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A Comprehensive Review of Rolando (Thumb) Fractures
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Posted on: 01/12/2011
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As you might guess with a label like Rolando fracture, this thumb injury was named after the surgeon from Italy who first named it back in 1910. Over 100 years later, the name has remained to describe a particular Y-shaped break at the base of the thumb joint. The Y-shaped Rolando fracture affects the joint surface of the trapeziometacarpal (TMC) joint.
In this article, hand surgeons from Barcelona, Spain offer a comprehensive review of Rolando fractures. They describe the anatomy involved, report how often these types of fractures occur, and who is most likely to experience such an injury. The pattern of fracture, mechanism of injury, and diagnosis are also included. Treatment options are provided with details of surgical procedures used.
Let's start with a little bit of anatomy and the mechanism of injury (how it happens). The TMC joint is located where the bone at the base of the thumb (metacarpal) meets the trapezium bone of the wrist. A Rolando fracture at the TMC occurs most often when someone falls and lands on the radial side of the thumb (side closest to the body) or when striking an object with a closed fist (thumb tucked inside the palm).
Men who get in fist fights make up the majority of patients with Rolando thumb fractures. The forces placed on the thumb from this type of action are enough to shatter the bone into tiny pieces. Continued use of the thumb can cause the tendons to pull the bone fragments out of place. The result is a displaced fracture.
The details of fragmentation and displacement will be more obvious when X-rays are taken. A single X-ray probably won't show everything the surgeon needs to see in order to make the final diagnosis. Fractures at the base of the thumb often require several different X-ray views to clearly show how much of the joint surface is involved. That is important information when planning treatment.
Surgeons can use an algorithm to guide treatment. An algorithm is a series of steps used to make a decision. In the case of Rolando fractures, the algorithm begins with the question of whether the fracture is displaced. If no, then a cast can be put on the hand, wrist, and forearm until the fracture heals (usually four to five weeks).
If yes (the fracture has separated), then the next decision point is made based on whether the two ends of the separated bone can be brought back together. The process of reducing the space between the two pieces of bone is called reduction. Reduction with less than a two millimeter gap is a good result. A wider gap than that would require surgery.
Rolando fractures that include many tiny fragments of bone (called comminuted) cannot be surgically reduced. It's next to impossible to line up all the pieces of bone to recreate a smooth joint surface. The surgeon does what he or she can to use traction (downward pull) to line up the trapeziometacarpal (TMC) joint. Then a cast is placed on the arm to protect the fractured site until healing takes place. Immobilization with a cast also makes sure the muscles and tendons don't pull on the fracture site (further deforming the damaged area).
When adequate reduction is impossible with traction alone, then surgery is needed. Under the relaxing effects of anesthesia, the surgeon can pull the bones and realign them. Then wires, screws, or other hardware are used to hold everything together. If an incision is needed to gain access to the joint, the procedure is called open reduction and internal fixation (ORIF). If the operation can be done through the skin, it is referred to as a closed reduction and percutaneous fixation.
The authors provide detailed instructions for the reduction and fixation procedures. There are three specific methods described (Iselin, Wagner, Wiggins and Bundens). Photographs of X-rays show the angle of pull used with traction to reduce the fracture and the placement of wires, plates, other hardware, and fixation devices.
The surgeon does everything possible to avoid injury to nerves and blood vessels in the area and to get the best possible stabilization of the joint. Sometimes internal fixation isn't possible. The surgeon can use external fixation instead. Pins are placed on either side of the fracture through the skin and soft tissues with rods outside the arm between the pins.
The authors point out that no one knows if there is a "best" way to treat Rolando fractures. There are advantages and disadvantages to each surgical approach (open versus closed) and technique. Likewise, choosing the method of fixation becomes another decision point. Wires can be used for smaller fractures. Plates may be better for large fracture fragments.
There is a need for studies based on results of current surgical techniques for Rolando fractures. This type of research would help guide surgeons when treating these injuries. Modern treatment as described in this article is currently based on the few studies done that suggest a two millimeter gap as the defining point between conservative (nonoperative) and surgical care.
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References:
Ignacio Proubasta, MD, PhD, et al. Rolando Fractures. In Current Orthopaedic Practice. November/December 2010. Vol. 21. No. 6. Pp. 615-623.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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