554357 research-article2014
JHS0010.1177/1753193414554357Journal of Hand SurgeryLiverneaux et al.
JHS(E)
Review Article
Fractures and dislocation of the base of the thumb metacarpal P. A. Liverneaux1, S. Ichihara1,2, S. Hendriks1, S. Facca1 and F. Bodin3
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(1) 42–50 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193414554357 jhs.sagepub.com
Abstract Acute traumatic lesions of the base of the first metacarpal are frequent and their consequences can affect the opposition of the thumb. They usually occur after trauma in compression along the axis of the thumb in flexion. Restoring the anatomy and biomechanics of the trapeziometacarpal joint is essential when treating these injuries, hence why surgical treatment is usually indicated. We distinguish trapeziometacarpal dislocations, small-fragment and large-fragment Bennett’s fractures, articular three-fragment Rolando and comminutive fractures and extra-articular fractures of the base of the first metacarpal. All carry the risk of narrowing of the first web. Recent studies have described poor results with conservative treatment. Surgical techniques are varied: percutaneous surgery, open surgery and arthroscopic surgery. The techniques of osteosynthesis are various: locking plates, and direct or indirect screw fixation or pinning. The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint. Level of evidence: 4 Keywords First metacarpal, fracture, dislocation, Bennett, Rolando Date received: 29 May 2014; revised: 30 August 2014; accepted: 1 September 2014
Introduction Acute traumatic injuries to the base of the thumb metacarpal are common; their sequelae may affect the opposition of the thumb. The treatment of acute traumatic injuries of the base of the thumb metacarpal vary according to their proximity to the trapeziometacarpal joint. Unlike lesions of the finger metacarpal, extra-articular fractures of the base of the first metacarpal tolerate moderate malunion in rotation or inclination in the frontal and sagittal planes due to the compensatory effects of the adjacent joints (Ozer et al., 2008). Narrowing of the first web, due to shortening and varus angulation of the metacarpal of 1 mm increases the risk of post-traumatic arthrosis (Kjaer-Petersen et al., 1990). Leclère et al. reported their long-term results of treating 21 Bennett’s fractures with a large fragment by open screw osteosyntheses. After 4 years, the overall strength of the hand was 89% of that of the contralateral side, but one patient had a secondary subluxation 9 weeks after surgery (Leclère et al., 2012). Lutz et al. reported results at a mean of 7 years comparing open screw fixation to percutaneous trans-articular pinning in 32 Bennett’s fractures with large fragments. Although the percutaneous pinning group had a significantly higher incidence of adducted thumb deformities, the type of treatment did not influence the final clinical outcome, nor the prevalence of post-traumatic radiological arthrosis (Lutz et al., 2003). Postoperatively, a removable commissural splint is usually necessary for about 4 weeks, allowing early mobilization if the strength of the fixation permits it. We have developed a technique of percutaneous screw fixation under arthroscopy (Zemirline et al., 2014). If the anteromedial fragment is too small to be fixed directly, reduction by external manipulation and percutaneous pinning is recommended by most authors (Van Niekerk and Ouwens, 1989). Authors
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Figure 4. Clinical example of indirect pinning in Bennett’s fracture, according to Adi, our preferred technique.
who recommend percutaneous pinning suggest various sites for the wires, either through the trapezometacarpal joint (Wagner, 1950; Wiggins et al., 1954) or extra-articular through the intermetacarpal spacing (Iselin et al., 1956). Intra-articular pins can cause further damage to the articular surface. Some authors have reported their results at a mean of 18 months after transarticular percutaneous pinning. Although the average strength was 80% of that of the contralateral side and the opposition of the thumb was complete in all patients, 16 of 21 patients presented at last follow-up with a thinning of the trapeziometacarpal joint indicating post-traumatic arthrosis (Brüske et al., 2001). The Iselin technique can also lead to complications. For example, if the distal pin protrudes from the dorsum of the second intermetacarpal space, it can cause irritation the extensor apparatus of the index finger. In a series of 25 patients operated for fractures of the base of the first metacarpal with a mean follow-up of 24 months, there were three infections along the pin tracks and one notable cosmetic abnormality (Greeven et al., 2012).
poor prognostic factor in fractures with large fragments (Moutet et al., 1993).
