Original Article
Treatment of Rolando Fractures by Open Reduction and Internal Fixation using Mini T-Plate and Screws Mohammad Umar Mumtaz1
Fiaz Ahmad1
Altaf Ahmad Kawoosa1
1 Department of Orthopaedics, Government Hospital for Bone and
Joint Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India J Hand Microsurg 2016;8:80–85.
Abstract
Keywords
► Rolando fracture ► base of first metacarpal fracture ► internal fixation ► mini Tplate
Iftikhar Wani1
Address for correspondence Mohammad Umar Mumtaz, MS (Ortho), Department of Orthopaedics, Government Medical College, Care of Academic Section, Government Hospital for Bone and Joint Surgery, Barzalla, Srinagar, Jammu and Kashmir, India 190005 (e-mail: [email protected]).
Introduction Rolando fractures being intra-articular fractures of the most mobile joint of the thumb, assume significance because any residual incongruity of the articular surface may result in loss of motion as well as secondary osteoarthritis and hence serious disability. This fracture continues to pose difficulties to the treating surgeons and although several treatment options have been described for these fractures, there are no definite guidelines. Methods The present study describes the results of open reduction and internal fixation of nine Rolando fractures with large and single fragments, using mini T-plate and screws. Results At 3-year follow-up all the fractures had united, functional results were excellent or good in most cases, and all the patients had returned to previous activities. Significant complications such as deep infection and loss of reduction were not encountered in any patient. Conclusion Open reduction and internal fixation with mini T-plates in properly selected cases of Rolando fracture with large and single palmar and dorsal articular fragments offers several advantages such as allowing direct visualization of the joint, removal of interposed soft tissues, and exact anatomical restoration of the articular surface. The fixation in most cases is rigid enough to allow early mobilization without loss of reduction. Thus, complications such as stiffness as well as future arthrosis may be minimized. However, the technique is demanding and needs high degree of precision. The possibility of implant removal should be discussed beforehand with the patient.
Introduction The thumb is a unique digit which bestows the hand with highly specialized function and precision. It has been stated that the thumb accounts for 40% of hand function. This is attributed to a large extent to the special structure of the first carpometacarpal joint, which gives the thumb an unparalleled mobility as well as sufficient stability to perform a wide
received January 25, 2016 accepted after revision March 15, 2016 published online May 12, 2016
Imtiyaz Hussain1
spectrum of functions. The trapeziometacarpal joint has been described as two opposed reciprocal interlocked saddles (concave–convex joint) which permit a wide arc of motion. Intra-articular fractures involving the base of the first metacarpal assume significance because any residual incongruity or subluxation at the carpometacarpal joint can produce loss of motion, especially the opposition, as well as progressive secondary arthritis with serious functional disability.1,2
© 2016 Society of Indian Hand & Microsurgeons
DOI http://dx.doi.org/ 10.1055/s-0036-1583300. ISSN 0974-3227.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
80
No. 2/2016
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Good 0 Fall Y R M 21 9 Vol. 8
Abbreviations: IP, interphalangeal; L, left; M, male; MCP, metacarpophalangeal; N, no; R, right; TAM, total active motion; VAS, visual analog scale; Y, yes.
2 60–100 > 45
Excellent > 100 > 45 0 Traffic accident Y L M 30 8
Journal of Hand and Microsurgery
81
–
– 1
Implant tenderness
–
Fair
1
Excellent > 100
> 80
> 45 0 Fist fight
Fall Y
Y L
R
27
24
6
M
0
30–40
1
Mumtaz et al.
