Sagittally split fracture of trapezium associated with subluxated carpo-metacarpal joint of thumb

doi:10.1016/j.injury.2003.09.004

Injury

Volume 35, Issue 11, November 2004, Pages 1172-1175

https://doi.org/10.1016/j.injury.2003.09.004 Get rights and content

Abstract

Trapezial fractures are uncommon, and require careful clinical and radiological assessment and treatment. Poor or inadequate treatment of displaced fractures of trapezium can lead to long-term morbidity. We report two displaced fractures of the trapezium. The clinical and radiological features are discussed. Both fractures were treated operatively and a good functional outcome was achieved.

Introduction

The carpo-metacarpal joint is important in the function of the thumb and in the performance of strong pinch and grasp. Most often, it is associated with other carpo-metacarpal injuries such as Bennett’s fracture-dislocation, Rolando fracture, fractures of the scaphoid, hook of hamate, distal radius and carpo-metacarpal dislocations.¹⁰ Indirect force may produce fractures of the body of trapezium, whereas either avulsion or a direct force may produce ridge fractures. Inadequately treated fractures of the trapezium can produce long-term morbidity. Two case studies of trapezial fractures with associated subluxation of the carpo-metacarpal joint of the thumb are presented.

Section snippets

Case report (1)

A 24 year-old man sustained an axial injury to his right (dominant) hand in a rugby-tackling incident. Radiographs revealed an unusual displaced, intra-articular, and longitudinal sagittally split fracture of body of the trapezium with associated subluxation of the carpo-metacarpal joint of thumb (Fig. 1). The fracture was manipulated under general anaesthetic but the reduction was unstable. The patient then underwent open reduction and internal fixation with a mini fragment 2.7 mm lag

Case report (2)

An 18 year-old right-handed man sustained an injury to his right hand whilst playing rugby. He sustained an intra-articular, sagittally split, displaced fracture of the trapezium (Fig. 3). He underwent open reduction and internal fixation with a single 2.7 mm lag screw. A below-elbow plaster cast extending up to the finger carpo-metacarpal joints was applied for 6 weeks. A radiograph taken at 6 weeks was satisfactory (Fig. 4). He made an uneventful recovery following his operation and has

Discussion

Fractures of the trapezium are usually associated with other hand or wrist injuries. They are rare, constituting about 3.5–5% of all carpal bone fractures. Isolated fractures are rare and almost impossible to produce experimentally.

Trapezial fractures may be produced by both direct dorso-radial impact and by indirect axial loads. Axial loads and radial deviation have been implicated in compressive injuries to the trapezium. The trapezium is probably injured by compression between the radial

Conclusion

Longitudinal injuries of carpo-metacarpal joint of thumb are unstable and are accompanied by subluxation of the thumb metacarpal. Oblique X-rays and occasionally CT scan are required for an accurate diagnosis. If these injuries are not accurately diagnosed and treated, they may cause pain, limitation of motion and/or weakness leading to permanent impairment of function. Fixation with Kirschner-wires, Herbert’s type compression screws, or inter-fragmentary lag compression screws may be required