Prognosis
Treatment
The prognosis of Bennett’s fracture dislocations treated in the acute stage is favourable, especially with small fragment fractures (Surzur et al., 1994). A persisting step in the articular surface >1–2 mm is a
Being a three-fragment articular fracture, the reduction must be perfect in order to avoid articular incongruence, which is arthrogenic. Reduction by external manipulation is usually impossible, because of the
Rolando fractures Definition Rolando fractures differ from Bennett’s fractures by direction, number and displacement of the fracture lines (Figure 2). An extra-articular fracture line, generally transverse, separates diaphysis and epiphysis. A second vertical intra-articular fracture line splits the epiphysis into two fragments. A central joint depression is often present. Each of these fragments undergoes a specific displacement. The large distal diaphyseal fragment is pulled in adduction, thus closing the first web under the effect of medial thenar muscles. The lateral epiphyseal fragment is drawn upward and outward, under the effect of the long abductor of the thumb. The medial epiphyseal fragment remains in place, attached to the trapezium, because of the oblique posteromedial ligament.
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complexity of the fracture. Conservative treatment and direct percutaneous osteosynthesis usually do not give a good result. Some authors have shown that trapezometacarpal joint pinning does not give a satisfactory reduction as well as causing further iatrogenic joint damage (Vichard et al., 1982). An articular approach is recommended to restore joint congruity and stability, either by open surgery or for us by arthroscopy (Zemirline et al., 2014). Whatever the technique, the articular approach allows removal of any ligament or capsular interposition, identification of a possible joint depression and anatomical reduction of the fracture under visual control, and temporary K-wire fixation and then fixation of the epiphysis to the diaphysis either by pins or miniplates. Postoperatively, a removable commissural splint is put in place for 4 weeks. We recommend immediate mobilization if the strength of the construct permits it (Liverneaux, 2006).
Comminuted fractures Comminuted fractures can be regarded as Rolando fractures, of which they represent the worse stage (Figure 2). Surgical treatment depends on the degree of comminution. There is no consensus, but the major challenge is to maintain the opening of the first web, at best indirectly by intermetacarpal blocked pinning (Adi et al., 2014), at worst by external fixation (Giesen et al., 2012; Keramidas and Miller, 2005). Additional trapeziometacarpal arthroscopy may be useful for the resection of a free osteochondral fragment or to perform a ligament repair.
Extra-articular fractures of the base of the first metacarpal They define themselves by their fracture line, transverse or short oblique with two separate fracture fragments. In children, they correspond to epiphyseal fracture-separations, often Salter–Harris type II fractures. The proximal fragment remains in place, attached to the trapezium because of the oblique posteromedial ligament. The dislocating effect of the abductor pollicis longus, which is also inserted on the proximal fragment, is offset by the strength of the oblique posteromedial ligament. In contrast, the distal fragment is displaced and tipped in adduction, under the effect of the medial thenar muscles, which tend to close the first web. In the absence of treatment, these fractures may cause narrowing of the first web space. An opposite displacement of the distal fragment has been described, with a deformation in abduction (Kapandji, 1983).
Being an extra-articular fracture, perfect reduction is not necessary, but it must maintain the opening of the first web. This reduction, though generally obtained by abduction of the thumb column, is unstable. For some authors, extra-articular fractures with less than 30° angular displacement can be treated by closed reduction by external manipulation and cast immobilization (Stern, 2005). For most authors, extra-articular fractures with more than 30° angular displacement should be treated surgically because of the risk of narrowing the first web. Osteosynthesis is recommended, by indirect percutaneous intermetacarpal pinning, by direct ascending intramedular pinning or by open miniplates (Diaconu et al., 2011). For some, the trapezometacarpal pinning appears to give good results (Vichard et al., 1982), but the risk of iatrogenic joint damage seems disproportionate for an extra-articular fracture. T-shape plates do not avoid secondary displacement (Diaconu et al., 2011). The prognosis for extra-articular fractures is better than for intra-articular fractures (Brazier et al., 1996; Sulzur et al., 1994).