7
M
Superficial infection implant tenderness 3 < 80 4 31 5
M
R
Y
Fall
< 30
Poor
–
Implant tenderness 1
1 Good
Excellent > 100
60–100
> 45
> 45
0
0 Fall
Traffic accident Y
Y R
L M
M
24
35
3
4
Superficial infection implant tenderness 2 Fair > 80 30–40 0 Fall Y R M 22 2
– 1 60–100 20 1
M
R
Y
Fall
0
> 45
Good
Arthritis-modified Eaton and L ittler class Functional results TAM of MCP and IP joints (degrees) Palmar abduction (degrees)
Range of motion
Pain (VAS) Mechanism Dominant (Y/N) Side Sex Age (y)
From 2002 to 2011 nine patients of Rolando fracture were treated by open reduction and internal fixation using mini Tplates and screws. The average age was 26 years. All the patients were males. The right hand was involved in six cases, while the left hand was involved in three cases (►Table1). The
Case
Material and Methods
Table 1 Data of patients with Rolando fracture treated by open reduction and mini T-plate and screw fixation
Rolando3 in 1910 was the first to describe a “Y-shaped” intra-articular fracture pattern of the base of thumb metacarpal, which has since been named after him. Although “Y” or “T” configuration is the classical fracture pattern, the term “Rolando fracture,” at present encompasses any comminuted intra-articular fracture of the base of the first metacarpal.4 The mechanism of injury in these fractures is an axial force directed through the partially flexed metacarpal shaft resulting in a dorsal and a palmar fragment with or without variable communition.2,4,5 The abductor pollicis tendon pulls the lateral epiphyseal fragment upwards and outwards while as the medial epiphyseal fragment is maintained in position by virtue of its attachment to the trapezium by an oblique posteromedial ligament.2,4 Rolando stated that the prognosis in these fractures was poor after both cast treatment as well as skin traction. However, fortunately this fracture is the least common amongst thumb metacarpal fractures.6 Intra-articular fractures of the base of first metacarpal constitute only 1.4% of all hand fractures, out of which approximately 15% are Rolando fractures.7 Today, even after a century, this fracture continues to present the treating surgeon with difficult problems, a fact which is attested by the sheer number of treatment options described for these fractures.4 The treatment modalities include closed reduction and use of a bulky dressing,1,8 closed reduction and Kirschner-wire (K-wire) fixation,3 oblique skeletal traction,5,9 open reduction and internal fixation using mini fragment T- or L-plates and screws,10 ligamentotaxis with an external fixator,7 external fixation with limited internal fixation of the major fragments with bone grafting.11 Recently, an arthroscopic-assisted technique for restoration of articular surface has been described.2,12 The selection of the most appropriate treatment in a particular case depends primarily on the severity of communition of the fragments and to a lesser extent on the degree of displacement.1,4,6 When the fracture is associated with severe communition and the fragments are too small for internal fixation, it is preferable to use skeletal traction or an external fixator for ligamentotaxis.1,6,7 Closed reduction and percutaneous pinning has been associated with poor results due to inadequate articular restoration as well as pin complications.4 On the other hand, when the palmar and dorsal fragments are large, single, and displaced open reduction is a reasonable option because it allows direct visualization of the joint, removal of interposed capsule ligamentous soft tissues, and exact anatomical restoration of the articular surface.2,4 Internal fixation with mini T-plate and screws can provide a fixation which is rigid enough to allow early mobilization without loss of reduction.4 Thus, good functional results can be expected while minimizing the chances of stiffness and arthrosis.
Complications
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws most common mechanism of injury was fall (six cases) followed by road traffic accident (two cases) and fist fight (one case). Preoperative radiographs in all the nine selected cases revealed large and single palmar and dorsal fragments and the fractures were considered suitable for internal fixation (►Fig. 1A, B). The patients were taken up for surgery within 5 days of trauma. All the fractures were operated by the same surgeon who had experience in plating of other hand fractures.
Operative Technique Surgery in all the patients was performed under general anesthesia and tourniquet. Step by step technique as described by Foster and Hastings1 was followed. Open reduction was performed through a curved palmar–radial incision over the base of thenar eminence as described by Gedda and Moberg.8 The radial end of the incision was extended distally along the diaphyseal portion of the thumb metacarpal. The proximal origins of the abductor pollicis brevis and opponens pollicis were elevated subperiosteally from the proximal portion of the thumb metacarpal to expose the capsule of the first carpometacarpal joint which was opened transversely to allow direct visualization of the articular surfaces and removal of hematoma
Mumtaz et al.
as well as interposed portions of the capsule or ligament. The two large articular fragments were reduced anatomically with a pointed reduction forceps. A small K-wire was then used for provisional stabilization of the fragments. At this stage interfragmentary lag screw fixation was considered if it was deemed compatible with the subsequent plate application. A definitive rigid internal fixation of the fracture was performed using a 2.0-mm mini T-plate. The transverse portion of the T-plate was approximated and fixed to the reduced basilar fragments of the thumb metacarpal with 2.0-mm screws. The metacarpal shaft was then reduced to the stabilized intra-articular fragments and fixed to the long portion of the T-plate with 2.0-mm screws. The tourniquet was released and complete hemostasis ensured. The skin incision was closed with interrupted nonabsorbable sutures. A soft compression dressing and a removable thumb spica splint were then applied. The limb was kept elevated overnight. We used 1 g cephazolin intravenously every 8 hours for first 24 hours. Gentle active range of motion exercises were started on the 2nd postoperative day. The patients were then followed up on an outpatient basis where regular clinical and radiological evaluation was performed (►Fig. 1C, D). An intensive expert supervised physiotherapy program was performed in all the patients. Removable thumb splint protection was used for 6 weeks. During this period range of motion exercises out of splint were progressively increased. At 6 weeks the splint was discarded and physiotherapy continued. However, unrestricted use of the hand was allowed only after radiological union was confirmed, usually by 3 months. The final assessment was made after 3 years. The functional results included measurement of the range of motion based on the available palmar abduction and total active flexion of metacarpophalangeal and interphalangeal joints of the thumb.13 The visual analogue scale (VAS) was used to quantify any residual pain. The grip and pinch strength were compared with the normal side. For radiological assessment van Niekerk and Ouwens modification of the Eaton and Littler classification of posttraumatic osteoarthritis14,15 was used: Stage I: no clear arthrotic changes, stage II: osteophytes smaller than 2 mm, stage III: osteophytes larger than 2 mm or joint narrowing, and stage IV: joint space more or less disappeared.
