The Kaplan’s Lesion - A Childs Nightmare, A Surgeons Adventure

Oct 28, 2026

A surgical case describes an irreducible dorsal metacarpal head dislocation of the right index finger in an 11-year-old boy after a school fall. Closed manual reduction and repeated CMR failed, leading to open reduction under general anesthesia. A volar approach was selected; intra-operatively the metacarpal head was buttonholed and trapped among volar structures, with displacement of the volar plate. Careful disengagement and guarded traction enabled successful reduction and full pain-free ROM by follow-up.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Introduction

Report

Conclusion

References

Malaysian Orthopaedic Journal 2024 Vol 17, Supplement A The Kaplan’s Lesion : A Childs Nightmare, A Surgeons Adventure 1Nasir Naim 1Hand, Upper Limb, and Microsurgery unit, Hospital Kuala Lumpur. INTRODUCTION: In 1957, Kaplan described an irreducible index finger dorsal metacarpal head dislocation, and the relevant anatomy that prevents the reduction of the joint. It is a relatively a rare occurrence and surgical reduction still remains as the gold standard. The concept of ‘buttonholing’ of the metacarpal head through volar structures is still relatively unpopular and thus might prevent the surgeon from making an informed decision in regards to the surgical approach and technique. REPORT: An 11 year old boy sustained a right index finger dorsal metacarpal head dislocation when a fellow student fell on his hand. The index was fully extended and the palm faced upwards when the fall happened in school. He was brought to a clinic, where closed manual reduction was attempted and failed, he was bought to the emergency department and CMR was attempted again, which also failed. Child was subsequently arranged for open reduction under general anesthesia. Choice was approach is volar, due to the anticipation of the metacarpal head getting stuck in between the volar structures. Intra-operatively, it was noted that the metacarpal head is buttonholed and trapped inbetween the natatory ligament distally, the superficial transverse ligament proximally, flexor tendon radially, and the lumbricals ulnarly. In addition , the volar plate was also displaced inbetween the joint space. Both the digital arteries and nerves were identified and protected during the surgery Gentle axial traction was applied, with careful disengagement of the structures stuck around the metacarpal head, and also ‘fishing out’ of the volar plate, we are successful in reducing the metacarpal head. Approximation sutures were applied at the proximal end of the volar plate. And intraoperatively range of motion of the joint is full with no dislocation or subluxation. Patient was put on a dorsal malleable splint fora few days, and 2 weeks later, assessment shows full, painless ROM of the index MCP joint. Figure 1: Clinical pictures and xray Figure 2: approach and operative finding CONCLUSION: In complex metacarpal dislocation, choice of approach is important due to the structures involved that prevents the metacarpal head from reduction. The easier, more common dorsal approach allows for splitting of the displaced volar plate and allows it to be pushed volarly. However if the metacarpal head is also stuck atthe volar structures, another volar incision would have to be made, thus complicating the surgery. We highly recommend single volar approach as it more versatile. REFERENCES: 1. Kaplan EB. Dorsal dislocation of the metacarpophalangeal joint of the index finger. J Bone Joint SurgAm 1957;39:1081–6 2. Um, Junghwan et al. “Kaplan’s Lesion of the Little Finger Treated with Open Reduction by a Volar Approach: A Case Report.”(2021).

FAQs

Why did the surgeons choose a volar approach for this case?

The volar approach was selected because the surgeon anticipated the metacarpal head would get stuck between volar structures, making the reduction unlikely through a more common dorsal route.

What was found during surgery about the position of the metacarpal head?

Intra-operatively, the metacarpal head was buttonholed and trapped between structures including the natatory ligament distally, the superficial transverse ligament proximally, and other volar components; the volar plate was also displaced into the joint space.

How was recovery assessed after open reduction?

After surgery the patient was placed in a dorsal malleable splint for a few days, and two weeks later assessment showed full, painless range of motion of the index MCP joint.

Oct 28, 2026

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