Conclusion Acute injuries of the thumb vary. Restoration of the opposition function of the thumb is essential. In our experience, this often requires surgical rather than conservative treatment. Restoration of the first carpometacarpal joint mobility remains the major objective. Conflict of interest P. Liverneaux is a consultant for Newclip Technics, Argomedical, Integra, iiN Medical. No conflict declared by any other authors.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Adi M, Miyamoto H, Taleb C et al. Percutaneous fixation of first metacarpal base fractures using locked K-wires: A series of 14 cases. Tech Hand Up Extrem Surg. 2014, 18: 77–81. Bennani A, Zizah S, Benabid M et al. The intermetacarpal double pinning in the surgical treatment of Bennett fracture (report of 24 cases). Chir Main. 2012, 31: 157–62. Bennett EH. Fractures of metacarpal bone of the thumb. Br Med J. 1886, 2: 12–5. Brazier J, Moughabghab M, Migaud H, Fontaine C. Articular fractures of the base of the first metacarpal. Comparative study of direct osteosynthesis and closed pinning. Ann Chir Main. 1996, 15: 91–9.
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Liverneaux et al. Brüske J, Bednarski M, Niedźwiedź Z, Zyluk A, Grzeszewski S. The results of operative treatment of fractures of the thumb metacarpal base. Acta Orthop Belg. 2001, 67: 368–73. Burdin G. Arthroscopic management of tibial plateau fractures: surgical technique. Orthop Traumatol Surg Res. 2013, 99: S208–18. Cannon SR, Dowd GS, Williams DH, Scott JM. A long-term study following Bennett’s fracture. J Hand Surg Br. 1986, 11: 426–31. Capo JT, Kinchelow T, Orillaza NS, Rossy W. Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett’s fracture. J Hand Surg Am. 2009, 34: 637–41. Cullen JP, Parentis MA, Chinchilli VM, Pellegrini VD Jr. Simulated Bennett fracture treated with closed reduction and percutaneous pinning. A biomechanical analysis of residual incongruity of the joint. J Bone Joint Surg Am. 1997, 79: 413–20. Culp RW, Johnson JW. Arthroscopically assisted percutaneous fixation of Bennett fractures. J Hand Surg Am. 2010, 35: 137–40. Diaconu M, Facca S, Gouzou S, Liverneaux P. Locking plates for fixation of extra-articular fractures of the first metacarpal base: a series of 15 cases. Chir Main. 2011, 30: 26–30. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973, 55: 1655–66. Edmunds I, Trevicick B, Honner R. Fusion of the first metacarpophalangeal joint for post traumatic conditions. Aus-N-Z J Surg. 1994, 64: 771–4. Foster RJ, Hastings H 2nd. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop Relat Res. 1987, 214: 121–9. Foucher G. Injuries of the trapezo-metacarpal joint. Ann Chir Main. 1982, 2: 168–79. Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett’s fracture in the carpo-metacarpal joint of the thumb. Acta Orthop Scand. 1952, 22: 249–57. Ghilardi G, Parmeggiani G. Trapezio-metacarpal luxation and subluxation. Minerva Orthop. 1960, 11: 498–503. Giesen T, Cardell M, Calcagni M. Modified Suzuki frame for the treatment of a difficult Rolando’s fracture. J Hand Surg Eur. 2012, 37: 905–7. Greeven AP, Alta TD, Scholtens RE, de Heer P, van der Linden FM. Closed reduction intermetacarpal Kirschner wire fixation in the treatment of unstable fractures of the base of the first metacarpal. Injury. 2012, 43: 246–51. Holzach P, Matter P, Minter J. Arthroscopically assisted treatment of lateral tibial plateau fractures in skiers: use of a cannulated reduction system. J Orthop Trauma. 1994, 8: 273–81. Hove LM. Fractures of the hand. Distribution and relative incidence. Scand J Plast Reconstr Surg Hand Surg. 1993, 27: 317–9. Huang JI, Fernandez DL. Fractures of the base of the thumb metacarpal. Instr Course Lect. 2010, 59: 343–56. Iselin M, Blanguernon S, Benoist D. First metacarpal base fracture. Mém Acad Chir. 1956, 82: 771–4.