Results
Fig. 1 (A and B) Radiographs of a case of Rolando fracture with displaced single and large palmar and dorsal fragments. (C and D) Radiographs of same case after open reduction and internal fixation with a miniature T-plate and screws, 1 and 12 weeks after surgery, respectively. A separate intrafragmentary lag screw with restoration of articular surface can also be seen. Although there is a small extra-articular step it was inconsequential. Journal of Hand and Microsurgery
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The final assessment in all the nine cases was made at 3 years follow-up. All the fractures had united consistently. All the patients had returned to their previous activities and all except one patient were pain free. They said the patient had occasional mild-to-moderate pain on activity (VAS score of 4) which responded well to rest and analgesics. The functional results based on measurement of palmer abduction and sum of total active flexion of metacarpophalangeal and interphalangeal joints13 were excellent in three cases (►Fig. 2), good in three cases, fair in two cases, and poor in one case as depicted in ►Table 2.
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82
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws
Mumtaz et al.
83
infections. Loss of reduction was not seen in any case. Four patients developed local tenderness over the implant, which necessitated its removal. Implant removal when necessary was undertaken only after at least 6 months of surgery. The thumb was protected with a removable splint for 4 weeks after implant removal to prevent refracture.
Fig. 2 Image showing excellent functional results seen in the same patient at 6 weeks follow-up.
There was no significant difference in grip and pinch strength between the injured and uninjured hand except in one patient. Radiological evaluation revealed modified Eaton and Littler stage II osteoarthritis in two patients and stage III in one patient.14,15 All the remaining six patients were in stage I. Two patients developed superficial infection, which responded well to parental antibiotics. There were no deep
Since its first description more than a century back several methods of treatment have been described for the treatment of Rolando fractures ranging from a simple bulky dressing with unrestricted early motion at one end of the spectrum to open reduction and internal fixation and even arthroscopicassisted fixations at the other end. Rolando had stated that the prognosis in these fractures was poor after both cast treatment as well as skin traction. Even today this fracture continues to remain a difficult one to treat, although fortunately this is the least common fracture of the thumb metacarpal.6 The optimal treatment of this fracture still remains a matter of controversy.16 Some treatment options available are closed reduction with the use of a bulky dressing,8 casting,4 closed reduction, and K-wire fixation,3 open reduction and internal fixation with a miniature T- or L-plate and screws,1,5,10 ligamentotaxis of the fragments with an external fixator or skeletal traction,5,7,9 and combined use of external fixator with limited internal fixation and bone grafting.11 Recently, an arthroscopic-assisted technique for restoration of articular surface has been described.2,12 Biomechanical study conducted by Cooney and Chao17 showed that joint compression forces at the trapeziometacarpal joint during a simple pinch approximate 12.0 k while during a strong grasp forces up to 120 k may develop. The sheer magnitude of the forces acting on the small surface area of this joint implies that significant incongruity of the articular surface may adversely affect the optimum hand function including grip, result in subluxation, and secondary arthritis. As in any other intra-articular fracture the aim of treatment is to restore the articular surface congruity as close to normal as possible while at the same time allow early mobilization to prevent stiffness in the short term as well as late secondary arthritis in the long term. The selection of the most appropriate treatment for a particular case is dictated mainly by the degree of communition of the fragments and to a lesser extent by the degree of displacement.1,6 Thus, when the communition is severe and the
Table 2 Functional results in patients based on the method described by Gingrass et al13 using palmar abduction and total active flexion of MCP and IP joints Palmar abduction (degrees)
Total active flexion of MCP and IP joints (degrees)
Result
Cases (n)
> 45
> 100
Excellent
3
> 45
60–100
Good
3
30–40
> 80
Fair
2
< 30
< 80
Poor
1
Abbreviations: IP, interphalangeal; MCP, metacarpophalangeal. Journal of Hand and Microsurgery
Vol. 8
No. 2/2016
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Discussion
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws fragments are too small to preclude the use of internal fixation, it will be more appropriate to use an external fixator for ligamentotaxis.7 On the other hand, when large and single palmar and dorsal fragments exist open reduction and internal fixation with a mini T-plate and screws is a reasonable option. Biomechanical study by Fyfe and Mason18 to evaluate the rigidity of various modes of internal fixation showed that mini plates and screws produced much stronger stabilization than K-wires. A similar study by Black et al19,20 concluded that dorsal plating with or without lag screws provided significantly more stability than K-wires or interosseous wiring. In our series of nine patients with Rolando fracture having suitable configuration who were taken up for open reduction and internal fixation with mini T-plates, six patients showed excellent or good functional results while two patients had a fair result. Poor results were seen in only one case. Significant complications such as deep infection and loss of reduction were not encountered in any patient. In our search of the literature there were only a few series with a sizeable number of cases and long-term follow-up. Some authors have described severe posttraumatic osteoarthritis and disability in patients with more than 1 mm of residual articular surface incongruity.14 Other investigators did not even find a correlation between the two entities, probably due to other factors such as initial articular cartilage damage, adhesions, and contractures of soft tissues with progressive loss of joint space.21 However, even these authors agree that articular surface should be reduced unless severe communition precludes it.
