What is Rolando Fracture?
A Rolando fracture, named after Italian surgeon Silvio Rolando who first described it in 1910, refers to a break that shatters the base of the thumb bone. This is different from a Bennett fracture, which only partially breaks the thumb at its base. The Rolando fracture often results in a “Y” or “T” shape due to the way the bone breaks, while the Bennett fracture typically involves two fragments with one piece remaining in place by its attachment to a nearby bone, the trapezium, through a ligament known as the anterior oblique ligament.
Typically, a Rolando fracture hampers the thumb bone connection, which splits the bone into two pieces, one towards the front (volar) and the one towards the back (dorsal) of the hand, often creating a dent in the surface of the joint. Nowadays, any fracture that results in multiple pieces at the base of the thumb bone is often classified as a Rolando fracture.
What Causes Rolando Fracture?
Rolando fractures happen when a strong force pushes along the length of the metacarpal bone (one of the long bones in the hand) while the joint between the wrist and the metacarpal bone is bent.
There’s a spot on the bone (called the locus minoris resistenziae, or the point of least resistance) that’s the weakest – it’s at the front and inside edge of the base of the first metacarpal. In Rolando fractures, this part of the bone breaks off in a way similar to another type of break called a Bennett-type fracture.
However, what sets a true Rolando fracture apart is that it also involves a break in the stronger, back and outside point that separates from the bone’s body. That results in the second fragment. When the fracture is in multiple pieces, it’s usually because a much stronger traumatic force has been applied.
Risk Factors and Frequency for Rolando Fracture
Fractures at the base of the first metacarpal, part of your hand, are quite rare overall. They make up between 1.4% and 4% of all hand fractures. A type of these fractures, known as Rolando fractures, account for 15% to 20% of all fractures at the base of the thumb metacarpal.
When it comes to different age groups, 22% of all tubular bone hand fractures in children happen in the thumb area. This is also the case for 20% of hand fractures in people over 65 years old, while 12% of fractures in people aged 17 to 40 occur in the thumb. Interestingly, up to 80% of all thumb fractures impact its metacarpal base.
Signs and Symptoms of Rolando Fracture
If you hurt your thumb and it remains painful for a while, you need to see a doctor for a clinical examination. However, just a physical check may not be able to identify specific types of fractures, like Rolando and Bennet fractures, or detect fractures with multiple breaks. Therefore, you should also undergo radiographic imaging like an X-ray for a complete evaluation of the injury.
Different characteristics define Rolando and Bennet fractures. For instance, Rolando fractures keep the ligament on the palm side of the wrist intact, hindering the displacement of the fragment on that side. However, the fragment on the backside is moved by a muscle called the abductor pollicis longus (APL). Also, the bone at the base of the thumb called the thumb metacarpal shaft is displaced by two other muscles called the adductor and the extensor pollicis longus (EPL). The fragment at the palm side and on the side of the little finger is kept steady by its connection to a wrist bone called the trapezium via a ligament called the anterior oblique ligament, previously known as the beak ligament.
Testing for Rolando Fracture
If a doctor suspects an issue with your thumb, they will need to take X-rays from two different angles. This is due to the thumb’s unique position compared to the rest of the hand. Two specific types of X-ray views, the Robert view and the Bett view, are extremely helpful for identifying and grading the problem.
The Robert view provides a precise view from the front to the back of the thumb. For this X-ray, the back of your thumb will rest on the imaging plate while your hand is rotated as much as possible. Then, the Bett view provides a side view of the thumb joint. This is achieved by placing the palm of your hand on the imaging plate and slightly rotating it around 15 to 35 degrees. The X-ray beam will be inclined at a 15-degree angle.
More advanced scans, like a CT scan, may also be used. With this, your doctor will capture many images in thin slices from different angles, which can be combined to form a detailed 3D image. This can be particularly useful for planning any necessary surgery.
If there’s a possibility that the ligaments, tendons, or bones in your thumb might be damaged, you might have an MRI. This form of scan can visualize soft tissues and bones more clearly. For the best results, they’ll use small fields and specific tools to improve image clarity.
Treatment Options for Rolando Fracture
This type of fracture is harder to treat than a Bennett fracture because it is inherently more unstable. The best treatment method depends primarily on how many pieces the bone broke into and how much they’ve moved. For these fractures, treatment typically follows these steps:
– Closed reduction and thumb spica splinting/immobilization: This is typically used for fractures where the bone hasn’t broken the surface of the skin, or for 2-part fractures that have moved less than 1mm. “2-part fractures” are fractures where the bone has broken into two parts.
– Closed reduction and percutaneous pinning (CRPP): This treatment uses pins inserted through the skin to set the bone in place. This is necessary for fractures where the bone hasn’t broken the surface of the skin but has moved more than 30 degrees, or for complex Rolando fractures that have moved less than 1mm or fractures not suitable for screw fixation.
– Open reduction internal fixation (ORIF): This treatment is chosen when the fractures have moved more than 1 mm and involve the base of the hand bone. It’s used when the pieces are big enough for screw fixation.
– Distraction and external fixation: This is chosen for Rolando fractures that have moved more than 1mm and have significant soft tissue injury not suitable for ORIF, or severe fractures with too small fragments for ORIF.
Both open and closed surgeries must be carried out with a focus on the joint. In an open reduction, this is typically done through a Wagner incision, which is a cut made to the side of the hand’s creases. The treatment works by using plates, screws, tension banding, and wires to hold the bone together. The surgery provides the ability to free ligaments, remove any capsular interpositions, and visually monitor the reduction process. A temporary Kirshner wire fixation and screws or small T-plates might be used for securing the bone pieces. If the structure is strong enough, it’s beneficial to move the joint early or immediately after surgery, usually with a removable splint for the first month.
What else can Rolando Fracture be?
A Bennett fracture is a specific type of hand injury. But, alongside this, other injuries can occur to the ‘thumb ray’ – which is basically everything that makes up your thumb, including the skin, muscles, and bone. Some of these injuries are things like damage to the thumb’s UCL, which is a ligament that helps your thumb move. Common examples of these kinds of injuries include ‘gamekeeper’s thumb’ and ‘skier’s thumb’.
What to expect with Rolando Fracture
The available scientific research on the long-term outcomes of Rolando fractures is limited. According to a study by Langhoff and colleagues, out of 17 Rolando fractures, 82% needed surgery. Out of those that needed surgery, 11 were treated with open reduction, a surgical procedure where the bones are put back in place, while three cases were treated with percutaneous K-wire fixation, another method of repairing the bone.
The results of the surgery were excellent in 45.4% of patients who had open surgery according to radiological evaluations, which use imaging to assess healing. However, none of the cases treated with the percutaneous method showed excellent results on these evaluations.
Yet, in a follow-up study of 16 patients from the original group after a median period of 5.8 years, there seemed to be no relation between the quality of the bone repair and the presence of symptoms or the development of osteoarthritis, a condition where joints become stiff and painful. In this group, 37% were dealing with either symptoms or osteoarthritis.
Possible Complications When Diagnosed with Rolando Fracture
The key long-term problems resulting from Rolando’s fracture are stiffness and the development of osteoarthritis. The most serious type of this fracture is the multi-fragmentary form. This version of the fracture greatly increases the chances of experiencing joint stiffness and developing osteoarthritis.
