Updated: 5/14/2021

Trapezial Fracture

Review Topic
  • 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
          • most common
          • can result from a variety of mechanisms (see table)
          • vertical fracture pattern is the most common, resulting from axial loading
            • May be accompanied by Bennett fracture of first metacarpal
        • 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:
          • Trapeziometacarpal (TM)
          • Trapeziotrapezoid
          • Scaphotrapezial (ST)
          • Trapezium-index metacarpal
      • 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
          • injured in dorsal CMC dislocation
        • strongest and thickest ligament
          • posterior oblique ligament
          • intermetacarpal ligament
  • Classification
    • Trapezium Fractures
      • Type 1: base of ridge
      • Type 2: smaller avulsion fractures
      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)
      • 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
          • Displaced body fractures in active patients
          • Large fracture fragments can be fixed with headless compression screws or mini-fragmentation screws
          • Good results have also been described with k-wire fixation
        • outcomes
          • Excellent results with good restoration of thumb and wrist motion and pinch function compared to uninjured side
      • Fragment excision
        • Indications
          • Symptomatic trapezial ridge fractures
          • Consider early fragment excision for type-2 (avulsion) trapezial ridge fractures as these are associated with higher risk of symptomatic nonunion
      • Trapeziectomy
        • Indications
          • Lower demand patients
          • Painful first CMC joint prior to injury
          • Degeneartive changes of first CMC joint
      • Primary arthrodesis
        • Indications
          • Highly comminuted fractures in high demand patients
      • External fixation
        • Indications
          • Comminuted fractures with adequate alignment of articular surface
  • Techniques
    • Open reduction and internal fixation (ORIF)
      • Approach
        • Dictated by fracture pattern
        • Dorsal approach
          • Can go between EPL and EPB tendons or retract tendons out of the way
          • longitudinal capsulotomy
        • Wagner approach
          • Incision at the glabrous border
          • Good for sagittally oriented fractures
        • Volar approach
          • Excision of trapezial ridge fracture fragments
  • 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
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