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CASE REPORT  
Year : 2012  |  Volume : 46  |  Issue : 1  |  Page : 99-101
Isolated coronal split fracture of the trapezium


Department of Orthopaedics, Ibri Regional Referral Hospital, Ibri 516, Oman

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Date of Web Publication10-Jan-2012
 

   Abstract 

Trapezium fractures account for <5% of all carpal fractures. Of these about 20% are vertical sagittal fractures of the body of trapezium and are classified as type IV. We report a case of coronal fracture of the trapezium, which was treated by open reduction and internal fixation with Kirschner wires and ligamentotaxis by external fixator. This fracture pattern has not been reported before.

Keywords: Carpal bones, trapezium carpometacarpal joint, internal fixation, open reduction

How to cite this article:
Suresh S S. Isolated coronal split fracture of the trapezium. Indian J Orthop 2012;46:99-101

How to cite this URL:
Suresh S S. Isolated coronal split fracture of the trapezium. Indian J Orthop [serial online] 2012 [cited 2019 Dec 12];46:99-101. Available from: http://www.ijoonline.com/text.asp?2012/46/1/99/91643

   Introduction Top


The carpometacarpal joint (CMC) of the thumb contributes primarily to the prehension, opposition, and circumduction of the thumb. [1] Any damage to the articular surface of the trapezium or the base of the first metacarpal leads to restriction of all ranges of movements from extension through abduction to flexion. [2] This includes fractures of the base of the first metacarpal and trapezium and CMC joint dislocations. Fractures of the trapezium account for about 5% of all carpal bone fractures. [1],[2],[3],[4],[5],[6] Of these, about 20% are vertical sagittal split fractures occur rarely in isolation. Various methods of treatment have been described [3],[6],[7],[8],[9],[10] to regain the articular congruity.


   Case Report Top


A 40-year-old right hand dominant male patient presented with pain in the left hand due to a fall on the out stretched hand. He had pain and tenderness over the base of the first ray. A bony fragment was felt over the dorsum of the hand near the anatomical snuff box. Movements of his thumb was only restricted in the terminal range.

Plain radiographs of the left hand showed a coronal fracture of the trapezium, with the base of the first metacarpal impacted in between the two fragments. A reduction was attempted in the emergency room under intravenous sedation, which showed the fracture geometry more clearly in the immediate postreduction radiographs. CT scan was asked for better evaluation [Figure 1] and [Figure 2] which confirmed the coronal split fracture of the trapezium with articular involvement. There was a major volar fragment and a dorsal fragment [Figure 2].
Figure 1: Anteroposterior radiograph of the wrist (a) showing the coronal fracture of the trapezium (b) after attempted reduction showing minimal subluxation of the CMC joint

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Figure 2: CT scan (a) showing a major volar fragment (arrow head) and smaller dorsal fragment (white arrow) (b) 3D reconstruction CT scan showing the volar fragment (black arrow), dorsal fragment (black star), Scaphoid (S), and the first metacarpal (M)

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Under general anesthesia and tourniquet control the fracture was exposed through a dorsoradial approach. The fracture was well visible through the tear in the capsule. The fragments were reduced and held with a reduction clamp. Our original plan was to fix the fragments with a 2.7 mm screw, passed from the dorsal fragment. However, tightening of the screw to get compression resulted in fragmentation of the dorsal fragment. Hence the fragments were fixed with two, 1.6 mm Kirschner wires [Figure 2]. To keep the joint reduced and to maintain the articular congruity, the joint was stabilized further with a joint spanning mini fixator. The K wires and the external fixator were removed at 6 weeks, and the patient was sent for hand physiotherapy where he was started with an active and active assisted range of movements [Figure 3].
Figure 3: (a) Postoperative radiograph showing the fixation with K-wires and a mini fixator (b) radiographs at 1-year follow-up showing healed fracture with congruent joints

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At 1-year follow-up radiographs showed normal articular relationship of the trapezium with the base of first metacarpal and scaphoid. The anatomic relationship of the bases of the first and second metacarpal was also maintained. He had a complete range of motion of the left thumb, when compared to the uninjured side. His grip strength was normal.


