, J. N.: Locked middle finger. J. Bone and Joint Surg.,42-B(1): 75-79, 1960.42-B(1)75 1960

Charendoff, M. D.: Locking of the metacarpophalangeal joint: a case report. J. Hand Surg.,4: 173-175, 1979.4173 1979

Flatt, A. E.: Recurrent locking of an index finger. J. Bone and Joint Surg.,40-A: 1128-1130, Oct. 1958.40-A1128 1958

Flatt, A. E.: A locking little finger. J. Bone and Joint Surg.,43-A: 240-242, March 1961.43-A240 1961

Goodfellow, J. W., and Weaver, J. P. A.: Locking of the metacarpo-phalangeal joints. J. Bone and Joint Surg.,43-B(4): 772-777, 1961.43-B(4)772 1961

Guly, H. R., and Azam, M. A.: Locked finger treated by manipulation. A report of three cases. J. Bone and Joint Surg.,64-B(1): 73-75, 1982.64-B(1)73 1982

Harvey, F. J.: Locking of the metacarpo-phalangeal joints. J. Bone and Joint Surg.,56-B(1): 156-159, 1974.56-B(1)156 1974

Inoue, G.; Nakamura, R.; and Miura, T.: Intra-articular fracture of the metacarpal head of the locked index finger due to forced passive extension. J. Hand Surg.,13-B: 320-322, 1988.13-B320 1988

Langenskiöld, A.: Habitual locking of a metacarpo-phalangeal joint by a collateral ligament, a rare cause of trigger finger. Acta Chir. Scandinavica,99: 73-78, 1949.9973 1949

Pirotta, T.: Locked finger. Med. J. Australia,2: 924-925, 1964.2924 1964 [PubMed]

Posner, M. A.; Langa, V.; and Green, S. M.: The locked metacarpophalangeal joint: diagnosis and treatment. J. Hand Surg.,11A: 249-253, 1986.11A249 1986

Stewart, G. J., and Williams, E. A.: Locking of the metacarpophalangeal joints in degenerative disease. Hand,13: 147-151, 1981.13147 1981 [PubMed]

Takeuchi, T.; Takazawa, H.; Yamaguchi, S.; and Hozumi, Y.: [Four cases of locked metacarpophalangeal joint of the index finger.]. Seikei Geka,23: 1190-1191, 1972.231190 1972

Tanabu, S., and Fukushima, M.: [Locked finger; a report of eight cases.]. Seikei Geka,43: 625-630, 1992.43625 1992

Tanaka, K., and Uchinishi, K.: [The locked index finger; mechanism and treatment.]. Seikei Geka,27: 355-360, 1976.27355 1976

Taylor, T. K. F.: Locked index finger. Australian and New Zealand J. Surg.,33: 103-107, 1963.33103 1963

Watari, K., and Tsuge, K.: [Case of intra-articular locking of the finger.]. Seikei Geka,20: 1312-1317, 1969.201312 1969 [PubMed]

Yancey, H. A., Jr., and Howard, L. D., Jr.: Locking of the metacarpophalangeal joint. J. Bone and Joint Surg.,44-A: 380-382, March 1962.44-A380 1962

Topics

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FIG3:: Fig. 3 Diagram showing the anatomical appearance of the joint during step 1 of the reduction. A = accessory collateral ligament, C = collateral ligament, and VP = volar plate.

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FIG5:: Fig. 5 Radiographs of the metacarpal head in two patients, showing one (Case 9) in which the tip of the condyle had a sharp edge (a) and one (Case 7) in which it had a dull edge (b).

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TABLE I: DATA ON THE PATIENTS

Case	Age (yrs.)	Involved Finger	Cause of Injury	Duration from Injury to Treatment at Previous Clinic (days)	Unsuccessful Treatment at Previous Clinic	Index Procedure			Recurrence
Duration from Injury to Manual Reduction (days)	Radiographic Appearance at Tip of Condyle	Duration of Follow-up (mos.)	Frequency of Episodes	Duration from First Examination to Initial Recurrence (mos.)	Treatment
1	65	Right index	Writing	1	Manipulation	4	Dull	111	Once only	1	Manual reduction
2	27	Right index	Grasping a pillow	0	Manipulation	2	Dull	86	None
3	64	Left long	Grasping an object	—	None	1	Sharp	86	None
4	45	Left index	Sewing a bag	—	None	4	Dull	83	Once only	4	Manual reduction
5	16	Right little	Grasping an object	1	Manipulation	6	Dull	78	None
6	37	Right index	Unfolding a carton	0	Manipulation	4	Dull	72	Once only	33	Manual reduction
7	56	Right index	Dragging a cushion	—	None	1	Dull	68	None
8	56	Left index	Holding a telephone receiver	—	None	2	Dull	58	None
9*	36	Left index	Holding a shopping bag	1	Manipulation	6	Sharp	53	Frequent	1	Manual reduction
10	30	Left index	Holding a fish	1	Manipulation	6	Dull	52	Twice only	2	Manual reduction
11	34	Left index	Grasping an object	1	Manipulation	5	Dull	38	None
12*	75	Right index	Grasping an object	—	None	8	Sharp	41	Frequent	2	Manual reduction

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TABLE I: DATA ON THE PATIENTS

Case	Age (yrs.)	Involved Finger	Cause of Injury	Duration from Injury to Treatment at Previous Clinic (days)	Unsuccessful Treatment at Previous Clinic	Index Procedure			Recurrence
Duration from Injury to Manual Reduction (days)	Radiographic Appearance at Tip of Condyle	Duration of Follow-up (mos.)	Frequency of Episodes	Duration from First Examination to Initial Recurrence (mos.)	Treatment
1	65	Right index	Writing	1	Manipulation	4	Dull	111	Once only	1	Manual reduction
2	27	Right index	Grasping a pillow	0	Manipulation	2	Dull	86	None
3	64	Left long	Grasping an object	—	None	1	Sharp	86	None
4	45	Left index	Sewing a bag	—	None	4	Dull	83	Once only	4	Manual reduction
5	16	Right little	Grasping an object	1	Manipulation	6	Dull	78	None
6	37	Right index	Unfolding a carton	0	Manipulation	4	Dull	72	Once only	33	Manual reduction
7	56	Right index	Dragging a cushion	—	None	1	Dull	68	None
8	56	Left index	Holding a telephone receiver	—	None	2	Dull	58	None
9*	36	Left index	Holding a shopping bag	1	Manipulation	6	Sharp	53	Frequent	1	Manual reduction
10	30	Left index	Holding a fish	1	Manipulation	6	Dull	52	Twice only	2	Manual reduction
11	34	Left index	Grasping an object	1	Manipulation	5	Dull	38	None
12*	75	Right index	Grasping an object	—	None	8	Sharp	41	Frequent	2	Manual reduction