Rolando Fracture Treatment & Management
- Author: John J Walsh, IV, MD; Chief Editor: Harris Gellman, MD more...
If 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 below). 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.[9, 11, 12, 13, 14] 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.
Byrne et al recommended dynamic "S"-Quattro (Stockport Serpentine Spring System) as a primary and definitive treatment modality for external fixation of complex fractures of the base of the thumb when conservative and other surgical interventions have failed.
Spangberg and Thoren described the use of oblique K-wire traction in the treatment of Bennett fracture. Gelberman expanded this to include comminuted metacarpal base fractures and trapezial fractures. 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.
Secure 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.
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 Prognosis
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. 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. 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. 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.
The average duration of follow-up was 35 months. No significant complications developed, and no loss of reduction, malalignment, or secondary subluxation developed. Grip and pinch strength were 81% and 88% of the contralateral side, respectively. Rotation of the thumb metacarpal was 79% of the unaffected side. No diffuse degenerative changes developed.
Future and Controversies
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.
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