   Discussion Top


Different types of trapezium fractures have been documented in the literature which includes avulsions, vertical, sagittal, comminuted, coronal, and horizontal fractures. Walker et al. classified fractures of the body of the trapezium into five types based on the articular surface involved. [4] Walker's classification distinguishes trapezial ridge from body fractures. [4],[11] Longitudinal injuries of the CMC joint of the thumb are unstable and may be associated with subluxation of the thumb metacarpal, leading to disability if not treated properly. [10] Our case did not fit into any of the groups described by Walker et al., but was similar to the type IV injury. [4] The base of the first metacarpal was driven into the trapezium, shearing it into a dorsal small fragment and a volar major fragment. Garavaglia et al. reported a case of horizontally displaced fracture, and the authors claim that their fracture pattern did not fit into any of the types described by Walker et al. [11] [Figure 4].
Figure 4: Line drawing showing the (a) Walker type IV fracture and (b) the fracture pattern in this case report

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Two types of injuries are thought to produce trapezium fractures. An indirect trauma by a fall on the out-stretched hand, where the hand goes into hyperextension and radial deviation, the trapezium getting compressed between the base of the first metacarpal and the radial styloid, [2],[12] is thought to be one mechanism. The trapezium fractures between the metacarpal and the radial styloid acting as the "anvil". [13] A direct trauma to the dorsoradial aspect of the hand also has been found to result in the trapezium fracture where the thumb is driven into the trapezium. [14] A fall on the hand in radial deviation and dorsiflexion was thought as the possible mechanism in our patient.

The clinical findings in trapezium fractures are usually minimal, with no gross deformity, and almost full range of movements of the wrist and fingers. [4],[5],[12] Only the terminal range of opposition of the thumb is usually impaired.

Standard anteroposterior, lateral and oblique views of the wrist sometimes fail to detect the fractures, especially the fracture of the ridge of the trapezium. Here a carpal tunnel view may be helpful. [15] Trapezial body fractures are difficult to detect on routine radiographs because of the overlap by the trapezoid shadow. [4]

A true anteroposterior view (Robert's view), done with the hand in full pronation, outlines the trapezium and the base of the first metacarpal clearly. [6],[8],[10] A CT scan helps in fractures which are not visualized in the plain films and also in finding out the amount of displacement and the size of the fragments.

Associated injuries reported include fracture of the proximal pole of the scaphoid, [3],[16] fracture of the thumb metacarpal, [1],[13] fracture of the distal radius, [4] fracture of other metacarpals, [4] and fracture of other carpals, including trapezoid and capitate. [4]

The trapezium fracture has to be accurately reduced and fixed to prevent contracture of the first web space and stiffness of the CMC joint otherwise it results in impairment of function due to pain, limitation of movements, or weakness of the thumb. [2] In conservatively managed patients by closed reduction and plaster cast immobilization more than 60% had either persistent pain, swelling, or limitation of movements of the wrist. The secondary displacement is likely to occur in plaster cast. [2]

There are reports of closed manipulative reduction followed by percutaneous Kirschner wire fixation, leading to good functional outcome. [5],[17] Various fixation methods have been used. These include headless screw fixation, [3],[6],[7] 3 mm cannulated screws, [8] 1.5 mm cortical screws, [9] and 2.7 mm screw fixation. [10]

The reported methods of immobilizing the CMC joint after trapezium fixation include plaster cast immobilization, percutaneous intermetacarpal K wires [4],[12] to external fixation. [4]

There are few reports of external fixation with distraction applied for comminuted fractures of the trapezium, where internal fixation was not possible. [1] The authors found external fixation as the suitable method since the trapezium fracture was found comminuted and slightly collapsed, in their reported open injury. [1] Walker et al. recommended external fixation with ligamentotaxis in comminuted fractures (Walker V), or cross pinning of the first and second metacarpals. [4] Since the base of the first metacarpal exerts pressure on the trapezium, there should be continued distraction across the CMC joint to relieve the pressure on the joint and the cartilaginous surface of the trapezium. An external fixator neutralizes the action of the abductor pollicis longus and the adductor pollicis longus on the first metacarpal. In our patient since the fracture became fragmented at attempted screw fixation, we thought ligamentotaxis with a mini-fixator would reduce the articular surface pressures. Trapezial fractures could be easily overlooked in the emergency room due to its rarity and due to the complex arrangements of the carpal bones. Special projections, such as Robert's view, Bett's view, carpal tunnel view or 3 dimensional CT scan, are mandatory as any articular incongruity leads to secondary arthritis.

