01Approach to the Critical Patient/attcp50

Immediate priorities

›Neurovascular threat screen

›Radial artery pulse at the wrist and thumb

›Absence suggests vascular injury requiring emergent vascular surgery consult

›Doppler assessment when pulse uncertain

›Digital perfusion of the thumb

›Capillary refill > 2 seconds

›Pallor or cyanosis of the thumb tip

›Sensory integrity of the thumb

›Radial digital nerve distribution

›Ulnar digital nerve distribution

›If neurovascular compromise confirmed, emergent hand surgery consultation

›Do not delay for further imaging

›Splint in position of function while awaiting consult

›Open fracture threat screen

›Skin integrity over thumb base

›Any breach is an open fracture until proven otherwise

›Wound irrigation and sterile coverage immediately

›Open fracture management

›Cefazolin 2 g IV within 1 hour of injury for Gustilo Grade I/II

›Add gentamicin for Gustilo Grade III

›Tetanus prophylaxis per immunization status

›Emergent hand surgery consultation for all open fractures

›Compartment syndrome screen

›Thenar eminence compartment

›Pain out of proportion to injury

›Pain with passive thumb extension

›Tense swelling of the thenar eminence

02History/hx63

Mechanism of injury

›Axial loading pattern

›Punch with thumb in flexion

›Classically a missed punch or hitting a hard surface

›Most common mechanism in young males

›Fall onto outstretched hand with thumb impact

›FOOSH with force transmitted through the thumb ray

›Ski pole impact in skiing injuries

›Sports-related collision

›Football, rugby, boxing, cycling, skiing

›Direct axial force through the thumb

›Force characteristics

›High-energy vs low-energy mechanism

›High-energy may have associated carpal or wrist injuries

›Low-energy in osteoporotic bone with lesser comminution threshold

›Direct blow vs axial compression

›Direct blow may cause isolated fragment patterns

›Axial compression produces the classic T- or Y-shaped comminution

Presenting symptoms

›Local symptoms

›Immediate pain at the base of the thumb

›Localized to the trapeziometacarpal joint

›Aggravated by any thumb movement

›Swelling at the thumb base

›Rapid onset within minutes to hours

›May extend into the thenar eminence

›Inability to grip or pinch

›Thumb opposition lost

03Physical Exam/exam69

Vitals and general

›Baseline vital signs

›Blood pressure and heart rate

›Assess for signs of pain-related tachycardia

›Baseline for procedural sedation planning if required

›Pain score documentation

›Pre- and post-analgesia comparison

›Guides adequacy of regional anesthesia

Thumb and hand inspection

›Anatomical deformity

›Swelling at the base of the first metacarpal

›Localized to the trapeziometacarpal joint

›Thenar eminence involvement if compartment pressure rising

›Ecchymosis distribution

›Radial and dorsal aspects of the thumb base

›May extend to the first web space

›Shortening of the thumb ray

›Comparison with contralateral thumb

›First web space narrowing

›Rotational deformity

›Thumb in adduction from abductor pollicis longus deforming force

›Comparison with contralateral hand alignment

Palpation

›Point tenderness localization

›Direct tenderness over the CMC joint

›At the base of the first metacarpal

›Differentiates from MCP joint or thumb IP joint injuries

›Scaphoid fossa tenderness

04Differential Diagnosis/ddx46

Intra-articular thumb base fractures

›Bennett fracture

›ICD-10 S62.211 (right), S62.212 (left)

›Two-part intra-articular fracture-subluxation at the first metacarpal base

›Single volar-ulnar fragment held by the anterior oblique ligament

›Remainder of the metacarpal subluxes radially and proximally

›Distinguishing feature: two fragments only, no comminution

›Rolando has three or more fragments in T or Y pattern

›Rolando fracture

›ICD-10 S62.201 (right), S62.202 (left)