The plates must be carefully contoured to avoid fracture site distraction. Drilling and tapping must be accurate so that no threads are stripped because in the event of loosening or stripping of screw holes, repositioning of the plate or replacement with a longer plate may not be possible because of the limited length of bone available. The possibility of implant removal should also be discussed beforehand with the patient and included in the written consent. Although the results in this series are encouraging, but this series has limitations in terms of the number of patients and duration of follow-up and hence a large prospective series with long-term follow-up is needed to set the optimal treatment guidelines.
References 1 Foster RJ, Hastings H II. Treatment of Bennett, Rolando, and vertical
2
3
4 5 6 7
Conclusion In our series the only patient with poor functional result and residual pain had a significant articular step off demonstrable in the immediate postoperative radiograph and severe secondary osteoarthritis (modified Eaton and Littler stage III osteoarthritis) on final follow-up. All the remaining eight patients had a near-anatomical reduction of the articular construct and most of these patients (six out of eight) demonstrated modified Eaton and Littler stage 1 at final follow-up (►Table 1). These results imply that that significant residual incongruity of the articular surface may be associated with severe secondary arthritis and adversely affect the optimum hand function. Thus, the goal of surgery should be to achieve and maintain articular reduction during early mobilization. Open reduction and internal fixation with mini T-plate and screws in properly selected cases of Rolando fracture offers several advantages such as allowing direct visualization of the joint, removal of interposed soft tissues, and exact anatomical restoration of the articular surface. The fixation in most cases is rigid enough to allow early mobilization without loss of reduction. Thus, complications such as stiffness as well as future arthrosis may be minimized. However, we would like to emphasize that the technique is demanding and needs high degree of precision. Surgical dissection should be meticulous avoiding excessive soft tissue trauma and periosteal stripping. Journal of Hand and Microsurgery
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8
9
10 11
12
13 14
15
16 17
intraarticular trapezial fractures. Clin Orthop Relat Res 1987; 214(214):121–129 Liverneaux PA, Ichihara S, Hendriks S, Facca S, Bodin F. Fractures and dislocation of the base of the thumb metacarpal. J Hand Surg Eur Vol 2015;40(1):42–50 Rolando S. Fracture de la base du premier metacarpien, et principalement sur une variete non encore decrite. Presse Med 1910; 18:303 Proubasta I, Lamas C, Itarte J, Sarasquete J, Carrera I. Rolando fractures. Curr Orthop Pract 2010;21(6):615–623 Breen TF, Gelberman RH, Jupiter JB. Intra-articular fractures of the basilar joint of the thumb. Hand Clin 1988;4(3):491–501 Green DP, Butler TE. Rockwood and Green’s Fractures in Adult’s. 4th ed. Philadelphia, PA: Lippincott-Raven; 1996 Houshian S, Jing SS. Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator: a report of 16 cases. Hand Surg 2013;18(1):73–78 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(1–4):249–257 Gelberman RH, Vance RM, Zakaib GS. Fractures at the base of the thumb: treatment with oblique traction. J Bone Joint Surg Am 1979;61(2):260–262 Rüedi TP, Burri C, Pfeiffer KM. Stable internal fixation of fractures of the hand. J Trauma 1971;11(5):381–389 Buchler U, McCollam SM, Oppikofer C. Communited fractures of the basilar joint of the thumb: combined treatment by external fixation, limited internal fixation and bone grafting. J Hand Surg [Br] 1991;16A:556–560 Zemirline A, Lebailly F, Taleb C, Facca S, Liverneaux P. Arthroscopic assisted percutaneous screw fixation of Bennett’s fracture. Hand Surg 2014;19(2):281–286 Gingrass RP, Fehring B, Matloub H. Intraosseous wiring of complex hand fractures. Plast Reconstr Surg 1980;66(3):383–394 van Niekerk JLM, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury 1989;20; (6):359–362 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(2):246–251 Mahoney M, Marsland D, Garagnani L, Sauve P’. Rolando and his fracture. Trauma 2015;17(1):24–28 Cooney WP III, Chao EYS. Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg Am 1977;59; (1):27–36
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Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws