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A technical note on percutaneous fixation of trapezium fracture under gravitational traction
2023, Hand Surgery and Rehabilitation
Trapezium fractures rarely present as isolated fractures and warrant anatomical fixation to minimize post-traumatic arthritis. Fixation techniques reported include open approach to trapezium fracture and fixation, percutaneous fixation under image intensifier guidance or percutaneous arthroscopic fixation under gravitational traction. We have reported a novel method of percutaneous fixation of a trapezium Walker type IV coronal split fractures under gravitational traction and per-operative image intensifier guidance. Two percutaneous headless differential pitch screws were used for fixation, which was off-loaded using an inter-metacarpal K-wire. Patient was discharged on the same day with a light-weight cast. The fixation yielded acceptable reduction of the articular surface as confirmed by radiographs. The cast and off-loading K-wire were removed at four weeks post-surgery and hand therapy was commenced. 3-month review showed optimal radiological healing with excellent return to function without pain. In conclusion, using gravitational traction can allow percutaneous fixation of trapezium fractures with excellent results and also make an otherwise complex procedure simpler.
IV.
Les fractures du trapèze se présentent rarement comme des fractures isolées et justifient une fixation anatomique pour minimiser l'arthrose post-traumatique. Les techniques d’ostéosynthèse rapportées sont: la voie ouverte, la fixation percutanée sous guidage par amplificateur de brillance et la voie arthroscopique sous traction gravitationnelle. Nous rapportons une nouvelle méthode d’ostéosynthèse percutanée d'une fracture du trapèze coronale de Walker type IV sous traction gravitationnelle et guidage per-opératoire par amplificateur de brillance. Deux vis percutanées sans tête auto-compressives ont été utilisées pour la fixation, qui a été déchargée à l'aide d'une broche inter-métacarpienne. Le patient est sorti le même jour avec un plâtre léger. L’osteosynthèse a entraîné une réduction acceptable de la surface articulaire confirmée par les radiographies. Le plâtre et la broche de Kirschner de décharge ont été retirés quatre semaines après la chirurgie et une rééducation manuelle a commencé. L'examen à 3 mois a montré une consolidation radiologique optimale avec un excellent retour à la fonction sans douleur. En conclusion, l'utilisation de la traction gravitationnelle peut permettre une fixation percutanée des fractures du trapèze avec d'excellents résultats et ainsi simplifier une procédure souvent complexe.
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Les fractures isolées du trapèze sont rares et peuvent passer inaperçues si les examens cliniques et radiologiques n’ont pas été correctement effectués. Notre patient a présenté une fracture verticale déplacée du corps du trapèze, le traitement chirurgical par abord dorsal et ostéosynthèse par mini-vis a permis d’obtenir un bon résultat clinique et radiologique.
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Citation Excerpt :
Even more uncommon are TMC fracture-dislocations involving separation of a trapezium fragment. Fifteen or so cases have been reported in the literature [11–25]. These injuries are vertical shear fractures at the dorsal side of the trapezium, which occur in combination with dorsal M1 dislocation and correspond to a bony avulsion of the dorsal radial ligament.
The authors report and discuss the management of a 25-year-old male patient with a trapeziometacarpal joint dislocation complicated by a trapezium fracture. This injury combination is rare with only reported 15 cases. After closed reduction resulted in dorsal instability, anatomical reduction of the trapezium fracture and internal screw fixation were performed using an open approach. This fixation stabilized the joint but was fragile due to the small fragment size. For this reason, ligament reconstruction using half of the flexor carpi radialis tendon was added. At the last follow-up, 16 months later, the trapeziometacarpal joint was stable with a normal range of motion, but the patient had slight pain during physical effort and decreased pinch strength.
Les auteurs rapportent et discutent la prise en charge d’un patient de 25 ans présentant une luxation trapézo-métacarpienne (TM) droite compliquée d’une fracture du rebord dorso-latéral du trapèze. Il s’agit d’une lésion rare avec une quinzaine de cas rapportés dans la littérature. Après une réduction par manœuvres externes montrant une instabilité résiduelle, le traitement chirurgical a d’abord consisté en une réduction anatomique et un vissage du fragment trapézien à foyer ouvert. Cette ostéosynthèse a permis de stabiliser l’articulation, mais était précaire du fait de la faible épaisseur du fragment. Pour cette raison, une ligamentoplastie utilisant un hémi-fléchisseur radial du carpe a été associée. À 16 mois de recul, l’articulation TM était stable et souple, mais il existait de légères douleurs d’effort et une baisse de force de pince.
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2023, Techniques in Hand and Upper Extremity Surgery
Association of Acute Trapeziometacarpal Joint Dislocation and Trapezium Fracture in a 14-Year-Old Boy: A Case Report
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