Summary Trapezial Fractures are carpal fractures that often result from axial compression to the wrist. Diagnosis is confirmed with orthogonal radiographs of the wrist. Treatment can be nonoperative, surgical excision or surgical fixation depend on fracture pattern and patient activity demands. Epidemiology Incidence rare (<1% of all fractures) third most common carpal bone fracture makes up 1-5% of carpal fractures Etiology Pathophysiology mechanism of injury (trauma) trapezial body login to view 4 more bullets trapezial ridge fracture-dislocations Associated conditions Bennett fracture of base of first metacarpal Associated with high energy mechanisms and vertical fractures of the trapezial body fractures of scaphoid, trapezoid, capitate, neighboring metacarpals, and the distal radius (particularly with fracture-dislocations) Anatomy Osteology trapezium located at base of thumb thumb carpometacarpal joint is a biconcave saddle joint Consists of four articulations: login to view 4 more bullets trapezium has palmar groove for flexor carpi radialis (FCR) tendon Ligaments anterior oblique (volar beak) ligament Primary stabilizing static restraint to subluxation of CMC joint Originates from the palmar tubercle of the trapezium and inserts on the articular margin of the ulnar metacarpal base dorsoradial ligament primary restraint to dorsal dislocation login to view 1 more bullet strongest and thickest ligament login to view 2 more bullets Classification Trapezium Fractures Ridge Type 1: base of ridge Type 2: smaller avulsion fractures Body Walker Classification: Vertical intra-articular (most common, due to axial compression) Horizontal (horizontal shear) Dorsal radial tuberosity (vertical shear) Anterior medial ridge (loading or avulsion of transverse carpal ligament) Comminuted (high energy) Fracture-Dislocation High energy injuries Often missed due to concomitant injuries Presentation History Patients typically recall trauma to the thumb and acute onset of pain Physical exam Point tenderness over base of thumb Ecchymosis Trapezial ridge fractures may present with more subtle "achy" pain over volar base of thumb Imaging Radiographs recommended views Standard PA Pronated AP Lateral Bett view optional views Carpal tunnel view (trapezial ridge fracture) CT indications Normal x-rays with high index of suspicion May be required to delinate size and degree of displacement of fracture fragments Allows better assessment of articular involvement MRI Indications Typically not required Can identify occult fractures or ligamentous injuries Differential Triquetrum fracture Pisiform fracture Bennett fracture Metacarpal fractures Diagnosis Radiographic diagnosis confirmed by history, physical exam, and radiographs Treatment Nonoperative Thumb spica case for 4-6 weeks Nondisplaced body fractures Acute trapezial ridge fractures Observation Subacute trapezial ridge fractures with stable CMC joint Operative Open reduction and internal fixation indications login to view 3 more bullets outcomes login to view 1 more bullet Fragment excision Indications login to view 2 more bullets Trapeziectomy Indications login to view 3 more bullets Primary arthrodesis Indications login to view 1 more bullet External fixation Indications login to view 1 more bullet Techniques Open reduction and internal fixation (ORIF) Approach Dictated by fracture pattern Dorsal approach login to view 2 more bullets Wagner approach login to view 2 more bullets Volar approach login to view 1 more bullet Complications Non-union Incidence not well defined Type 2 trapezial ridge (avulsion) fractures high risk CMC instability Post-traumatic arthritis Can be treated with delayed trapeziectomy