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20 Black DM, Mann RJ, Constine RM, Daniels AU. The stability of
fractured phalanges. Hand 1979;11(1):50–54 19 Black D, Mann RJ, Constine R, Daniels AU. Comparison of internal fixation techniques in metacarpal fractures. J Hand Surg Am 1985; 10(4):466–472
internal fixation in the proximal phalanx. J Hand Surg Am 1986; 11(5):672–677 21 Langhoff O, Andersen K, Kjaer-Petersen K. Rolando’s fracture. J Hand Surg [Br] 1991;16(4):454–459
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
18 Fyfe IS, Mason S. The mechanical stability of internal fixation of
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Journal of Hand and Microsurgery
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Treatment of Rolando Fractures by Open Reduction and Internal Fixation using Mini T-Plate and Screws Mohammad Umar Mumtaz1
Fiaz Ahmad1
Altaf Ahmad Kawoosa1
1 Department of Orthopaedics, Government Hospital for Bone and
Joint Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India J Hand Microsurg 2016;8:80–85.
Abstract
Keywords
► Rolando fracture ► base of first metacarpal fracture ► internal fixation ► mini Tplate
Iftikhar Wani1
Address for correspondence Mohammad Umar Mumtaz, MS (Ortho), Department of Orthopaedics, Government Medical College, Care of Academic Section, Government Hospital for Bone and Joint Surgery, Barzalla, Srinagar, Jammu and Kashmir, India 190005 (e-mail: [email protected]).
Introduction Rolando fractures being intra-articular fractures of the most mobile joint of the thumb, assume significance because any residual incongruity of the articular surface may result in loss of motion as well as secondary osteoarthritis and hence serious disability. This fracture continues to pose difficulties to the treating surgeons and although several treatment options have been described for these fractures, there are no definite guidelines. Methods The present study describes the results of open reduction and internal fixation of nine Rolando fractures with large and single fragments, using mini T-plate and screws. Results At 3-year follow-up all the fractures had united, functional results were excellent or good in most cases, and all the patients had returned to previous activities. Significant complications such as deep infection and loss of reduction were not encountered in any patient. Conclusion Open reduction and internal fixation with mini T-plates in properly selected cases of Rolando fracture with large and single palmar and dorsal articular fragments offers several advantages such as allowing direct visualization of the joint, removal of interposed soft tissues, and exact anatomical restoration of the articular surface. The fixation in most cases is rigid enough to allow early mobilization without loss of reduction. Thus, complications such as stiffness as well as future arthrosis may be minimized. However, the technique is demanding and needs high degree of precision. The possibility of implant removal should be discussed beforehand with the patient.
Introduction The thumb is a unique digit which bestows the hand with highly specialized function and precision. It has been stated that the thumb accounts for 40% of hand function. This is attributed to a large extent to the special structure of the first carpometacarpal joint, which gives the thumb an unparalleled mobility as well as sufficient stability to perform a wide
received January 25, 2016 accepted after revision March 15, 2016 published online May 12, 2016
Imtiyaz Hussain1
spectrum of functions. The trapeziometacarpal joint has been described as two opposed reciprocal interlocked saddles (concave–convex joint) which permit a wide arc of motion. Intra-articular fractures involving the base of the first metacarpal assume significance because any residual incongruity or subluxation at the carpometacarpal joint can produce loss of motion, especially the opposition, as well as progressive secondary arthritis with serious functional disability.1,2
© 2016 Society of Indian Hand & Microsurgeons
DOI http://dx.doi.org/ 10.1055/s-0036-1583300. ISSN 0974-3227.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
80
No. 2/2016
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Good 0 Fall Y R M 21 9 Vol. 8
Abbreviations: IP, interphalangeal; L, left; M, male; MCP, metacarpophalangeal; N, no; R, right; TAM, total active motion; VAS, visual analog scale; Y, yes.
