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Rolando Fracture

  • Author: John J Walsh, IV, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Jan 15, 2014
 

Background

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.

The images below depict Rolando fractures.

Lateral tomograph of a Rolando fracture clearly sh Lateral tomograph of a Rolando fracture clearly shows the varus angulation at the fracture, as well as the multiple fragments of the articular surface.
Anteroposterior tomograph of a Rolando fracture fu Anteroposterior tomograph of a Rolando fracture further emphasizes the extent of comminution of the articular surface (same patient as in Image above).
Radiograph of a healed Rolando fracture following Radiograph of a healed Rolando fracture following fixation of the articular surface and neutralization with a small plate.

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.[1, 2, 3, 4, 5]

Related Medscape Reference topics

Metacarpal Fractures - Orthopedic Surgery

Thumb Fractures and Dislocations - Plastic Surgery

Thumb Dislocation Joint Reduction - Clinical Procedures

Metacarpal Fractures and Dislocations - Plastic Surgery

Bennett Fracture - Orthopedic Surgery

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History of the Procedure

Rolando 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.[6, 7] 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.[8]

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.

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Etiology

Rolando 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.[6]

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Pathophysiology

Following 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.

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Presentation

Following 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.

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Indications

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.[9]

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Relevant Anatomy

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.[10] 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.

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Contraindications

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.

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Contributor Information and Disclosures
Author

John J Walsh, IV, MD Professor and Chairman, Department of Orthopedic Surgery, University of South Carolina School of Medicine

John J Walsh, IV, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Christian Medical and Dental Associations, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael Yaszemski, MD, PhD Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School

Disclosure: Nothing to disclose.

Chief Editor

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, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

References
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  14. Greeven AP, Alta TD, Scholtens RE, de Heer P, van der Linden FM. Closed reduction intermetacarpal Kirschner wire fixation in the treatment of unstable fractures of the base of the first metacarpal. Injury. 2012 Feb. 43(2):246-51. [Medline].

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  17. Langhoff O, Andersen K, Kjaer-Petersen K. Rolando's fracture. J Hand Surg [Br]. 1991 Nov. 16(4):454-9. [Medline].

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  19. Buchler U, McCollam SM, Oppikofer C. Comminuted fractures of the basilar joint of the thumb: combined treatment by external fixation, limited internal fixation, and bone grafting. J Hand Surg [Am]. 1991 May. 16(3):556-60. [Medline].

  20. Brüske J, Bednarski M, Niedzwiedz Z, Zyluk A, Grzeszewski S. The results of operative treatment of fractures of the thumb metacarpal base. Acta Orthop Belg. 2001 Oct. 67(4):368-73. [Medline].

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Lateral radiograph of a Rolando fracture. Note how the comminution is not easily viewed on this film.
Lateral tomograph of a Rolando fracture clearly shows the varus angulation at the fracture, as well as the multiple fragments of the articular surface.
Anteroposterior tomograph of a Rolando fracture further emphasizes the extent of comminution of the articular surface (same patient as in Image above).
Radiograph of a healed Rolando fracture following fixation of the articular surface and neutralization with a small plate.
 
 
 
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