Kapandji A, Moatti E, Raab C. Specific radiography of the trapezo-metacarpal joint and its technique. Ann Chir. 1980, 9: 719–26. Kapandji A. Closed reduction osteosynthesis of non-articular proximal fractures of the 1st metacarpal bone. Crossed ascending double pinning. Ann Chir Main. 1983, 2: 179–85. Keramidas EG, Miller G. The Suzuki frame for complex intraarticular fractures of the thumb. Plast Reconstr Surg. 2005, 116: 1326–31. Kjaer-Petersen K, Langhoff O, Andersen K. Bennett’s fracture. J Hand Surg Eur. 1990, 15: 58–61. Leclère FM, Jenzer A, Hüsler R et al. 7-year follow-up after open reduction and internal screw fixation in Bennett fractures. Arch Orthop Trauma Surg. 2012, 132: 1045–51. Liverneaux P. Fracture and dislocation of the thumb. In: Duparc J (ed.) Conférences d’Enseignement de la SOFCOT. Paris, Exp sci. Fr, 2006: 144–68. Liversley PJ. The conservative management of Bennett’s fracture-dislocation: a 26-year follow up. J Hand Surg Br. 1990, 15: 291–4. Lutz M, Sailer R, Zimmermann R, Gabl M, Ulmer H, Pechlaner S. Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett’s fracture dislocation. J Hand Surg Br. 2003, 28: 142–7. Meyer C, Hartmann B, Böhringer G, Horas U, Schnettler R. Minimal invasive cannulated screw osteosynthesis of Bennett’s fractures. Zentralbl Chir. 2003, 128: 529–33. Moutet F, Bellon-Champel P, Guinard D, Gérard P. Synthetic ligament reconstruction of the thumb metacarpophalangeal joint. 21 cases. Ann Chir Main Memb Super. 1993, 12: 196–9. Oosterboss CJM, De Boer HH. Nonoperative treatment of Bennett’s fracture: a 13 year follow-up. J Orthop Trauma. 1995, 9: 23–7. Ozer K, Gillani S, Williams A, Peterson SL, Morgan S. Comparison of intramedullary nailing versus platescrew fixation of extra-articular metacarpal fractures. J Hand Surg Am. 2008, 33: 1724–31. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1998, 23: 827–32. Pavić R1, Malović M. Operative treatment of Bennett’s fracture. Coll Antropol. 2013, 7: 169–74. Péquignot JP, Giordano P, Boatier C, Allieu Y. Traumatic dislocation of the trapezio-metacarpal joint. Ann Chir Main. 1988, 7: 14–24. Proubasta IR. Rolando’s fracture of the first metacarpal. Treatment by external fixation. J Bone Joint Surg Br. 1992, 74: 416–7. Sawaizumi T, Nanno M, Nanbu A, Ito H. Percutaneous leverage pinning in the treatment of Bennett’s fracture. J Orthop Sci. 2005, 10: 27–31. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968–1975. Clin Orthop Relat Res. 1979, 138: 94–104. Sidharthan S, Shetty SK, Hanna AW. Median nerve injury following K-wire fixation of Bennett’s fracture-lessons learned. Hand (NY). 2010, 5: 440–3.
