![]() Two small fragment lag screws (1.0 mm and 1.5mm) were inserted after drilling appropriately perpendicular to the fracture plane. Entry points for two lag screws were planned in such a way as to avoid any hardware contact with extensor pollicis brevis tendon. After achieving satisfactory reduction under direct vision and the image intensifier guidance, and securing it with a small reduction clamp, two fracture spanning K wires of 0.5mm diameter each, were inserted from Dorsoradial to volar medial direction. The forces on the distal fragment were therefore countered by flexing and adducting the thumb as a whole to relax the adductor pollicis and flexors of thumb. ![]() The proximal fragment was long and stable, and easy to manipulate in flexion-extension and adduction-abduction plane because of the saddle joint at its base articulating with the trapezium. While the varus deviation was perhaps because of the pulling force of adductor pollicis in an orthogonal direction to the axis of thumb compared to that of abductor pollicis brevis which had an obliquely pulling force, the flexion of the head fragment was probably because of the stronger pull of the flexors of thumb in comparison to the extensors ( Fig. 3a and b). As it was evident in preoperative radiographs, there was a constant tendency of varus deviation and volar displacement of the head fragment. The reduction was attempted by manipulating the fractured ends while visualizing the extracapsular part of fracture ( Fig. 2a and b) and using image intensifier guidance. Therefore, we chose not to breach the capsule in order to avoid any compromise in joint stability. It was observed that the dorsolateral spike of the proximal fragment was actually intracapsular in location. The fracture site was exposed and cleaned. The dorsoulnar and dorsoradial divisions of the dorsal sensory branch of the radial nerve were protected. The fracture site was approached using a 2.5cm long longitudinal dorsoradial incision over the fracture site and a plane was created between extensor pollicis brevis and thenar muscles. ![]() Open reduction and internal fixation was planned under regional anesthesia and tourniquet control. The proximal fragment appeared to have a dorsolateral spike while the head fragment had a volar-medial spike. Plain radiographs of the left hand including the anteroposterior and lateral projections of the first metacarpophalangeal joint were ordered which revealed an oblique fracture of the first metacarpal head with a palmar - medial displacement ( Fig. 1). The injury was a closed one without any distal neurovascular deficit, and other hand movements were normally present. He had presented in the emergency department with an isolated swelling and deformity of the first metacarpophalangeal joint. A 23-year-old male patient, a computer programmer by occupation, had sustained an injury to his left thumb due to fall from his bike, with a direct axial load on the left thumb in an extended and abducted position. ![]()
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