eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Rolando Fracture
Updated: Feb 17, 2009
Introduction
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.
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.
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 eMedicine topics
Metacarpal Fractures - Orthopedic Surgery
Hand, Fracture and Dislocations: Thumb - Plastic Surgery
Joint Reduction, Thumb Dislocation - Clinical Procedures
Hand, Fracture and Dislocations: Metacarpal - Plastic Surgery
Bennett Fracture - Orthopedic Surgery
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.
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.
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
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.
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.
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.8
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.9 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.
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.
More on Rolando Fracture |
 Overview: Rolando Fracture |
| Workup: Rolando Fracture |
| Treatment: Rolando Fracture |
| Follow-up: Rolando Fracture |
| Multimedia: Rolando Fracture |
| References |
| Further Reading |
| Next Page » |
References
Breen TF, Gelberman RH, Jupiter JB. Intra-articular fractures of the basilar joint of the thumb. Hand Clin. Aug 1988;4(3):491-501. [Medline].
Foster RJ, Hastings H 2nd. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop Relat Res. Jan 1987;(214):121-9. [Medline].
Howard FM. Fractures of the basal joint of the thumb. Clin Orthop Relat Res. Jul 1987;(220):46-51. [Medline].
Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the athlete. Clin Sports Med. Jul 2006;25(3):527-42, vii-viii. [Medline].
Stern P. Fractures of the metacarpals and phalanges. In: Green D, Hotchkiss R, Pederson WC, eds. Green's Operative Hand Surgery. Vol 2. 4th ed. New York, NY: Churchill Livingstone; 1999:763-4.
Rolando S. Fracture of the base of the first metacarpal and a variation that has not yet been described. 1910. Clin Orthop Relat Res. Jun 1996;(327):4-8. [Medline].
Rolando S. Fracture of the base of the first metacarpal and a variation that has not yet been described: 1910. (Translated by Roy A. Meals). Clin Orthop Relat Res. Apr 2006;445:15-8. [Medline].
De Kesel R, Burny F, Schuind F. Mini external fixation for hand fractures and dislocations: The current state of the art. Hand Clin. Aug 2006;22(3):307-15. [Medline].
Kent R, Stacey S, Parenteau C. Dynamic pinch tolerance of the phalanges and interphalangeal joints. Traffic Inj Prev. Mar 2008;9(1):83-8. [Medline].
Byrne AM, Kearns SR, Morris S, Kelly EP. "S" Quattro external fixation for complex intra-articular thumb fractures. J Orthop Surg (Hong Kong). Aug 2008;16(2):170-4. [Medline].
Edmunds JO. Traumatic dislocations and instability of the trapeziometacarpal joint of the thumb. Hand Clin. Aug 2006;22(3):365-92. [Medline].
Geissler WB. Cannulated percutaneous fixation of intra-articular hand fractures. Hand Clin. Aug 2006;22(3):297-305, vi. [Medline].
Spangberg O, Thoren L. Bennett's fracture. A method of treatment with oblique traction. J Bone Joint Surg Br. Nov 1963;45:732-6. [Medline]. [Full Text].
Gelberman RH, Vance RM, Zakaib GS. Fractures at the base of the thumb: treatment with oblique traction. J Bone Joint Surg Am. Mar 1979;61(2):260-2. [Medline]. [Full Text].
Langhoff O, Andersen K, Kjaer-Petersen K. Rolando's fracture. J Hand Surg [Br]. Nov 1991;16(4):454-9. [Medline].
Proubasta IR. Rolando's fracture of the first metacarpal. Treatment by external fixation. J Bone Joint Surg Br. May 1992;74(3):416-7. [Medline]. [Full Text].
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]. May 1991;16(3):556-60. [Medline].
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. Oct 2001;67(4):368-73. [Medline].
Kontakis GM, Katonis PG, Steriopoulos KA. Rolando's fracture treated by closed reduction and external fixation. Arch Orthop Trauma Surg. 1998;117(1-2):84-5. [Medline].
Pehlivan O, Cilli F, Mahirogullari M, Ozyurek S. Management of combined open fractures of thumb metacarpal and trapezium (surgical tip). Hand (N Y). Jun 2007;2(2):48-50. [Medline].
Pelissier P, Sawaya E, Sabri E. Re: "inside screw" wire-frame for internal fixation of intraarticular fracture. J Hand Surg Eur Vol. Apr 2008;33(2):223-4. [Medline].
Schramm JM, Nguyen M, Wongworawat MD, Kjellin I. Does thumb immobilization contribute to scaphoid fracture stability?. Hand (N Y). Mar 2008;3(1):41-3. [Medline].
Soyer AD. Fractures of the base of the first metacarpal: current treatment options. J Am Acad Orthop Surg. Nov-Dec 1999;7(6):403-12. [Medline].
Further Reading
Clinical guidelines and trials:
ACR Appropriateness Criteria® acute hand and wrist trauma. American College of Radiology. 1998 (revised 2005). 8 pages. [NGC Update Pending] NGC:004607
CMC (Carpometacarpal) OA (Osteoarthritis) Thumb Splint Study
Prolotherapy Versus Steroids for Thumb Carpo-Metacarpal Joint Arthritis
Keywords
Rolando fracture, Rolando's fracture, comminuted thumb, metacarpal base fractures, fractures of the thumb base, thumb injury, broken thumb, thumb fracture, juxta-articular metaphyseal fracture, Bennett fracture
