Trapezium fractures are rare and can be missed easily. Intra-articular fractures often lead to arthritis. Failure to restore the articular congruity increases the risk of arthritis. We present a case of an isolated intra-articular fracture of the trapezium treated successfully with open reduction and internal fixation using a single screw.
A 17 year-old boy fell on his outstretched hand. He experienced immediate pain at the base of the thumb. On examination there was no swelling, no pain elicited by palpation and the thumb had a full range of motion. Movement of the thumb did produce pain in the carpo-metacarpal joint of thumb, especially during a power grip. Radiographs demonstrated an isolated intra-articular fracture of the trapezium. Fig 1,2 This fracture was exposed through a dorso-radial approach and reduced anatomically. Reduction was maintained with a bone clamp and a fine K-wire temporarily. The K-wire was removed and a 2mm screw inserted and the position was checked on image intensifier. Post-op the patient's hand was elevated and mobilised and formal check radiographs were taken. Fig 3,4 At 6 weeks follow-up, radiographs showed healing of the fracture with a congruent joint. Fig 5+6 Clinically the outcome was excellent with return to normal function with minimal stiffness of the carpo-metacarpal joint on opposition of the thumb, this was treated with continued physiotherapy.
Fractures of the trapezium are rare. They account for only 5% of all carpal fractures.1 They can be caused by forced flexion of the thumb, usually as the result of a high-energy injury.2+3 Trapezium fractures are commonly associated with Bennett's fracture, fracture of the posterior lip of the radius, fracture of the base of the second metacarpal or another carpal bone fracture.1,2,3,5 The patient will usually have an aching pain at the base of the thumb and stiffness, particularly when opposing the thumb. There may be difficulty with a power grip or a pincer grip due to pain. On palpation there may be only mild tenderness and crepitus may be felt.2,3,4 Radiographic examination consists of a standard wrist series and Bett's view. Bett's view is taken with the wrist in pronation with the hypothenar eminence resting on the cassette, the beam is directed towards the trapeiziometacarpal and scaphotrapezial joints in order to visualise these joints specifically.2 The Robert's view is a true anteroposterior radiograph taken with the hand in full pronation and has also been recommended for visualising the trapezium.8 CT can also help to identify the fracture configuration.3,6,8 Due to the subtle signs and symptoms and difficultly of identifying trapezium fractures on standard plain radiographs of the wrist these fractures can sometimes go undiagnosed. A high index of suspicion is required.6,8 Intra-articular fractures of the body of the trapezium usually occur as a vertical split with or without comminution. A number of treatment options are available. Conservative treatment of intra-articular fractures in a thumb spica can lead to painful non-union, and post-traumatic arthritis.3 These problems can cause functional impairment of the hand. With closed reduction and fixation using K-wires it can be difficult to achieve joint congruency and it is not possible to apply inter-fragmentary compression. Current literature favours open reduction and internal fixation with or without bone grafting to treat fractures with articular displacement of greater than 2mm or carpo-metacarpal subluxation with or without comminution. 2,3,4,5,6,7
An isolated intra-articular fracture of the trapezium.
1. From the provided wrist X-ray images (anteroposterior and lateral views), a clear fracture line can be seen at the radial side of the wrist, near the base of the thumb. This appears to involve one of the radial carpal bones, most likely the Trapezium (also called the Greater Multangular bone).
2. The fracture line runs vertically or near-vertically and involves the articular surface. Discontinuity of the joint surface is noted, with slight displacement of certain fragments.
3. Follow-up postoperative images show that the fracture has been internally fixed with a single screw. The screw passes through the fracture line, securing both fragments. The articular surface is essentially restored, with acceptable alignment and apposition.
4. Surrounding soft tissue swelling is relatively mild, and there is no obvious bone defect or osteopenia. No other significant abnormalities are observed in the remaining carpal bones or joint spaces.
Based on the radiographic findings, the patient's age of 17, and the reported thumb injury history, the possible diagnoses include:
1. Trapezium Fracture (Greater Multangular Bone Fracture): This is associated with trauma and forceful impact, hyperflexion, or axial loading of the thumb. Imaging shows a clear fracture line in the Trapezium with an interrupted articular surface, consistent with the patient’s clinical presentation.
