J Hand Microsurg (January–June 2013) 5(1):36–42

DOI 10.1007/s12593-012-0067-x

CASE REPORT

Modified Eaton-Littler’s Reconstruction for Traumatic Dislocation

of the Carpometacarpal Joint of the Thumb—A Case Report
and Review of Literature
Karthikeyan Iyengar & Surya Gandham &
Jayant Nadkarni & William Loh

Received: 6 October 2011 / Accepted: 9 April 2012 / Published online: 28 April 2012
# Society of the Hand & Microsurgeons of India 2012

Abstract Isolated traumatic dislocation of the carpometa- Dorso-radial ligament as being the main restraint to dorsal
carpal joint of the thumb is an uncommon injury. Left subluxation of the CMC joint. [3–5].
untreated, resulting mechanical instability of this joint inter- Optimal treatment option is still controversial. Treatment
feres with normal function of the hand and can lead to options for acute CMC joint dislocation include closed
articular degeneration of the joint. Most are amenable to reduction [6, 7], closed reduction with pinning [8], or open
closed reduction with or without supplementary pinning. We reduction with capsular repair and ligament reconstruction
present a case of a 21 year old female patient with continual [9–11]. Continual instability following closed treatment
instability of the carpometacarpal joint of her right thumb, necessitates surgery; however debate exists as to which
following closed reduction and pinning. Surgical stabiliza- ligaments are damaged and hence appropriate treatment
tion was achieved by anterior oblique ligament reconstruc- approach. Whichever the ligament injury, the aim is to
tion using a Modified Eaton- Littler’s technique. At 1 year restore the stability of the CMC joint of the thumb.
follow-up evaluation the patient was pain free with no Diagnosis of instability due rupture of the anterior
clinico-radiological evidence of instability. oblique ligament is difficult. History and specific clinical
tests are important in making a diagnosis [12]. Eaton and
Keywords Carpometacarpal joint . Dislocation . Thumb . Littler have described a technique of ligament reconstruc-
Anterior oblique ligament . Ligament reconstruction tion of the CMC joint using a slip of flexor carpi radialis
tendon [2]. In our patient, we were able to achieve stability
of the CMC joint of the thumb using a Modified Eaton-
Introduction Littler technique for anterior oblique ligament. The tech-
nique described simultaneously reinforces the anterior
Acute traumatic dislocation of the carpometacarpal (CMC) oblique ligament and the Dorso-radial ligament to achieve
joint of the thumb is rare because of strong capsule- global stability.
ligamentous structure. The anterior oblique ligament, also
known as the beak or volar ligament has traditionally been
described as the primary static stabilizer, preventing dorsal
translation of the thumb metacarpal [1, 2]. Presently, how- Case Report
ever this view has been debated with more emphasis on the
A 21-year-old, right hand dominant nursing home care
Author’s contributions Mr. Karthikeyan Iyengar—1st Author of case assistant presented to accident & emergency (A& E) with an
report, performed the operation, involved in writing 1st draft of case injury to her right thumb. She sustained the injury by sand-
report, literature search. wiching her thumb between a bed and wall and forcefully
K. Iyengar : S. Gandham (*) : J. Nadkarni : W. Loh hyper extending the digit.
Trauma and Orthopaedics, Clinical examination revealed obvious deformity at the
Southport and Ormskirk Hospital NHS trust,
Town Lane, Kew, Southport,
CMC joint of the thumb. Range of movement at this joint
Merseyside PR8 6PN, UK was greatly reduced and painful. Antero-posterior and
e-mail: [email protected] oblique radiographs of the hand and thumb showed CMC
J Hand Microsurg (January–June 2013) 5(1):36–42 37

joint dislocation of the thumb with no associated fracture

(Fig. 1). An intra-articular injection of 2 % Lignocaine was
then used for a closed reduction of this dislocation in the
A& E but revealed persistent articular in-congruity and fore-
shortening of the right thumb metacarpal with anterior an-
gulation at the CMC joint on check radiographs (Fig. 2).
Hence a further reduction was undertaken under general
anaesthesia. This was stabilized with two percutaneous
cross Kirschner wires to maintain the reduction (Fig. 3).
The patient was then placed in a scaphoid cast for 4 weeks.
At 4 weeks the k-wires were removed and gentle hand
therapy with intermittent use of a thumb brace was under-
taken for 6 weeks. Unfortunately, the patient did not respond
to this treatment and continued to have pain at the base of
her thumb. Provocative stress tests for suspected rupture of
the volar beak ligament were positive. These included the
‘Torque’ test described by Eaton and Littler [2] and Stress
test described by Takwale et al. [12]. The instability was
confirmed by examination of the thumb under anaesthesia
with x-ray control. Reconstruction was undertaken using a
Fig. 2 Post reduction check radiographs showing persistent articular
modified Eaton-Littler technique (Figs. 4, 5, 6 and 7). in-congruency