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Soyer AD. Fractures of the base of the first metacarpal: current treatment options. J Am Acad Orthop Surg. 1999, 7: 403–12. Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur. 2007, 32: 626–36. Stern PJ. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Pederson WC and Wolfe SW (eds.) Green’s operative hand surgery. Philadelphia, Elsevier Churchill Livingstone, 5th Edn. 2005, Vol 1: 277–341. Strömberg L. Compression fixation of Bennett’s fracture. Acta Orthop Scand. 1977, 48: 586–91. Surzur P, Rigault M, Charissoux JL, Mabit C, Arnaud JP. Recent fractures of the base of the 1st metacarpal bone. A study of a series of 138 cases. Ann Chir Main. 1994, 13: 122–34. Toupin JM, Milliez PY, Thomine JM. Recent post-traumatic luxation of the trapeziometacarpal joint. A propos of 8 cases. Rev Chir Orthop Reparatrice Appar Mot. 1995, 81: 27–34. Tourne Y, Moutet F, Lebrun C, Massart P, Butel J. The value of compression screws in Bennett fractures. A propos of a series of 44 case reports. Rev Chir Orthop Reparatrice Appar Mot. 1988, 74: 153–5.
Uludag S, Ataker Y, Seyahi A, Tetik O, Gudemez E. Early rehabilitation after stable osteosynthesis of intra-articular fractures of the metacarpal base of the thumb. J Hand Surg Eur. Epub ahead of print 21 Jun 2013. DOI: 10.1177/1753193413494035. Van Niekerk JL, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury. 1989, 20: 359–62. Vichard P, Tropet Y, Nicolet F. Longitudinal pinning of fractures of the base of the first metacarpal. Ann Chir Main. 1982, 1: 301–6. Wagner CJ. Methods of treatment of Bennett’s fracturedislocation. Am J Surg. 1950, 80: 230–1. Wiggins HE, Bundens WD, Park BJ. Method of treatment of fracture-dislocations of first metacarpal bone. J Bone Joint Surg. 1954, 36: 810–9. Wintman BI, Fowler JL, Baratz ME. Traumatic dislocation of trapezium: case report and review of the literature. Am J Orthop (Belle Mead NJ). 2000, 29: 229–32. Zemirline A, Lebailly F, Taleb C, Facca S, Liverneaux P. Arthroscopic assisted percutaneous screw fixation of Bennett fracture. J Hand Surg Asian Vol. 2014, 19: 281–6.
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JHS0010.1177/1753193414554357Journal of Hand SurgeryLiverneaux et al.
JHS(E)
Review Article
Fractures and dislocation of the base of the thumb metacarpal P. A. Liverneaux1, S. Ichihara1,2, S. Hendriks1, S. Facca1 and F. Bodin3
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(1) 42–50 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193414554357 jhs.sagepub.com
Abstract Acute traumatic lesions of the base of the first metacarpal are frequent and their consequences can affect the opposition of the thumb. They usually occur after trauma in compression along the axis of the thumb in flexion. Restoring the anatomy and biomechanics of the trapeziometacarpal joint is essential when treating these injuries, hence why surgical treatment is usually indicated. We distinguish trapeziometacarpal dislocations, small-fragment and large-fragment Bennett’s fractures, articular three-fragment Rolando and comminutive fractures and extra-articular fractures of the base of the first metacarpal. All carry the risk of narrowing of the first web. Recent studies have described poor results with conservative treatment. Surgical techniques are varied: percutaneous surgery, open surgery and arthroscopic surgery. The techniques of osteosynthesis are various: locking plates, and direct or indirect screw fixation or pinning. The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint. Level of evidence: 4 Keywords First metacarpal, fracture, dislocation, Bennett, Rolando Date received: 29 May 2014; revised: 30 August 2014; accepted: 1 September 2014