2. First Metacarpal Base Joint Injury or Bennett Fracture: In some cases, a fracture line near the Trapezium can be confused with a fracture of the first metacarpal base (Bennett fracture). However, in this case, the images clearly show a fracture in the Trapezium, and the first metacarpal base appears intact, so this is not the primary diagnosis.
3. Other Associated Carpal Fractures or Chondral Injuries: In high-energy trauma, one should also consider concurrent fractures of the scaphoid or trapezoid. However, based on the current images, no obvious fracture lines are noted in the other carpal bones.
Combining the radiological findings, the mechanism of injury in a young male, and the clinical symptoms, the most likely diagnosis is a solitary intra-articular fracture of the Trapezium. Postoperative X-rays indicate fixation with a single screw, showing good reconstruction of the articular surface and alignment. If there are no other associated injuries, clinical symptoms should gradually improve.
1. Treatment Strategy:
- Surgical Treatment: For Trapezium fractures with articular displacement greater than 2 mm or significant joint instability, open reduction and internal fixation (ORIF) is recommended. In this case, a single screw fixation has been performed, providing sufficient stability and restoring articular congruity.
- Postoperative Immobilization and Protection: After surgery, short-term casting or splinting is typically required to protect the injury and prevent excessive movement of the thumb and wrist, facilitating fracture healing.
- Medication: Early-stage pain relief and anti-inflammatory drugs may be used, depending on the patient's pain level.
- Imaging Follow-up: X-ray or CT re-examinations are advised at 2–4 weeks, 6–8 weeks postoperatively, and as needed, to evaluate fracture healing and articular alignment.
2. Rehabilitation/Exercise Prescription (Following the FITT-VP Principle):
- Early Stage (0–2 weeks post-op):
· Focus on protection and maintaining relative immobilization of the injured limb. Commence gentle finger exercises (e.g., making a fist and spreading the fingers) to prevent stiffness in other fingers.
· Frequency (F): 3–5 sessions per day;
· Intensity (I): Minimal range of motion to avoid severe pain around the thumb base;
· Time (T): Approximately 5 minutes each session;
· Type (T): Gentle active finger movements;
· Progression (P): Gradually increase range of motion based on pain and swelling.
- Intermediate Stage (2–6 weeks post-op):
· Gradually discontinue the external immobilization or switch to a lighter brace. Begin specialized hand rehabilitation exercises, focusing on active thumb movements and improving joint range of motion.
· Frequency: 2–3 sessions per day;
· Intensity: Slightly increase range of motion within tolerable pain levels;
· Time: 10–15 minutes per session;
· Type: Thumb-to-finger opposition exercises, mild grip training, wrist flexion-extension and pronation-supination exercises;
· Progression: Increase grip strength and thumb opposition resistance exercises weekly, depending on joint flexibility and fracture healing.
- Late Stage (6 weeks post-op and onward):
· If imaging indicates stable fracture healing, progressively enhance thumb and wrist strength training (e.g., pinch and grip strength exercises, fine motor function training).
· Frequency: 3–5 sessions per week;
· Intensity: Gradually increase resistance to build joint strength and stability;
· Time: 20–30 minutes per session;
· Type: Squeezing stress balls, elastic band exercises for thumb abduction and adduction, functional grip and lifting activities;
· Progression: Adjust training difficulty and resistance based on hand strength and pain assessment.
Important Note: If significant pain, swelling, or mobility restriction occurs during rehabilitation, reduce or pause activities and consult a specialist or rehabilitation therapist. Patients with weaker bone quality or chronic conditions should have individualized adjustments to their rehab plan under professional supervision.
Disclaimer: This report is based solely on the current imaging and clinical information for reference purposes and cannot replace in-person consultations or professional medical diagnoses and treatment. Specific treatment and rehabilitation programs should be formulated and supervised by professional orthopedic or hand surgery rehabilitation specialists, according to the patient’s individual condition.
An isolated intra-articular fracture of the trapezium.