2 60–100 > 45
Excellent > 100 > 45 0 Traffic accident Y L M 30 8
Journal of Hand and Microsurgery
81
–
– 1
Implant tenderness
–
Fair
1
Excellent > 100
> 80
> 45 0 Fist fight
Fall Y
Y L
R
27
24
6
M
0
30–40
1
Mumtaz et al.
7
M
Superficial infection implant tenderness 3 < 80 4 31 5
M
R
Y
Fall
< 30
Poor
–
Implant tenderness 1
1 Good
Excellent > 100
60–100
> 45
> 45
0
0 Fall
Traffic accident Y
Y R
L M
M
24
35
3
4
Superficial infection implant tenderness 2 Fair > 80 30–40 0 Fall Y R M 22 2
– 1 60–100 20 1
M
R
Y
Fall
0
> 45
Good
Arthritis-modified Eaton and L ittler class Functional results TAM of MCP and IP joints (degrees) Palmar abduction (degrees)
Range of motion
Pain (VAS) Mechanism Dominant (Y/N) Side Sex Age (y)
From 2002 to 2011 nine patients of Rolando fracture were treated by open reduction and internal fixation using mini Tplates and screws. The average age was 26 years. All the patients were males. The right hand was involved in six cases, while the left hand was involved in three cases (►Table1). The
Case
Material and Methods
Table 1 Data of patients with Rolando fracture treated by open reduction and mini T-plate and screw fixation
Rolando3 in 1910 was the first to describe a “Y-shaped” intra-articular fracture pattern of the base of thumb metacarpal, which has since been named after him. Although “Y” or “T” configuration is the classical fracture pattern, the term “Rolando fracture,” at present encompasses any comminuted intra-articular fracture of the base of the first metacarpal.4 The mechanism of injury in these fractures is an axial force directed through the partially flexed metacarpal shaft resulting in a dorsal and a palmar fragment with or without variable communition.2,4,5 The abductor pollicis tendon pulls the lateral epiphyseal fragment upwards and outwards while as the medial epiphyseal fragment is maintained in position by virtue of its attachment to the trapezium by an oblique posteromedial ligament.2,4 Rolando stated that the prognosis in these fractures was poor after both cast treatment as well as skin traction. However, fortunately this fracture is the least common amongst thumb metacarpal fractures.6 Intra-articular fractures of the base of first metacarpal constitute only 1.4% of all hand fractures, out of which approximately 15% are Rolando fractures.7 Today, even after a century, this fracture continues to present the treating surgeon with difficult problems, a fact which is attested by the sheer number of treatment options described for these fractures.4 The treatment modalities include closed reduction and use of a bulky dressing,1,8 closed reduction and Kirschner-wire (K-wire) fixation,3 oblique skeletal traction,5,9 open reduction and internal fixation using mini fragment T- or L-plates and screws,10 ligamentotaxis with an external fixator,7 external fixation with limited internal fixation of the major fragments with bone grafting.11 Recently, an arthroscopic-assisted technique for restoration of articular surface has been described.2,12 The selection of the most appropriate treatment in a particular case depends primarily on the severity of communition of the fragments and to a lesser extent on the degree of displacement.1,4,6 When the fracture is associated with severe communition and the fragments are too small for internal fixation, it is preferable to use skeletal traction or an external fixator for ligamentotaxis.1,6,7 Closed reduction and percutaneous pinning has been associated with poor results due to inadequate articular restoration as well as pin complications.4 On the other hand, when the palmar and dorsal fragments are large, single, and displaced open reduction is a reasonable option because it allows direct visualization of the joint, removal of interposed capsule ligamentous soft tissues, and exact anatomical restoration of the articular surface.2,4 Internal fixation with mini T-plate and screws can provide a fixation which is rigid enough to allow early mobilization without loss of reduction.4 Thus, good functional results can be expected while minimizing the chances of stiffness and arthrosis.
Complications
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws most common mechanism of injury was fall (six cases) followed by road traffic accident (two cases) and fist fight (one case). Preoperative radiographs in all the nine selected cases revealed large and single palmar and dorsal fragments and the fractures were considered suitable for internal fixation (►Fig. 1A, B). The patients were taken up for surgery within 5 days of trauma. All the fractures were operated by the same surgeon who had experience in plating of other hand fractures.