›Comminuted T- or Y-shaped intra-articular fracture of the first metacarpal base

›Three or more major fragments involving the articular surface

›Inherently unstable due to multiple deforming muscle forces

Extra-articular and adjacent fractures

›Extra-articular fracture of the first metacarpal base

›Fracture line does not involve the articular surface

›Generally more stable and better prognosis

›Can be managed with closed reduction and thumb spica casting in many cases

›Transverse or oblique metaphyseal patterns

›Distal radius fracture

›Mechanism overlap with FOOSH

›Wrist tenderness localizes to distal radius

›Dedicated wrist radiographs required

›Scaphoid fracture

›Anatomical snuffbox tenderness as distinguishing feature

›May coexist with Rolando fracture after high-energy trauma

›MRI or CT if clinical suspicion despite negative plain films

05Laboratory Tests/lt30

Routine labs for isolated fracture

›Standard isolated hand fracture

›Routine labs generally not indicated

›No infection risk for closed fractures

›Imaging is the diagnostic priority

›Metabolic panel only if surgical planning

›Renal function for anesthetic risk stratification

›Electrolytes for baseline before procedural sedation

Preoperative and risk-stratification labs

›Surgical planning labs when operative fixation anticipated

›Complete blood count

›Baseline hemoglobin for surgical risk

›Platelet count for bleeding risk

›Basic metabolic panel

›Renal function for antibiotic dosing adjustment

›Glucose for wound healing risk assessment

›Coagulation studies

›Prothrombin time and INR if anticoagulant use or liver disease

›Platelet function assessment if aspirin or NSAIDs used

›Diabetes-related labs

›Hemoglobin A1c if diabetes known or suspected

›HbA1c > 8% associated with impaired wound healing post-operatively

›Random glucose if HbA1c unavailable acutely

Open fracture labs

›Open fracture infection risk assessment

›Complete blood count for baseline white cell count

›Baseline leukocyte count for comparison if infection develops

›Wound swab culture

06Diagnostic Tests/dt65

Scoring Systems

›Fracture characterization and outcome prediction

›No validated ED-specific scoring system for Rolando fracture

›Treatment decisions guided by fracture pattern, fragment size, and displacement on imaging

›Clinical and radiographic assessment supersedes any single score

›Gustilo-Anderson classification for open fractures

›Grade I: wound < 1 cm, minimal contamination

›Grade II: wound 1–10 cm, moderate contamination

›Grade IIIA: wound > 10 cm, adequate soft tissue coverage

›Grade IIIB: wound > 10 cm with periosteal stripping

›Grade IIIC: any size wound with arterial injury requiring repair

›QuickDASH score for functional outcome tracking

›11-item questionnaire for upper extremity disability

›Useful at follow-up to track recovery; not an acute ED tool

›Articular step-off threshold

›Step-off > 1 mm associated with increased post-traumatic arthritis risk

›Anatomic reduction to < 1 mm is the surgical goal

MRI

›MRI indications for thumb base injuries

›Limited acute utility in confirmed Rolando fracture

›CT provides superior bony detail for surgical planning

›MRI reserved for specific diagnostic uncertainty

›Indications where MRI adds value

›Suspected occult scaphoid fracture coexisting with thumb injury

›Suspected ligamentous injury at the CMC or MCP joint

›Soft tissue mass or concern for pathologic fracture underlying injury

›Protocol considerations

›Dedicated thumb or hand coil for optimal resolution

›T1 and STIR sequences for bone marrow edema detection

›Contraindications

›Ferromagnetic metallic implants

›Pacemaker or cochlear implant without MR-conditional certification

›Patient unable to tolerate positioning

CT

›CT indications for Rolando fracture

›Primary indication: surgical planning

›Characterizes fragment size, number, displacement, and articular step-off

›Critical for determining ORIF versus external fixation versus combined approach

›Diagnostic utility

›Identifies all fracture fragments not visible on plain radiograph

›Quantifies articular surface incongruity with precision

›Step-off > 1 mm on CT correlates with post-traumatic arthritis risk

›CT protocol

›Thin-slice CT (1 mm) of the hand with coronal and sagittal reconstructions

›3D reconstruction aids operative planning

›No contrast required for fracture characterization

›CT findings in Rolando fracture

›T-shaped or Y-shaped fracture pattern at the first metacarpal base

›Dorsal and palmar articular fragments

›Central comminuted zone with variable fragment count

›Subluxation of the trapeziometacarpal joint

›Dorsoradial displacement of the metacarpal shaft

›Residual volar-ulnar fragment attached to the trapezium by the anterior oblique ligament