Introduction Acute traumatic injuries to the base of the thumb metacarpal are common; their sequelae may affect the opposition of the thumb. The treatment of acute traumatic injuries of the base of the thumb metacarpal vary according to their proximity to the trapeziometacarpal joint. Unlike lesions of the finger metacarpal, extra-articular fractures of the base of the first metacarpal tolerate moderate malunion in rotation or inclination in the frontal and sagittal planes due to the compensatory effects of the adjacent joints (Ozer et al., 2008). Narrowing of the first web, due to shortening and varus angulation of the metacarpal of 1 mm increases the risk of post-traumatic arthrosis (Kjaer-Petersen et al., 1990). Leclère et al. reported their long-term results of treating 21 Bennett’s fractures with a large fragment by open screw osteosyntheses. After 4 years, the overall strength of the hand was 89% of that of the contralateral side, but one patient had a secondary subluxation 9 weeks after surgery (Leclère et al., 2012). Lutz et al. reported results at a mean of 7 years comparing open screw fixation to percutaneous trans-articular pinning in 32 Bennett’s fractures with large fragments. Although the percutaneous pinning group had a significantly higher incidence of adducted thumb deformities, the type of treatment did not influence the final clinical outcome, nor the prevalence of post-traumatic radiological arthrosis (Lutz et al., 2003). Postoperatively, a removable commissural splint is usually necessary for about 4 weeks, allowing early mobilization if the strength of the fixation permits it. We have developed a technique of percutaneous screw fixation under arthroscopy (Zemirline et al., 2014). If the anteromedial fragment is too small to be fixed directly, reduction by external manipulation and percutaneous pinning is recommended by most authors (Van Niekerk and Ouwens, 1989). Authors
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Figure 4. Clinical example of indirect pinning in Bennett’s fracture, according to Adi, our preferred technique.
who recommend percutaneous pinning suggest various sites for the wires, either through the trapezometacarpal joint (Wagner, 1950; Wiggins et al., 1954) or extra-articular through the intermetacarpal spacing (Iselin et al., 1956). Intra-articular pins can cause further damage to the articular surface. Some authors have reported their results at a mean of 18 months after transarticular percutaneous pinning. Although the average strength was 80% of that of the contralateral side and the opposition of the thumb was complete in all patients, 16 of 21 patients presented at last follow-up with a thinning of the trapeziometacarpal joint indicating post-traumatic arthrosis (Brüske et al., 2001). The Iselin technique can also lead to complications. For example, if the distal pin protrudes from the dorsum of the second intermetacarpal space, it can cause irritation the extensor apparatus of the index finger. In a series of 25 patients operated for fractures of the base of the first metacarpal with a mean follow-up of 24 months, there were three infections along the pin tracks and one notable cosmetic abnormality (Greeven et al., 2012).
poor prognostic factor in fractures with large fragments (Moutet et al., 1993).
Prognosis
Treatment
The prognosis of Bennett’s fracture dislocations treated in the acute stage is favourable, especially with small fragment fractures (Surzur et al., 1994). A persisting step in the articular surface >1–2 mm is a
Being a three-fragment articular fracture, the reduction must be perfect in order to avoid articular incongruence, which is arthrogenic. Reduction by external manipulation is usually impossible, because of the
Rolando fractures Definition Rolando fractures differ from Bennett’s fractures by direction, number and displacement of the fracture lines (Figure 2). An extra-articular fracture line, generally transverse, separates diaphysis and epiphysis. A second vertical intra-articular fracture line splits the epiphysis into two fragments. A central joint depression is often present. Each of these fragments undergoes a specific displacement. The large distal diaphyseal fragment is pulled in adduction, thus closing the first web under the effect of medial thenar muscles. The lateral epiphyseal fragment is drawn upward and outward, under the effect of the long abductor of the thumb. The medial epiphyseal fragment remains in place, attached to the trapezium, because of the oblique posteromedial ligament.