Surgical Technique crease as far as the flexor carpi radialis tendon (Fig. 7). The
superficial sensory branches of the radial nerve, palmar cuta-
The thumb carpometacarpal joint was approached through an neous branch of the median nerve and the superficial branch
anterior curvilinear incision along the lateral margin of the of the radial artery were protected. The thenar muscles were
thumb metacarpal, curving ulnar towards the distal wrist reflected extra-periosteally from the metacarpal and the

Fig. 1 Showing the isolated carpometacarpal thumb dislocation suffered Fig. 3 Kirschner wire stabalisation of thumb carpometacarpal joint
by the case study following failed closed reduction
38 J Hand Microsurg (January–June 2013) 5(1):36–42

Fig. 4 Pictures showing range

of movement and scar healing
following modified Eatons
Reconstruction

Fig. 5 Post operative

radiographs following modified
Eatons Reconstruction showing
good joint congruency at the
carpometacarpal joint of the
thumb
J Hand Microsurg (January–June 2013) 5(1):36–42 39

Fig. 7 Modified Eaton-Littler’s technique

Fig. 6 Traditional Eaton-Littler’s technique

We have modified this classical technique by restricting the
release of FCR slip 2 to 2.5 cm short of its insertion. This slip
trapezium to expose the thumb carpometacarpal joint. In our was then directed in an oblique manner to reproduce the
patient the volar joint capsule was thinned out and lax. The direction of active action of the anterior oblique ligament. A
anterior oblique ligament (beak ligament) was found to be couple of sutures were placed at this bifurcation point of the
torn; while the dorsoradial ligament was intact. Arthrotomy of FCR slip to prevent further splitting of the slip towards the
the joint allowed inspection of the articular surfaces. These insertion of FCR on the index finger. The FCR slip was routed
were not damaged. through the extra-articular bone tunnel and sutured in a taut
A separate 1 cm transverse incision was made proximally position back to itself. The routed FCR slip covered both the
in the forearm to harvest a 10 cm long FCR tendon slip using dorsal (Dorso-radial ligament) and volar aspect (volar beak
Carroll’s tendon forceps. An extra-articular bone tunnel was ligament) of the carpometacarpal joint by passing under the
then prepared from the dorsum of the thumb metacarpal abductor pollicis longus tendon. An appropriate tension was
placed 7–8 mm distal and parallel to the thumb metacarpal created in the routed FCR slip by wrist tenodesis manoeuvre
articular surface. to avoid thumb contracture. The joint capsule was repaired in
In the traditional Eaton-Littler technique, the FCR slip, an end-to-end fashion using 4–0 polydioxanone (PDS) inter-
based distally is released in continuity till its insertion on the rupted sutures. Wound was then closed and a thumb spica
index metacarpal. It is then re-routed through a drill hole in the applied for 6 weeks. Hand therapy was commenced after
base of the thumb metacarpal, under the abductor pollicis removal of the plaster to allow active and passive mobilization
longus insertion and secured on the radial side of the joint. of the thumb under hand therapist’s supervision.
40 J Hand Microsurg (January–June 2013) 5(1):36–42

