You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY Rolando FractureArticle Last Updated: Jun 29, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: John J Walsh IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Carolina School of Medicine John J Walsh, IV, is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Christian Medical & Dental Society Editors: A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: comminuted thumb metacarpal base fractures, fractures of the thumb base, thumb injury, broken thumb, thumb fracture, juxta-articular metaphyseal fracture, Bennett fracture INTRODUCTIONSection 2 of 12
  Thumb function constitutes about 50% of hand function as a whole. The thumb metacarpal base is a unique joint that allows a wide range of motion while maintaining stability for grasp and pinch in a variety of positions. Multiple fracture patterns of the thumb base have been described, including juxta-articular metaphyseal fracture, Bennett fracture, and Rolando fracture. Interest in the fixation of these fractures has been stimulated by the marked decrease in hand function that can develop in the affected patients if disabling arthritis occurs in the thumb carpometacarpal articulation as a result of articular incongruity following such fractures. History of the ProcedureRolando fracture initially was described in 1910 in a series of 12 metacarpal base fractures, of which 3 involved a Y-shaped split of the joint surface.1 The fracture was described as having 3 major fragments: metacarpal shaft, dorsal metacarpal base, and volar metacarpal base. Currently, the term has come to include essentially all comminuted thumb metacarpal base fractures. The initial treatment options that were described mainly focused on closed treatment, either cast immobilization or a short period of splinting followed by early motion to mold joint surfaces. With the advent of internal fixation techniques, especially smaller implants, interest in operative treatment has increased over the past few decades. EtiologyRolando fracture is analogous to the pilon fracture of the distal tibia and appears to be secondary to a significant axial load that splits and crushes the metacarpal articular surface. Rolando described 2 cases that occurred secondary to a fall on the radial side of the hand, with the thumb in adduction, and a third case that was caused by a closed fist, with the thumb folded and held in the palm, striking an adversary's head.1 PathophysiologyFollowing an injury similar to that described above, the fracture is at risk of further displacement due to the resting tone present in the multiple tendons that act on the thumb. The extensor pollicis brevis and longus shorten the thumb ray, as does the pull of the flexor pollicis longus. The adductor pollicis muscle tends to pull the distal metacarpal toward the palm, which, in conjunction with the abductor pollicis longus acting on the metacarpal base, commonly produces varus at the metaphyseal-diaphyseal junction. ClinicalFollowing injury, patients present with a swollen, tender thumb base. If significant varus has developed, a clinically visible deformity may be present. However, swelling can mask a surprising amount of angulation. Neurovascular and tendon injuries are not commonly associated with this fracture. INDICATIONSSection 3 of 12
Significant joint incongruity (ie, >1-2 mm of articular step-off) mandates treatment. However, the type of treatment can vary and is somewhat controversial. Large articular fragments in which screws can be used are probably best supported by plate and screw fixation, whereas massive comminution is best treated with a form of traction (see Future and Controversies). Open fractures require debridement, and operative stabilization is recommended to stabilize the skeleton and allow soft-tissue healing. Pin fixation or external fixation is preferred in the presence of open injuries to minimize soft-tissue stripping. RELEVANT ANATOMYSection 4 of 12
The carpometacarpal joint surface consists of 2 reciprocal interlocked saddles that allow motion parallel and perpendicular to the plane of the palm. Compressive forces across the joint appear to be magnified during pinch and have been estimated at 12 times the pinch force. Articular incongruity, therefore, is subjected to high forces and increases the likelihood of arthrosis development. As a result, interest has been spurred to improve the accuracy and security of reduction techniques. CONTRAINDICATIONSSection 5 of 12
Contraindications to surgery are few; a systemically ill patient following polytrauma who cannot undergo any surgical procedure is an example of a patient in whom surgery would be contraindicated. An open fracture that has large fragments (normally treated with plate and screw fixation) and is massively contaminated would best be managed with traction and repeated debridements. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Surgical therapyIf open reduction is thought to be a reasonable choice for the patient with a Rolando fracture, a curvilinear incision is made at the thumb base. Branches of the superficial radial nerve dorsally and lateral antebrachial cutaneous nerve volarly are identified with loupe magnification, isolated, and protected. The periosteum is split along the first metacarpal shaft, and the joint is entered in the interval between the abductor pollicis longus and extensor pollicis brevis tendons. Large articular fragments are identified. The articular surface is reconstructed in a piecemeal fashion with fine Kirschner wires (K-wires) and then secured to the metacarpal shaft using a small T plate (see Image 4). Obtain intraoperative radiographs to confirm a satisfactory reduction, and place the limb in a thumb spica splint. Comminuted metacarpal base fractures that cannot be secured with pins or screws can be treated with external fixation. One technique involves a quadrilateral frame with 2 pins each in the thumb and index metacarpal, limited K-wire fixation of the articular surface, and bone grafting of any metaphyseal void that has been created after length restoration. Another technique involves placing fixator pins in the trapezium and metacarpal shaft to maintain distraction. Spangberg and Thoren described the use of oblique K-wire traction in the treatment of Bennett fracture.2 Gelberman expanded this to include comminuted metacarpal base fractures and trapezial fractures.3 The technique involves use of a single K-wire that is passed from the metacarpal base out of the thumb web, with a small hook on the proximal end of the wire. The distal end is then attached to an outrigger through rubber bands. Active motion is started to mold the joint surface. This traction neutralizes displacing muscle forces and maintains reduction through ligamentotaxis. Follow-upSecure plate fixation can allow early motion of the joint surface. However, if the comminution requires grafting and stability is a concern, immobilization in a thumb spica cast for 4-6 weeks is the safest course of action. External fixation and/or K-wires can be removed at approximately 6 weeks postoperatively, and active motion can begin. COMPLICATIONSSection 8 of 12
Complications are often directly related to the extent of the comminution. Hardware-related issues can develop, such as pin tract infection or screw pullout with resultant loss of fixation. Soft-tissue complications include damage to the nerve branches of the superficial radial or lateral antebrachial cutaneous nerve. Some degree of joint stiffness is inevitable, given the articular nature of the fracture. OUTCOME AND PROGNOSISSection 9 of 12
In a study by Langhoff et al, 16 patients had a mean follow-up of 5.8 years following open reduction with fine K-wires.4 Nine had no residual symptoms, 6 had symptoms with moderate activity, and 1 had significant symptoms that required a change in occupation. Reduced range of motion was noted in 8 patients, and 3 had a visible deformity of the thenar base region that was related to large residual angulations of 35-55 degrees. Of the 11 patients with radiographs at follow-up, osteoarthritic changes were present in 6 (55%); this did not appear to correlate with the quality of reduction or with late symptoms. Proubasta reported the results of 5 patients treated with a mini–external fixator.5 Pins were placed in the trapezium and thumb metacarpal shaft, and the fracture was reduced with distraction. At short-term follow-up at 3 months, no complications were noted, and the patients all were free from pain and had a full range of thumb movements. Buchler and coauthors reviewed their experience in the management of 13 complex thumb metacarpal base fractures in which multiple fragments were involved.6 The authors treated the fractures with external fixation between the index and thumb metacarpals and limited internal fixation of the joint surface using pins and/or screws. Buchler et al performed bone grafting of the metaphyseal void present after distraction. FUTURE AND CONTROVERSIESSection 10 of 12
Future research will help to identify fractures that safely can be managed with internal fixation alone, as well as help to differentiate these injuries from the more severely comminuted fractures that need external fixation for ligamentotaxis and protection of the fracture. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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