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complexity of the fracture. Conservative treatment and direct percutaneous osteosynthesis usually do not give a good result. Some authors have shown that trapezometacarpal joint pinning does not give a satisfactory reduction as well as causing further iatrogenic joint damage (Vichard et al., 1982). An articular approach is recommended to restore joint congruity and stability, either by open surgery or for us by arthroscopy (Zemirline et al., 2014). Whatever the technique, the articular approach allows removal of any ligament or capsular interposition, identification of a possible joint depression and anatomical reduction of the fracture under visual control, and temporary K-wire fixation and then fixation of the epiphysis to the diaphysis either by pins or miniplates. Postoperatively, a removable commissural splint is put in place for 4 weeks. We recommend immediate mobilization if the strength of the construct permits it (Liverneaux, 2006).
Comminuted fractures Comminuted fractures can be regarded as Rolando fractures, of which they represent the worse stage (Figure 2). Surgical treatment depends on the degree of comminution. There is no consensus, but the major challenge is to maintain the opening of the first web, at best indirectly by intermetacarpal blocked pinning (Adi et al., 2014), at worst by external fixation (Giesen et al., 2012; Keramidas and Miller, 2005). Additional trapeziometacarpal arthroscopy may be useful for the resection of a free osteochondral fragment or to perform a ligament repair.
Extra-articular fractures of the base of the first metacarpal They define themselves by their fracture line, transverse or short oblique with two separate fracture fragments. In children, they correspond to epiphyseal fracture-separations, often Salter–Harris type II fractures. The proximal fragment remains in place, attached to the trapezium because of the oblique posteromedial ligament. The dislocating effect of the abductor pollicis longus, which is also inserted on the proximal fragment, is offset by the strength of the oblique posteromedial ligament. In contrast, the distal fragment is displaced and tipped in adduction, under the effect of the medial thenar muscles, which tend to close the first web. In the absence of treatment, these fractures may cause narrowing of the first web space. An opposite displacement of the distal fragment has been described, with a deformation in abduction (Kapandji, 1983).
Being an extra-articular fracture, perfect reduction is not necessary, but it must maintain the opening of the first web. This reduction, though generally obtained by abduction of the thumb column, is unstable. For some authors, extra-articular fractures with less than 30° angular displacement can be treated by closed reduction by external manipulation and cast immobilization (Stern, 2005). For most authors, extra-articular fractures with more than 30° angular displacement should be treated surgically because of the risk of narrowing the first web. Osteosynthesis is recommended, by indirect percutaneous intermetacarpal pinning, by direct ascending intramedular pinning or by open miniplates (Diaconu et al., 2011). For some, the trapezometacarpal pinning appears to give good results (Vichard et al., 1982), but the risk of iatrogenic joint damage seems disproportionate for an extra-articular fracture. T-shape plates do not avoid secondary displacement (Diaconu et al., 2011). The prognosis for extra-articular fractures is better than for intra-articular fractures (Brazier et al., 1996; Sulzur et al., 1994).
Conclusion Acute injuries of the thumb vary. Restoration of the opposition function of the thumb is essential. In our experience, this often requires surgical rather than conservative treatment. Restoration of the first carpometacarpal joint mobility remains the major objective. Conflict of interest P. Liverneaux is a consultant for Newclip Technics, Argomedical, Integra, iiN Medical. No conflict declared by any other authors.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Adi M, Miyamoto H, Taleb C et al. Percutaneous fixation of first metacarpal base fractures using locked K-wires: A series of 14 cases. Tech Hand Up Extrem Surg. 2014, 18: 77–81. Bennani A, Zizah S, Benabid M et al. The intermetacarpal double pinning in the surgical treatment of Bennett fracture (report of 24 cases). Chir Main. 2012, 31: 157–62. Bennett EH. Fractures of metacarpal bone of the thumb. Br Med J. 1886, 2: 12–5. Brazier J, Moughabghab M, Migaud H, Fontaine C. Articular fractures of the base of the first metacarpal. Comparative study of direct osteosynthesis and closed pinning. Ann Chir Main. 1996, 15: 91–9.
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