Follow-up was done regularly at 3 monthly intervals and volar beak ligament injury can be difficult especially in pres-
at the end of 1 year. The patient was pain free and could ence of congruent joint on radiographs as in our patient.
undertake all of her pre-injury level of activity. There were Eaton and Littler described a ‘Torque test’ which
no complications. The thumb revealed full range of joint involves axial rotation of a distracted thumb to evaluate
mobility and there was no residual instability. The grip CMC joint instability [2]. This test is mentioned to be more
strength measured in kilograms (kg) by Jamar hand dyna- specific for synovitis. More recently Takwale et al. have
mometer improved from 10.6 kg pre-operatively to 20.8 kg described a two step clinical provocative test to detect
post-operatively (opposite hand 22 kg). The pinch grip instability of this joint [12]. The thumb first abducted in a
improved from 4.7 kg to 6.5 kg (opposite hand 8 kg). Radio- palmar direction and pronated. The second step involves
graphs demonstrated normal joint anatomy and congruity with gradual abduction, supination of the retro pulsed thumb
no evidence of subluxation. reproducing symptoms of instability in the patient.
The role of complementary imaging such as Ultrasonog-
raphy (USS), Magnetic Resonance Imaging (MRI) and
Discussion Magnetic Resonance Arthrography in assessing CMC joint
instability and other pathologies is still evolving. Chiavaras
The CMC joint of the thumb is a biconcave saddle joint, et al. used high-resolution ultrasound to identify and mea-
stability of which is provided by five main ligamentous sure the thickness of the anterior oblique ligament in a
structures during static pinch and grasp: (1) The anterior cadaveric study [18]. Though they conclude that dynamic
oblique ligament, (2) the dorsoradial ligament, (3) the first ultrasound imaging can depict volar translation of the meta-
inter-metacarpal ligament, (4) the posterior oblique liga- carpal, which may facilitate diagnosis of ligamentous injury,
ment, and (5) the ulnar collateral ligament [1]. presently, there are no clinical reports of ultrasound evalua-
Eaton and Littler believed that the anterior oblique ligament, tion of the anterior oblique ligament (or dorsoradial
also known as the beak or volar ligament, is a key stabiliser of ligament) in assessing traumatic instability of CMC joint.
the joint which prevents radio-dorsal subluxation of the thumb In their recent study, Connell et al. [19] evaluated trapezio-
metacarpal during key and dynamic pinch [2, 13]. This liga- metacarpal joint ligamentous injuries using conventional
ment is ruptured by an extension-supination injury when the MRI. They recommend coronal and axial imaging with fat
point of contact is the base of the metacarpal of the thumb suppression and a coronal STIR sequence to assess the
which probably happened in our patient [12]. A non-functional integrity of stabilizing ligaments. MR arthrography further
anterior oblique ligament either because of injury or instability improves visualization and provides detailed information
leads to progressive dorsal translation resulting in reduced about the anatomy of the ligaments around the trapeziome-
contact area between thumb metacarpal and trapezium. This tacarpal joint. However, guidelines are still being developed
produces a pattern similar to that of cartilage degeneration seen to provide accurate diagnosis on MRI. Hence at present a
in an osteoarthritic joint [14]. This research by Pelligrini et al. good clinical history, high index of suspicion and clinical
supports the hypothesis that pathological joint instability is the examination are a key to a correct diagnosis.
main cause of CMC joint osteoarthritis by the mechanism of Traditionally traumatic CMC dislocation of the thumb
abnormal translation of the joint. has been treated with closed reduction (CR) with or without
However, there appears to be considerable debate in the pinning. Conservative methods of CR and plaster applica-
literature about the principal restraint to dorsal dislocation. tion have been shown to produce good results by various
Strauch et al. [3] and van Brenk et al. [4] in separate authors [6, 20, 21]. In spite of this, healing of peri-articular
cadaveric studies found the dorsoradial ligament complex ligamentous structures and stability of the CMC joint has
to be the primary restraint to dorsal dislocation and was not been evaluated in long term studies following such
responsible for thumb stability. Shah and Patel [15] found injuries. On the other hand, CR with pinning has been
the dorsoradial ligament complex torn in their case series of applied with variable results [8, 22]. Both set of authors
four patients. The volar structures were found to be intact. noticed features of instability following this method of treat-
On the other hand, Simonian and Trumble found the volar ment in their patients on follow-up evaluation. Fotiadis et al.
beak ligament to be torn in all of their patients who under- point out the unpredictable outcome of conservative or
went ligament reconstruction [11]. These differences of the minimally invasive methods in achieving stability CMC
site of rupture may be explained on the position of the joint of the thumb [23].
thumb at the time of the injury. Continual instability following above methods of treat-
Plain radiographs usually demonstrate CMC joint disloca- ment should lead to a suspicion of a significant ligamentous
tion to confirm diagnosis. They should to be carefully evalu- injury. Left untreated, mechanical instability of the CMC
ated to assess associated injuries such as a fracture of the joint of the thumb interferes with normal function of the
trapezium [16, 17]. However, diagnosis of instability and hand and may lead to articular degeneration of the joint [24].
J Hand Microsurg (January–June 2013) 5(1):36–42 41

Techniques of Ligament Reconstruction Competing interests There were no competing interests.

A variety of ligamentoplasty techniques to stabilise the Funding No funding was involved in this study
CMC joint of the thumb have been described. These
involve substituting the anterior oblique ligament, the
dorsoradial ligament or the intermetacarpal ligament.
Brunelli et al., Eggers and Slocum have described techni- References
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