Ultrasound

›Ultrasound role in Rolando fracture

›Not standard for fracture characterization

›Plain radiographs and CT are the primary diagnostic modalities

›Ultrasound does not replace standard imaging

›Regional anesthesia guidance

›Ultrasound-guided radial nerve block at the wrist or forearm

›Improves accuracy of nerve block for thumb analgesia

›Reduces need for systemic opioids in the ED

›Vascular assessment adjunct

›Doppler assessment of the radial artery if pulse unclear clinically

›Identifies traumatic pseudoaneurysm in high-energy injuries

›Plain radiograph first-line imaging

›AP, lateral, and oblique views of the thumb

›Robert view (true AP with hand in hyperpronation) delineates articular surface

›Stress view occasionally used to assess joint instability

07Disposition/dispo40

Admission indications

›Indications for inpatient admission

›Open fracture

›Requires emergent operative washout and fixation

›Intravenous antibiotic continuation

›Neurovascular compromise

›Requires emergent vascular or hand surgery intervention

›Monitoring of perfusion post-repair

›Compartment syndrome confirmed or strongly suspected

›Requires urgent fasciotomy

›ICU-level or surgical ward monitoring

›Polytrauma setting

›Rolando fracture as part of multiple injuries

›Admission driven by overall injury burden

›Failed closed reduction with significant subluxation

›Urgent operative intervention required

Discharge criteria

›Criteria for ED discharge

›Closed fracture with intact neurovascular status

›Confirmed after splinting

›Adequate pain control achieved

›Oral analgesics tolerated

›Regional block provides interim pain relief

›Reliable follow-up plan established

›Hand surgery appointment within 3–5 days

›Earlier if significant displacement or subluxation

›Splint applied and patient instructed in care

›Thumb spica splint in position of function

08Treatment/t81

Immediate ED management

›Immobilization

›Thumb spica splint

›Wrist in 15–20 degrees of extension

›MCP joint in 30 degrees of flexion

›Thumb in palmar abduction (opposition posture)

›Plaster or fibreglass splint material

›Circumferential cast avoided acutely due to swelling

›Neurovascular recheck after splint application

›Ice and elevation

›Crushed ice pack wrapped in cloth over the thumb base

›20 minutes on, 20 minutes off for first 48 hours

›Hand elevated above heart level

›Reduces swelling and pain

›Sling use to maintain elevation when ambulatory

Analgesia

›Regional anesthesia

›Hematoma block

›5–10 mL of 1% lidocaine without epinephrine injected into fracture hematoma

›Onset within 5–10 minutes

›Duration 1–2 hours

›Radial nerve block at the anatomical snuffbox or wrist

›Provides analgesia to the dorsal radial hand and thumb

›Ultrasound guidance improves accuracy

›Systemic analgesia

›NSAIDs

›Ibuprofen 400–600 mg PO every 6–8 hours with food

›Ketorolac 15–30 mg IV/IM as single dose in the ED

›Avoid prolonged NSAID use if surgical fixation anticipated; may impair bone healing

›Acetaminophen

›1000 mg PO every 6–8 hours as baseline analgesia

›Suitable in combination with NSAIDs

›Opioids for severe pain

›Morphine 0.05–0.1 mg/kg IV titrated to effect

›Hydromorphone 0.5–1 mg IV for moderate to severe acute pain

›Short course oral oxycodone 5–10 mg every 4–6 hours for discharge

Definitive operative treatment

›ORIF with lag screws and buttress plate

›Indication: large, reducible T- or Y-pattern fragments

›Preferred when fragments are large enough to accept hardware

›Restores articular congruity with direct reduction

›Hardware options

›Mini lag screws (1.3–2.0 mm) for fragment fixation

›T- or L-shaped buttress plate for additional stability

›Goal: articular step-off < 1 mm

›Minimizes post-traumatic arthritis risk

›External fixation with ligamentotaxis

›Indication: severely comminuted fractures with fragments too small for direct fixation