Operative Technique Surgery in all the patients was performed under general anesthesia and tourniquet. Step by step technique as described by Foster and Hastings1 was followed. Open reduction was performed through a curved palmar–radial incision over the base of thenar eminence as described by Gedda and Moberg.8 The radial end of the incision was extended distally along the diaphyseal portion of the thumb metacarpal. The proximal origins of the abductor pollicis brevis and opponens pollicis were elevated subperiosteally from the proximal portion of the thumb metacarpal to expose the capsule of the first carpometacarpal joint which was opened transversely to allow direct visualization of the articular surfaces and removal of hematoma
Mumtaz et al.
as well as interposed portions of the capsule or ligament. The two large articular fragments were reduced anatomically with a pointed reduction forceps. A small K-wire was then used for provisional stabilization of the fragments. At this stage interfragmentary lag screw fixation was considered if it was deemed compatible with the subsequent plate application. A definitive rigid internal fixation of the fracture was performed using a 2.0-mm mini T-plate. The transverse portion of the T-plate was approximated and fixed to the reduced basilar fragments of the thumb metacarpal with 2.0-mm screws. The metacarpal shaft was then reduced to the stabilized intra-articular fragments and fixed to the long portion of the T-plate with 2.0-mm screws. The tourniquet was released and complete hemostasis ensured. The skin incision was closed with interrupted nonabsorbable sutures. A soft compression dressing and a removable thumb spica splint were then applied. The limb was kept elevated overnight. We used 1 g cephazolin intravenously every 8 hours for first 24 hours. Gentle active range of motion exercises were started on the 2nd postoperative day. The patients were then followed up on an outpatient basis where regular clinical and radiological evaluation was performed (►Fig. 1C, D). An intensive expert supervised physiotherapy program was performed in all the patients. Removable thumb splint protection was used for 6 weeks. During this period range of motion exercises out of splint were progressively increased. At 6 weeks the splint was discarded and physiotherapy continued. However, unrestricted use of the hand was allowed only after radiological union was confirmed, usually by 3 months. The final assessment was made after 3 years. The functional results included measurement of the range of motion based on the available palmar abduction and total active flexion of metacarpophalangeal and interphalangeal joints of the thumb.13 The visual analogue scale (VAS) was used to quantify any residual pain. The grip and pinch strength were compared with the normal side. For radiological assessment van Niekerk and Ouwens modification of the Eaton and Littler classification of posttraumatic osteoarthritis14,15 was used: Stage I: no clear arthrotic changes, stage II: osteophytes smaller than 2 mm, stage III: osteophytes larger than 2 mm or joint narrowing, and stage IV: joint space more or less disappeared.
Results
Fig. 1 (A and B) Radiographs of a case of Rolando fracture with displaced single and large palmar and dorsal fragments. (C and D) Radiographs of same case after open reduction and internal fixation with a miniature T-plate and screws, 1 and 12 weeks after surgery, respectively. A separate intrafragmentary lag screw with restoration of articular surface can also be seen. Although there is a small extra-articular step it was inconsequential. Journal of Hand and Microsurgery
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The final assessment in all the nine cases was made at 3 years follow-up. All the fractures had united consistently. All the patients had returned to their previous activities and all except one patient were pain free. They said the patient had occasional mild-to-moderate pain on activity (VAS score of 4) which responded well to rest and analgesics. The functional results based on measurement of palmer abduction and sum of total active flexion of metacarpophalangeal and interphalangeal joints13 were excellent in three cases (►Fig. 2), good in three cases, fair in two cases, and poor in one case as depicted in ►Table 2.
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infections. Loss of reduction was not seen in any case. Four patients developed local tenderness over the implant, which necessitated its removal. Implant removal when necessary was undertaken only after at least 6 months of surgery. The thumb was protected with a removable splint for 4 weeks after implant removal to prevent refracture.
Fig. 2 Image showing excellent functional results seen in the same patient at 6 weeks follow-up.
