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Rolando's fracture is an intra-articular fracture of the base of the first metacarpal bone, which is characterized by the presence of a T-shaped or Y-shaped comminuted fracture line.
Thumb function comprises about 50% of hand function as a whole. The thumb metacarpal base is a unique joint that allows a wide range of motion while maintaining stability for grasp and pinch in a variety of positions.
Multiple fracture patterns of the thumb base have been described, including juxta-articular metaphyseal fracture, Bennett fracture, and Rolando fracture.
Interest in fixation of these fractures has been stimulated by the marked decrease in hand function that can develop if disabling arthritis occurs in the thumb carpometacarpal articulation as a result of articular incongruity following the fracture.
Today, the term has come to include essentially all comminuted thumb metacarpal base fractures.
Initial treatment options described mainly focused on closed treatment, either cast immobilization or a short period of splinting followed by an early motion to mold joint surfaces.
With the advent of internal fixation techniques, especially smaller implants, interest in operative treatment has increased over the past 20-30 years.
Rolando fracture is analogous to the pilon fracture of the distal tibia and appears to be secondary to a significant axial load that splits and crushes the articular surface.
Rolando described 2 cases that occurred secondary to a fall on the radial side of the hand with the thumb in adduction and a third case caused by a closed fist with the thumb folded and held in the palm striking an adversary's head.
Following an injury similar to that described above, the fracture is at risk of further displacement due to the resting tone present in the multiple tendons acting on the thumb. The extensor pollicis brevis and longus act to shorten the thumb ray, as does the pull of the flexor pollicis longus.
The adductor pollicis muscle tends to pull the distal metacarpal toward the palm, which, in conjunction with the abductor pollicis longus acting on the metacarpal base, commonly produces varus at the metaphyseal-diaphyseal junction.
Patients present following injury with a swollen tender thumb base. If significant varus has developed, a clinically visible deformity may be present.
However, swelling can mask a surprising amount of angulation. Neurovascular and tendon injuries are not commonly associated with this fracture.
If an open reduction is thought to be a reasonable choice for the treatment of Rolando Fracture, a curvilinear incision is made at the thumb base. Branches of the superficial radial nerve dorsally and lateral antebrachial cutaneous nerve volar are identified with loupe magnification, isolated, and protected.
The periosteum is split along the first metacarpal shaft, and the joint is entered in the interval between the abductor pollicis longus and extensor pollicis brevis tendons.
Large articular fragments are identified. The articular surface is reconstructed in a piecemeal fashion using fine Kirschner wires (K-wires) and then is secured to the metacarpal shaft using a small T plate.
Obtain intraoperative radiographs to confirm a satisfactory reduction, and place the limb in a thumb spica splint.
Comminuted metacarpal base fractures that cannot be secured with pins or screws can be treated with external fixation.
One technique involves a quadrilateral frame with 2 pins each in the thumb and index metacarpal, limited K-wire fixation of the articular surface, and bone grafting of any metaphyseal void created after length restoration.
Another technique involves placing fixator pins in the trapezium and metacarpal shaft to maintain distraction