›Restores length and alignment without direct fragment manipulation

›Maintains articular reduction via joint distraction

›Mean time to external fixator removal approximately 28 days

›May be combined with supplemental K-wires or tension band wiring

›Closed reduction and percutaneous K-wire fixation

›Indication: minimally displaced fractures where adequate reduction achievable

›Less common given inherent instability of Rolando pattern

›Requires close radiographic follow-up

›K-wire removal typically at 4–6 weeks

›External fixation alone

›Indication: severely comminuted fractures where articular surface cannot be reconstructed

›Ligamentotaxis maintains alignment

›Accepts some residual articular incongruity when reconstruction not possible

Antibiotic management

›Closed fracture

›Antibiotics not indicated for closed Rolando fracture

›No infection risk in the acute setting

›Open fracture antibiotic prophylaxis

›Gustilo Grade I and II

›Cefazolin 2 g IV every 8 hours

›Initiate within 1 hour of injury

›Continue for 24 hours post-operative

›Gustilo Grade III

›Cefazolin 2 g IV every 8 hours

›Add gentamicin 5 mg/kg IV once daily

›Consider adding penicillin G for farm or soil contamination

›Penicillin allergy alternative

›Clindamycin 600–900 mg IV every 8 hours for Grade I/II

›Clindamycin plus gentamicin for Grade III

Non-operative management

›Thumb spica casting for minimally displaced fractures

›Immobilization for 4–6 weeks

›Serial radiographs at 1-week intervals for first 3 weeks

›Conversion to operative management if secondary displacement occurs

›Criteria for non-operative suitability

›Articular step-off < 1 mm on all radiographic views

›Minimal comminution without joint instability

›Patient compliance with follow-up assured

09Special Populations/sp84

Pregnancy

›Pregnancy-specific considerations

›Mechanism context

›Falls are a common trauma mechanism in pregnancy due to altered centre of gravity

›Sports-related mechanisms less common in mid to late pregnancy

›Imaging approach

›Plain radiographs of the thumb with lead shielding of the abdomen

›Radiation dose to the fetus is negligible for extremity radiographs

›Acceptable in all trimesters when clinically indicated

›CT of the thumb when essential for surgical planning

›Dose-distance attenuation makes fetal exposure extremely low

›Obtain when ORIF planning requires detailed fragment characterization

›Analgesia in pregnancy

›Acetaminophen 1000 mg PO every 6–8 hours is preferred

›Safe in all trimesters at recommended doses

›NSAIDs

›Avoid in third trimester: premature closure of ductus arteriosus

›Cautious use in first trimester: possible miscarriage association

›Opioids

›Short-course low-dose use acceptable with monitoring

›Neonatal abstinence syndrome risk with prolonged use

›Operative management timing

›Non-emergent operative fixation deferred to second trimester when feasible

›Lowest anaesthetic risk period

›General vs regional anaesthesia preference

›Regional technique preferred to avoid general anaesthesia risks in pregnancy

Geriatric

›Older adult-specific considerations

›Bone quality and fracture pattern

›Osteoporosis increases comminution severity

›Lower-energy mechanisms produce severely comminuted patterns

›Osteoporosis treatment

›Calcium and vitamin D supplementation should be initiated or continued

›DEXA scan referral if not previously assessed

›Fall prevention and mechanism

›Mechanical fall is the predominant mechanism in older adults

›Functional assessment and fall risk modification

›Vision, balance, and polypharmacy review

›Surgical risk stratification

›Higher anaesthetic risk in elderly with comorbidities

›Cardiology or internal medicine pre-operative assessment

›Cognitive status affects rehabilitation compliance

›Dementia may limit tolerance of external fixator or splint

›Analgesia considerations

›Reduced NSAID use in elderly due to renal and gastrointestinal risk

›Prefer acetaminophen as first-line

›Opioid risk in elderly

›Increased fall risk post-discharge

›Confusion and delirium risk

›Use lowest effective dose for shortest duration

›Functional goals

›Non-dominant hand injury may tolerate less aggressive reconstruction

›Quality of life and pain relief prioritized over anatomic perfection

›Hand therapy and occupational therapy critical for ADL recovery

Pediatrics

›Pediatric-specific considerations

›Physeal involvement

›The trapeziometacarpal joint in skeletally immature patients

›Physeal fractures at the base of the first metacarpal require careful evaluation

