Open Reduction and Internal Fixation of Ring and Small Fracture-Dislocations

Dislocations of the ring and small carpometacarpal (CMC) joints with dorsal shear fracture of the hamate (H)

Transverse or longitudinal incision over dislocated ring and small carpometacarpal (CMC) joints. Bluntly dissect through subcutaneous incision. Protect branches of ulnar sensory nerve. Identify extensor digitorum communis (EDC), extensor digiti quinti (EDQ), and extensor carpi ulnaris (ECU) tendons (Fig. 71-1A,B).
Careful dissection and mobilization of dorsal ulnar cutaneous nerves. Retract EDC and EDQ in a radial direction and ECU in an ulnar direction. Identify ring and small CMC joints.
Identification of hamate dorsal shear fracture (Fig. 71-2). Evacuation of fracture hematoma
Longitudinal traction and direct manipulation of fracture to accomplish reduction. Provision fixation with 0.45 in. (1.1 mm) trocar-tipped wire drilled from dorsal to palmar (Fig. 71-3A,B). Plan wire position to allow for definitive screw fixation. Reduction verified using fluoroscopy.
Definitive fixation with two 2.0 mm or 2.4 mm screws placed from dorsal to palmar into hamate. Countersink and lag to increase stability of fracture fixation.
Remove wires and assess stability of fracture fixation. Rigid fixation requires no additional hardware.
Percutaneously place a 0.045 in. wire through the bases of the fifth, fourth, and third metacarpals.