Rolando Fracture

Original Editor - Umamah Ejaz
Top Contributors - Umamah Ejaz, Vidya Acharya and Ewa Jaraczewska

Definition/Description

First metacarpal bone

A Rolando fracture is a comminuted (multi-fragmented), intra-articular fracture at the base of the first metacarpal (thumb), typically forming a Y- or T-shaped pattern. It was first described by Silvio Rolando in 1910, based on three cases with Y-shaped fracture patterns. This injury usually results from an axial force on a partially flexed thumb, such as during a fall or punching impact.

Compared to a Bennett fracture, which involves a single fracture line on the ulnar side Rolando fractures are more complex, unstable, and have a worse prognosis. They rarely heal well without surgery and are commonly treated with open reduction and internal fixation (ORIF) or external fixation. Until surgery, the thumb should be immobilized using a thumb spica splint.

Epidemiology

Fractures at the base of the first metacarpal (thumb) are relatively uncommon, accounting for about 1.4% to 4% of all hand fractures. Among these, Rolando fractures make up 15% to 20% of thumb metacarpal base fractures.

In children, about 22% of long bone (tubular bone) fractures in the hand occur along the thumb. In adults over 65, 20% of hand fractures involve the thumb, while in the 17–40 age group, only 12% do. Overall, up to 80% of all thumb fractures involve the base of the metacarpal.

Diagnostic Procedures

History and Physical examination

Rolando Fracture

Clinical examination is essential for all patients with acute or chronic thumb injuries. However, it is not sufficient to distinguish between Rolando and Bennett fractures or to detect complex fracture patterns. Therefore, radiographic imaging is necessary for accurate diagnosis and assessment.

In Rolando fractures, the volar (palmar) fragment remains stable due to its connection with the volar carpal ligament. In contrast, the dorsal fragment is pulled away by the abductor pollicis longus (APL). The metacarpal shaft of the thumb is displaced by the adductor pollicis and extensor pollicis longus (EPL). The volar-ulnar fragment stays in place because it is anchored to the trapezium by the anterior oblique ligament, previously known as the beak ligament.

Radiological Evaluation

Radiographic imaging in two orthogonal (perpendicular) views is essential for diagnosing thumb fractures. However, because the thumb lies in a different plane than the rest of the hand, special views are needed for better visualization and classification of the injury. The Robert and Bett views are particularly helpful for assessing joint alignment and the degree of fragment displacement.

Key Radiographic Views

Robert View (True AP of the Thumb)

The forearm is fully pronated, with the back of the thumb resting on the X-ray plate. This provides a clear front-to-back (anteroposterior) image of the thumb.

True Lateral View

The hand is pronated at about 30 degrees, and the X-ray beam is angled 15 degrees distally to capture a side view of the thumb.

Oblique View

Offers an angled view to further evaluate the joint and bone structure.

Bett View (Lateral View of the Carpometacarpal Joint)

The palm is placed on the plate with the hand pronated at an angle of 15–35 degrees. The X-ray beam is directed from distal to proximal at a 15-degree angle, giving a clear side image of the carpometacarpal joint.

Advanced Imaging

CT Scan

CT with thin slices (0.5–1.0 mm) and multiplanar or 3D reconstruction helps in surgical planning by providing detailed views of fracture patterns.

MRI

MRI is useful for detecting injuries to ligaments, tendons, or subtle bone changes. High-quality images require small field-of-view settings and specialized extremity coils to enhance image clarity.

Management/Interventions

The treatment of a Rolando fracture depends on the severity and level of bone displacement. The main goals are to restore normal bone alignment and ensure stable fixation. Treatment options include:

Non-Surgical Treatment

If the fracture is not displaced, it can be managed with immobilization using a cast or brace for 4–6 weeks.

Surgical Treatment

Surgery is usually needed for displaced fractures. Common surgical techniques include:

Closed reduction with K-wires

Realigning the bone and stabilizing it using thin wires.

Open reduction and internal fixation (ORIF)

Using a small T- or L-shaped plate to fix the fracture.

External fixation or skeletal traction:

Using external devices to align the bone through ligament tension (ligamentotaxis).

Combined approach:

Using an external fixator along with internal fixation and bone grafts for better support.

Arthroscopic-assisted repair:

Using a camera-guided method to restore the joint surface precisely.

Innovative Method

In complex or multi-fragmented fractures, especially in younger patients, a new approach involves implanting an endoprosthesis into the thumb’s carpometacarpal (CMC) joint to restore function and stability.

Rehabilitation Protocol

The rehabilitation plan focused on restoring thumb movement, reducing pain, and improving hand function after surgery. The steps included:

Initial Immobilization: The thumb was immobilized in a special plaster splint for two weeks following surgery.

Suture Removal and Mobility: After two weeks, the splint and skin sutures were removed. The patient was then allowed to gradually regain full range of motion in the thumb.

Home Exercise Program: The patient was educated on rehabilitation techniques and instructed to perform active thumb exercises at home twice daily.

Physical Therapy Treatments: A course of 10 therapy sessions was prescribed, including: Low-frequency pulsed magnetic field therapy

Laser biostimulation: These treatments were applied to the thumb’s CMC joint to support healing and pain relief