 
   References Top

1.Pehlivan O, Cilli F, Mahirogullari M, Ozyurek S. Management of combined open fractures of thumb metacarpal and trapezium (Surgical tip). Hand (N Y) 2007;2:48-50.  Back to cited text no. 1
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2.Cordrey LJ, Ferrer-Torells M. Management of fractures of the greater multangular. Report of five cases. J Bone Joint Surg Am 1960;42:1111-8.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Tohyama M, Miya S, Honda Y. Trapezium fracture associated with occult fracture of the proximal pole of the scaphoid. Arch Orthop Trauma Surg 2006;126:70-2.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Walker JL, Green TL, Lunseth PA. Fracture of the body of the trapezium. J Orthop Trauma 1988;2:22-8.  Back to cited text no. 4
    
5.Ramoutar DN, Katevu C, Titchener AG, Patel A. Trapezium fracture- a common technique to fix a rare injury: A case report. Cases J 2009;2:8304.  Back to cited text no. 5
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6.Inston N, Pimpalnerkar AL, Arafa MA. Isolated fracture of the trapezium: An easily missed injury. Injury 1997;28:485-8.  Back to cited text no. 6
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7.Horch R. A new method for treating isolated fractures of the os trapezium. Arch Orthop Trauma Surg 1998;117:180-2.  Back to cited text no. 7
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8.Pai V, Warbrick-Smith J, Pai V. Extensor pollicis longus dysfunction associated with non-united fracture of the trapezium. J Hand Microsurg 2010;2:42-4.  Back to cited text no. 8
    
9.Giannikas D, Karabasi A, Fotinopoulos E, Tyllianakis M. Open transtrapezial injuries of the thumb: Operative treatment. J Trauma 2008;65:1468-70.  Back to cited text no. 9
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10.Garneti N, Tuson CE. Sagittally split fracture of trapezium associated with subluxated carpo-metacarpal joint of thumb. Injury 2004;35:1172-5.  Back to cited text no. 10
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11.Garavaglia G, Bianchi S, Santa DD, Fusetti C. Trans-trapezium carpo-metacarpal dislocation of the thumb. Arch Orthop Trauma Surg 2004;124:67-8.  Back to cited text no. 11
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12.Chamseddine A, Hamdan H, Zein H. Fracture of trapezium with trapeziometacarpal subluxation. Eur J Orthop Surg Traumatol 2009;19:499-503.  Back to cited text no. 12
    
13.Jones WA, Ghorbal MS. Fracture of the trapezium. A report on three cases. J Hand Surg 1985;10B:227-30.  Back to cited text no. 13
    
14.Kukreti S, Harrington P. Carpometacarpal joint dislocation of the thumb associated with fracture of the trapezium: A case report. Eur J Orthop Surg Traumatol 2004;14:38-9.  Back to cited text no. 14
    
15.Abbitt PL, Riddervold HO. The carpal tunnel view: Helpful adjuvant for unrecognized fractures of the carpus. Skeletal Radiol 1987;16:45-7.  Back to cited text no. 15
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16.Van Schil P, De Smet C. Simultaneous fracture of the carpal scaphoid and trapezium. J Hand Surg 1986;11:112-4.  Back to cited text no. 16
    
17.Afshar A, Mirzatoloei F. Carpometacarpal joint dislocation of the thumb associated with the fracture of the trapezium. Arch Iran Med 2005;9:282-3.  Back to cited text no. 17
    

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Correspondence Address:
S S Suresh
PO Box 396, Ibri 516
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.91643

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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