Rolando Fracture

Rolando fracture is a comminuted intra-articular fracture of the base of the first metacarpal, with a Y-shaped, T-shaped or fully comminuted pattern. It is less common than the Bennett fracture and carries a worse outcome.

The mechanism is an axial load on the thumb, usually higher energy than the Bennett fracture (a fall, a punch or a sporting collision). Young men are the commonest group.

Complications are carpometacarpal arthritis, malunion, loss of the first web space, stiffness, weak pinch and grip, complex regional pain syndrome, and hardware problems.

Pathophysiology.

The articular surface is split into two or more large fragments with a metaphyseal fragment, or it is crushed. The shaft is pulled proximally by the abductor pollicis longus and adducted by the adductor pollicis, so reduction is unstable.

Joint congruity governs outcome. A residual step of over 1 to 2 mm is associated with early arthritis, but severely comminuted fractures often do well with movement started early, even without an anatomical reduction.

Pain, swelling and deformity at the base of the thumb, loss of motion and weak pinch. Tenderness at the carpometacarpal joint and crepitus. Check capillary refill, radial digital nerve sensation and the other digits. Look for associated injuries to the scaphoid and distal radius.

• Radiographs: true lateral, posteroanterior and Robert views. Count the articular fragments (T or Y pattern or comminuted), and measure the step.
• CT to plan fixation, particularly with comminution.

Differential diagnosis.

• Bennett fracture and extra-articular metacarpal base fracture.
• Carpometacarpal dislocation and trapezium fracture.
• Scaphoid fracture and ulnar collateral ligament injury.
• Distal radius fracture.

Treatment depends on the number and size of fragments and on the patient's demand.

• Large fragments (Y or T pattern): open reduction and internal fixation through a volar radial approach with lag screws or a small T-plate (1.5 to 2.0 mm), restoring the joint surface and the length of the metacarpal.
• Fixation of a displaced two part pattern may be achieved with closed reduction and percutaneous Kirschner wires (1.2 to 1.6 mm).
• Severe comminution (not reconstructable): ligamentotaxis with a mini external fixator for 4 to 6 weeks, with or without limited fixation and bone graft, or early mobilisation in a thumb spica without surgery.
• Early mobilisation at 2 to 4 weeks after fixation protects against stiffness and first web contracture.
• Late carpometacarpal arthritis: trapeziectomy with ligament reconstruction or fusion.

Analgesia.

• Paracetamol 1 g orally every 6 hours as needed for up to 5 to 7 days (maximum 4 g daily; 3 g daily when weight is under 50 kg, with chronic alcohol use or hepatic impairment).
• Ibuprofen 400 mg orally every 8 hours with food for up to 5 days (maximum 1200 mg daily); avoid with eGFR under 30 mL/min/1.73 m2, peptic ulcer, heart failure or anticoagulant use.
• Oral morphine 5 to 10 mg every 4 hours as needed for severe pain for up to 3 days (start 2.5 to 5 mg with age over 75 or eGFR under 30 mL/min/1.73 m2; avoid exceeding 60 mg in 24 hours without senior review); monitor sedation and respiration and prescribe a laxative.

Monitoring. Radiographs at 1 week, 2 weeks, 6 weeks and 3 months. Pin sites at each visit. Thumb range, first web space, pinch and grip at 3 months. Carpometacarpal arthritis at 1 year and later.

Referral and escalation. Refer every Rolando fracture to orthopaedics or hand surgery within 24 to 48 hours. Same day referral for open injury, neurovascular compromise, or irreducible dislocation.

Special groups.

• Children: physeal injuries need specialist assessment.
• Older adults: osteoporotic bone favours rigid fixation or early mobilisation.
• Kidney impairment: avoid ibuprofen and reduce morphine doses.