I have to make a decision quickly about surgery for my thumb. I have what's called a Rolando fracture of the thumb. There's a gap in the bone where the break is located. It's just on the edge where I can either go with manual traction (the surgeon uses his hands to pull the bones back where they belong) and a cast or surgery to repair the damage. What do you suggest?
Hand surgeons from Barcelona, Spain recently published a comprehensive review of Rolando fractures. They described the anatomy involved, reported how often these types of fractures occur, and who is most likely to experience such an injury. The pattern of fracture, mechanism of injury, and diagnosis were also included.
As you might guess with a label like Rolando fracture, this thumb injury was named after the surgeon from Italy who first described it back in 1910. Over 100 years later, the name has remained to refer to a particular Y-shaped break at the base of the thumb joint. The Y-shaped Rolando fracture affects the joint surface of the trapeziometacarpal (TMC) joint.
Of particular interest to you would be the authors' review of treatment options for Rolando fractures with details of surgical procedures used. Surgeons can use an algorithm to guide treatment. An algorithm is a series of steps used to make a decision. In the case of Rolando fractures, the algorithm begins with the question of whether the fracture is displaced. If no, then a cast can be put on the hand, wrist, and forearm until the fracture heals (usually four to five weeks).
If yes (the fracture has separated), then the next decision point is made based on whether the two ends of the separated bone can be brought back together. The process of reducing the space between the two pieces of bone is called reduction. Reduction with less than a two millimeter gap is a good result. A wider gap than that would usually require surgery.
Fractures that are on the edge of this measurement can present a challenge. In cases like this, it may be helpful to look at other factors. For example, Rolando fractures that include many tiny fragments of bone (called comminuted) cannot be surgically reduced. It's next to impossible to line up all the pieces of bone to recreate a smooth joint surface.
The surgeon does what he or she can to use traction (downward pull) to line up the trapeziometacarpal (TMC) joint. Then a cast is placed on the arm to protect the fractured site until healing takes place. Immobilization with a cast also makes sure the muscles and tendons don't pull on the fracture site (further deforming the damaged area).
When adequate reduction is impossible with traction alone, then surgery is needed. Under the relaxing effects of anesthesia, the surgeon can pull the bones and realign them. Then wires, screws, or other hardware are used to hold everything together. If an incision is needed to gain access to the joint, the procedure is called open reduction and internal fixation (ORIF). If the operation can be done through the skin, it is referred to as a closed reduction and percutaneous fixation.
Some things to consider include post-operative complications. Damage to the small nerves and blood vessels is more likely when open reduction and fixation are done. Arthritic changes may develop no matter what you do. If you are at risk for post-traumatic arthritis no matter which choice you make, then the least invasive approach is advised.
Whenever possible, surgeons try to restore the natural contours of the joint. Studies done so far have shown that a two millimeter gap does not adversely affect the biomechanics of the thumb when the joint surface is intact. This final tidbit of evidence-based information may be the most helpful for you to discuss with your surgeon when making the final treatment decision. X-rays will help determine the condition of the joint to aid in this dilemma.
Ignacio Proubasta, MD, PhD, et al. Rolando Fractures. In Current Orthopaedic Practice. November/December 2010. Vol. 21. No. 6. Pp. 615-623.
*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.