Thumb fracture

Definition

The thumb is formed by the metacarpal bone, the proximal and distal phalanges. A thumb fracture can occur in any of these three bones.

Illustration of thumb metacarpal base fractures of Rolando type

Pathology

The distal end of the thumb metacarpal forms a joint with the proximal phalange, which is named the metacarpo-phalangeal (MCP) joint. The proximal end of the thumb metacarpal and the carpal bone (trapezium) form the carpo-metacarpal (CMC) joint. A thumb fracture can occur in any of these anatomical regions but is more frequent at the base of the metacarpal bone. The thumb metacarpal is the broadest tubular metacarpal bone of the hand.  Anatomically it is slightly detached from the other bones of the hand to allow for grasping. Therefore, a thumb fracture can have serious functional implications.

Due to the unique anatomy, a fracture of the thumb metacarpal is quite different compared to other metacarpal bones. Metacarpal fractures can be isolated or combined with injury of the CMC joint and involve the trapezium. These fractures generate instability of the CMC joint producing chronic pain and weakness, commonly requiring surgical reconstruction of the joint surface. A fracture of the thumb metacarpal is also called skier’s thumb. In case of fractures to the metacarpal head, the knuckle seems to disappear and its movement triggers pain. When associated with damage to the tendon abductor pollicis longus (APL), it leads to instability of the CMC joint.

Classification of thumb fractures shown for the matacarpal bone

Classification

There are different types of thumb fractures that are named based either on their location relative to the joint and take the name of the specialist who first described them. These definitions are:

1. Intra-articular comminuted

2. Extra-articular transverse

3. Extra-articular oblique

4. Intra-articular or Bennett’s fracture

5. Intra-articular or Rolando’s fracture

Thumb fractures can be stable, non-displaced or minimally displaced, when the bone fragments maintain their anatomical position, or displaced when the bone fragments have moved from their original anatomy. They can also be transverse, oblique, spiral, or comminuted when multiple bone fragments are released.

A Bennett’s fracture of the thumb base is the most common type of fracture producing an oblique break of the metacarpal affecting the function of the underlying joint. This requires immediate medical attention.

A Rolando’s fracture is a 3-part fracture at the base of the thumb metacarpal generating a T- or Y-fracture pattern. It is located either in the frontal or in the sagittal plane. It is caused by an axial overload along the thumb metacarpal causing a compression fracture of the joint surface. This type of pathology is uncommon but has a worse prognosis than a Bennett's fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Mechanism leading to a thumb fracture

Causes

A thumb fracture is the result of an impact and/or torsion energy and is mostly found in men. It is caused by a force pulling the thumb backwards in a flexed position at the metacarpal joint as it happens in:

Falls onto the hand

When catching a ball

Contact sports

Manual work.

Catching a heavy ball can cause a thumb fracture

Risk factors

The following sports and activities represent the main risk factors for a thumb fracture: 

Basketball 

Netball

Contact sports (hockey, football, rugby)

Skiing

Martial arts

Carpentry work

Any kind of bruise may indicate an underlying fracture

Symptoms

The symptoms arising from thumb fractures are:

Pain

Swelling

Bruising

Movement restrictions

Thumb deformity

Knuckle asymmetry and/or depression

Instability of the carpo-metacarpal joint

 

Common types of thumb fracture of the phalanges and metacarpal bone

Diagnosis

During the medical examination the patient provides information including the history of previous hand injuries and mechanisms that have caused the current injury to the thumb. Clinical examination of the hand will determine:

Changes in the anatomy of the affected thumb against the healthy thumb

Presence of skin lacerations, bruises

Thumb malrotation

Tenderness at touch 

Pain triggered by movement

Reduced range of movement

If a thumb fracture is suspected X-rays are taken under the antero-posterior, lateral, and oblique view to confirm the presence of a fracture and assess its characteristics. CT and MRI scans may be required for a detailed definition of complex fractures.

Treatment

A brace is often used for the conservative treatment of a thumb fracture

Nonoperative treatment

Management of thumb fractures varies in relation to fracture site and its classification. In case of stable fractures surgery is not required and conservative treatment with a cast is usually sufficient. Sometimes a closed reduction by an orthopaedic/hand surgeon may be necessary to realign the fractured metacarpal. However, surgery is needed if displacement of the abductor pollicis longus (APL) muscle has occurred during the thumb reduction. A special cast named thumb spica cast or a splint are used to hold the bone fracture in place for 4-6 weeks and then replaced with a removable splint if there is sufficient stability with hand movement. Additional thumb fracture management includes:

Rest

Hand elevation

Ice pads

Administration of NSAIDs

Painkillers

Physiotherapy with specific thumb exercises while the hand is in a cast or brace.

Drawing of the surgical pinning of a Bennett’s thumb fracture

Surgical treatment

Surgery is required in significantly displaced thumb metacarpal fractures or those fractures that do not maintain alignment despite the immobilisation with a cast. Different methods are available for surgical fixation depending on the type of fracture:

Open reduction and internal fixation (ORIF) is used in displaced fractures. The procedure begins with a dorsal incision and the placement of screws, plates and k-wires. The pins are kept in place for 4-6 weeks.

External fixation is used in unstable complex thumb fractures. A closed reduction with percutaneous pinning using k-wires is also a frequent surgical option.

Traction of the fractured thumb with Chinese finger traps achieves fracture alignment and is used as a sort of traction device.

Complications

Complications after thumb fracture are rare and include:

Non-union of the thumb metacarpal may occur when a fracture is neglected, with delayed surgery, or in very unstable fractures. This results in bone misalignment causing improper thumb angulation and possibly surgery (or a second surgery)

Infection following surgery

Arthritis can develop if the joint and joint ligaments are affected

Chronic Regional Pain Syndrome (CRPS) leads to prolonged pain of the injured thumb area but is rare.

Physical exercise helps restoring the flexibility and strength of the thumb

Rehabilitation

With or without surgery, the use of a cast or splint is recommended for 6-12 weeks following thumb metacarpal fracture. The prognosis depends on the severity of the fracture. Any physical activities that involve grasping, gripping, pulling and punching should be avoided until a complete fracture healing has been achieved. Once pain has resolved the patient can begin to move the wrist, hand and fingers to prevent stiffness of all joints. Intensive physical therapy usually commences approximately 6-8 weeks after surgery. A physical or occupational therapist will recommend exercises to restore flexibility and strength of the thumb (thumb opposition, extension flexion, etc). The therapist will also advice the patient methods to avoid recurrent injuries. Standard rehabilitative therapy includes:

Massage

Joint mobilisation

Stretches

Electrotherapy

Return to activity plan

Taping / bracing

Wearing protective gear in contact sport can prevent thumb fractures

Prevention

Preventing thumb fractures is mostly achieved by reducing the risk of falls and protecting the thumb during sports and other professional activities. Common strategies are:

Postural taping

Use of devices to improve elderly patient stability and avoid falls

Wearing protective gear during sport training and carpentry work

Modification of physical activities

Exercise to improve muscle strength, flexibility and posture.