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Case Reports |
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Comminuted Fracture of Base of Ist Metacarpal
with Fracture Trapezium
Amit Kapoor*, Sameer Shah**, Sashidhar Yeluri*** |
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| Introduction |
In adult population three essential types of
basal fractures of thumb have been identified. These are extraarticular,
Bennet’s (partial articular) and Rolando’s (complete
articular).1 An unusual pattern for a thumb metacarpal fracture
would be a diaphyseal fracture or a fracture associated with
simultaneous fracture of Trapezium.2,3
We hereby present a case report of a comminuted fracture of base of first
Metacarpal associated with fracture of trapezium which was treated by closed
percutaneous pinning. The result was good in terms of range of movement
and radiological appearance with the patient returning to his routine daily
activities with ease. |
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| Case Report |
A 26 year old manual labourer suffered an injury
to his left hand due to fall from a height of about 10 meters.
The patient presented with swelling and tenderness over the
thenar area and functional impairment of left thumb. An anteroposterior
and oblique X-rays demonstrated comminuted fractures of base
of first metacarpal with an intraarticular fracture of the
trapezium (Fig. 1).
Both the fractures were treated by percutaneous K wire fixation, as a satisfactory
reduction and alignment was obtained by closed reduction (Fig. 2).
The patient was immobilized in a thumb spica for 6 wks after which the
K wires were removed and mobilization started with restriction of heavy
labour work initially. The fracture healed satisfactorily both clinically
and radiologically. There was minimal restriction of range of flexion extension
and abduction adduction of the carpometacarpal joint of the thumb as compared
to the opposite side. The patient was able to do his routine daily activities
and was able to return to his job with ease. |
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Fig. 1 : X-ray of the left hand showing comminuted fracture
of base of first metacarpal and fracture of the trapezium. |
| Discussion |
Fractures of trapezium account for 3-5% of all
carpal bone fractures and these may be associated with other
injuries, for example fracture of base of first metacarpal.
A similar mechanism of injury may explain both fractures
.
The combination of leverage applied to dorsum of first metacarpal and an
axial load transmitted along the shaft would result in increasing joint
compressive forces on the palmar aspect of articular surface leading to
Bennet’s fracture, with a distracting force on the dorsoradial trapeziometacarpal
ligament, causing avulsion of trapezium. Subsequent contraction of abductor
pollicis longus which usually has an insertion on the trapezium would enhance
a further displacement of fracture of trapezium.4,5 Hence a high index
of suspicion is required to diagnose a trapezium fracture which may be
associated with injuries like Bennet’s fracture dislocation, Rolando’s
fracture, fracture of the scaphoid, hook of hamate and carpometacarpal
joint dislocation.6
Plain radiographs often fail to show fractures of trapezial body because
of overlapping trapezoid. A true anteroposterior radiograph (Robert’s
view) taken with hand in full pronation is excellent for outlining the
trapezium and base of first metacarpal.7 A CT scan further provides the
details required for proper management by providing good multidirectional
images.
Fractures of the trapezium either isolated or in combination with other
injuries should not be underestimated as they can be responsible for prolonged
morbidity if inadequately treated.
Accurate reduction is advocated in isolated Bennet’s fracture to
avoid late arthritic changes and this is particularly important when there
is also a fracture disrupting the articular surface of trapezium.
Closed reduction and K wire fixation is the treatment of choice of nearly
all fractures of base of first metacarpal and the same was done in the
presented case. The primary aim was to provide distraction to allow healing
through the comminuted metaphyseal zone. Fractures of trapezium can be
treated by closed reduction and percutaneous pinning if satisfactory reduction
can be obtained. If not, an open reduction should be done to achieve anatomical
alignment.8
Our case reinforces and stresses the fact that achievement and maintenance
of an anatomical reduction of a combined fracture of base of first metacarpal
and trapezium is possible by closed means and satisfactory results can
be obtained by proper remobilization techniques post operatively. However
no less than an anatomical reduction should be accepted and a low threshold
for open reduction be kept for such cases to obtain excellent results. |
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Fig. 2 : Post operative X-ray of the left hand after percutaneous
fixation of the fractures of the base of first metacarpal
and the trapezium with K-wires in situ. |
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| References |
| 1. |
Green DP, O’Brien ET.
Fractures of thumb metacarpal. South Med Journal 1972;
65 : 807-14. |
| 2. |
Garcia - Elias M, Henriquez-Lluch A,
Rossignani P, et al. Bennet’s fracture combined
with fracture of Trapezium. A report of three cases.
J Hand Surgery 1993; 18B : 523-26. |
| 3. |
Radford PJ, Wilcox DT, Holdsworth BJ.
Simultaneous trapezium and Bennet’s fracture. J
Hand Surgery 1992; 17A ; 621-23. |
| 4. |
Imaeda T, An K, Cooney WP, et al. Anatomy
of trapezio metacarpal ligaments. J Hand Surgery 1993;
18A : 226-31. |
| 5. |
Kauer JMG. Functional anatomy of carpometacarpal
joint of the thumb. Clinical Orthopaedics and Related
Research 220; 7-13. |
| 6. |
Inston N, Pimpalnerkar AL, Arafa MAM.
Isolated fractures of trapezium : an easily missed injury.
Injury 1997; 28 (7) : 485-88. |
| 7. |
Binhammer P, Born T. Coronal fracture
of the body of the trapezium : A case report. J Hand
Surgery 1998; 23A : 156-57. |
| 8. |
Cordrey LJ, Ferrer-Terrells M. Management
of fractures of the great multangular : report of five
cases. J Bone and Joint Surgery 1960; 42A : 1111-18. |
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Book Review
“Herbal Drugs and Phytopharmaceuticals” edited
by Max Wichti.
The book is written by number of German scholars
and is meant actually for Europe.
Though it is written in the book in General Instructions that “Indian
Systems of Medicine (Ayurvedic and Unani) have also been included.
In the Synonyms Sanskrit and Hindi names are not included.
This is bound to go hard for Indians, reading the book, to understand
easily about the described herbs.
There are number of herbal drugs well detailed in books of Indian
Materia Medica, Dravya Guna Vigyan, etc. written by Indian scholars
like AK Nadkarni, Dr Priyavrat Sharma of Benaras Hindu University,
etc. They can be easily understood and used in practice by the
regular practitioners provided they are included in regular medical
education.
There are number of Indian drugs included in this book under
review like Tagar, Shatavari, Jeera, Kalajeera, Sounf, etc. but
they are not easily understood in this book written by Germans.
This book, therefore, is good for Institutions where it can be
read comparing with Indian Materia Medicas, etc.
PN Awasthi
Retd. Chief Surgeon
M.A. Podar Hospital
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