There was no significant difference in grip and pinch strength between the injured and uninjured hand except in one patient. Radiological evaluation revealed modified Eaton and Littler stage II osteoarthritis in two patients and stage III in one patient.14,15 All the remaining six patients were in stage I. Two patients developed superficial infection, which responded well to parental antibiotics. There were no deep
Since its first description more than a century back several methods of treatment have been described for the treatment of Rolando fractures ranging from a simple bulky dressing with unrestricted early motion at one end of the spectrum to open reduction and internal fixation and even arthroscopicassisted fixations at the other end. Rolando had stated that the prognosis in these fractures was poor after both cast treatment as well as skin traction. Even today this fracture continues to remain a difficult one to treat, although fortunately this is the least common fracture of the thumb metacarpal.6 The optimal treatment of this fracture still remains a matter of controversy.16 Some treatment options available are closed reduction with the use of a bulky dressing,8 casting,4 closed reduction, and K-wire fixation,3 open reduction and internal fixation with a miniature T- or L-plate and screws,1,5,10 ligamentotaxis of the fragments with an external fixator or skeletal traction,5,7,9 and combined use of external fixator with limited internal fixation and bone grafting.11 Recently, an arthroscopic-assisted technique for restoration of articular surface has been described.2,12 Biomechanical study conducted by Cooney and Chao17 showed that joint compression forces at the trapeziometacarpal joint during a simple pinch approximate 12.0 k while during a strong grasp forces up to 120 k may develop. The sheer magnitude of the forces acting on the small surface area of this joint implies that significant incongruity of the articular surface may adversely affect the optimum hand function including grip, result in subluxation, and secondary arthritis. As in any other intra-articular fracture the aim of treatment is to restore the articular surface congruity as close to normal as possible while at the same time allow early mobilization to prevent stiffness in the short term as well as late secondary arthritis in the long term. The selection of the most appropriate treatment for a particular case is dictated mainly by the degree of communition of the fragments and to a lesser extent by the degree of displacement.1,6 Thus, when the communition is severe and the
Table 2 Functional results in patients based on the method described by Gingrass et al13 using palmar abduction and total active flexion of MCP and IP joints Palmar abduction (degrees)
Total active flexion of MCP and IP joints (degrees)
Result
Cases (n)
> 45
> 100
Excellent
3
> 45
60–100
Good
3
30–40
> 80
Fair
2
< 30
< 80
Poor
1
Abbreviations: IP, interphalangeal; MCP, metacarpophalangeal. Journal of Hand and Microsurgery
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Discussion
Treatment of Rolando Fractures by ORIF using Mini T-Plate and Screws fragments are too small to preclude the use of internal fixation, it will be more appropriate to use an external fixator for ligamentotaxis.7 On the other hand, when large and single palmar and dorsal fragments exist open reduction and internal fixation with a mini T-plate and screws is a reasonable option. Biomechanical study by Fyfe and Mason18 to evaluate the rigidity of various modes of internal fixation showed that mini plates and screws produced much stronger stabilization than K-wires. A similar study by Black et al19,20 concluded that dorsal plating with or without lag screws provided significantly more stability than K-wires or interosseous wiring. In our series of nine patients with Rolando fracture having suitable configuration who were taken up for open reduction and internal fixation with mini T-plates, six patients showed excellent or good functional results while two patients had a fair result. Poor results were seen in only one case. Significant complications such as deep infection and loss of reduction were not encountered in any patient. In our search of the literature there were only a few series with a sizeable number of cases and long-term follow-up. Some authors have described severe posttraumatic osteoarthritis and disability in patients with more than 1 mm of residual articular surface incongruity.14 Other investigators did not even find a correlation between the two entities, probably due to other factors such as initial articular cartilage damage, adhesions, and contractures of soft tissues with progressive loss of joint space.21 However, even these authors agree that articular surface should be reduced unless severe communition precludes it.
The plates must be carefully contoured to avoid fracture site distraction. Drilling and tapping must be accurate so that no threads are stripped because in the event of loosening or stripping of screw holes, repositioning of the plate or replacement with a longer plate may not be possible because of the limited length of bone available. The possibility of implant removal should also be discussed beforehand with the patient and included in the written consent. Although the results in this series are encouraging, but this series has limitations in terms of the number of patients and duration of follow-up and hence a large prospective series with long-term follow-up is needed to set the optimal treatment guidelines.
References 1 Foster RJ, Hastings H II. Treatment of Bennett, Rolando, and vertical
2
3
4 5 6 7
Conclusion In our series the only patient with poor functional result and residual pain had a significant articular step off demonstrable in the immediate postoperative radiograph and severe secondary osteoarthritis (modified Eaton and Littler stage III osteoarthritis) on final follow-up. All the remaining eight patients had a near-anatomical reduction of the articular construct and most of these patients (six out of eight) demonstrated modified Eaton and Littler stage 1 at final follow-up (►Table 1). These results imply that that significant residual incongruity of the articular surface may be associated with severe secondary arthritis and adversely affect the optimum hand function. Thus, the goal of surgery should be to achieve and maintain articular reduction during early mobilization. Open reduction and internal fixation with mini T-plate and screws in properly selected cases of Rolando fracture offers several advantages such as allowing direct visualization of the joint, removal of interposed soft tissues, and exact anatomical restoration of the articular surface. The fixation in most cases is rigid enough to allow early mobilization without loss of reduction. Thus, complications such as stiffness as well as future arthrosis may be minimized. However, we would like to emphasize that the technique is demanding and needs high degree of precision. Surgical dissection should be meticulous avoiding excessive soft tissue trauma and periosteal stripping. Journal of Hand and Microsurgery
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10 11
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18 Fyfe IS, Mason S. The mechanical stability of internal fixation of
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