›Salter-Harris classification applies to physeal injuries

›Salter-Harris II fracture at the first metacarpal base

›Most common physeal fracture type at this location

›Generally managed with closed reduction if displaced

›Imaging in pediatric patients

›Plain radiographs with comparison views of the contralateral hand

›Growth plate identification requires comparison

›CT reserved for complex physeal fractures requiring surgical planning

›Analgesia in pediatric patients

›Ibuprofen 10 mg/kg PO every 6–8 hours (maximum 400–600 mg per dose)

›Effective for mild to moderate pain

›Acetaminophen 15 mg/kg PO every 4–6 hours (maximum 1000 mg per dose)

›Intranasal fentanyl 1.5 mcg/kg for severe acute pain in the ED

›Rapid onset without IV access requirement

›Hematoma block with reduced lidocaine volume

›3–5 mL of 1% lidocaine without epinephrine

›Management approach

›Closed reduction under procedural sedation for displaced fractures

›Ketamine 1.5 mg/kg IV with midazolam for procedural sedation

›Nitrous oxide alternative for cooperative children

›Percutaneous K-wire fixation for unstable reductions

›K-wires removed at 3–4 weeks given faster pediatric healing

›Thumb spica cast for 3–4 weeks post-reduction

›Shorter immobilization than adults due to faster remodelling

›Child protection considerations

›Mechanism inconsistent with injury raises safeguarding concern

›Detailed history from multiple sources

›Skeletal survey if non-accidental trauma suspected

10Background/b80

Epidemiology

›Incidence and demographics

›Rolando fracture is rarer than Bennett fracture

›Represents approximately 20% of all first metacarpal base fractures

›Bennett fracture accounts for the majority of CMC joint fractures

›Peak incidence in young males aged 10–29 years

›Sports and occupational injuries predominate in this group

›Males have 3:1 predominance over females

›Metacarpal fractures overall account for approximately 40% of all hand fractures

›First metacarpal fractures are among the most common

›Sports contribution

›Football, skiing, rugby, boxing, and cycling are leading sports mechanisms

›Ski pole impact is a classic mechanism during falls on snow

›Morbidity and prognosis

›Rolando fracture carries worse prognosis than Bennett fracture

›Greater articular surface disruption

›Inherent instability from comminution

›Post-traumatic arthritis of the trapeziometacarpal joint

›Most significant long-term complication

›Articular step-off > 1 mm increases arthritis risk significantly

›Chronic pain and functional limitation

›Grip strength and pinch strength commonly reduced at long-term follow-up

›Thumb opposition may be limited in severe cases

Pathophysiology

›Fracture mechanics

›Axial loading with the thumb in flexion

›Force transmitted along the first metacarpal axis into the articular surface

›Produces the characteristic T- or Y-shaped comminuted fracture pattern

›Comminution results from high-energy axial compression

›Articular cartilage and subchondral bone fragment into three or more pieces

›Dorsal and palmar fragments separated from the metacarpal shaft

›Deforming muscle forces

›Abductor pollicis longus

›Inserts at the base of the first metacarpal

›Pulls the metacarpal shaft proximally, radially, and dorsally

›Adductor pollicis

›Pulls the thumb into adduction

›Creates first web space narrowing

›Thenar musculature

›Flexor pollicis brevis and opponens pollicis

›Contribute to rotational deformity and further displacement

›Combined deforming forces make closed reduction inherently unstable

›Explains the need for operative fixation in most displaced fractures

›Joint anatomy and instability

›Trapeziometacarpal joint is a biconcave saddle joint

›Provides the thumb with its unique circumduction capability

›Anterior oblique ligament (volar beak ligament)

›Primary stabilizer of the CMC joint

›Attaches the volar-ulnar fragment to the trapezium

›This fragment remains reduced while the metacarpal shaft subluxes

›Dorsoradial ligament and posterior oblique ligament provide secondary stability

›Often disrupted in high-energy Rolando fractures

Therapeutic Considerations

›Principles of articular fracture management

›Anatomic reduction of the articular surface is the primary goal

›Step-off < 1 mm is the accepted threshold

›Better articular reduction correlates with lower post-traumatic arthritis rates

›Stable fixation allows early mobilization

›Critical for preventing joint stiffness

›Internal fixation preferred over cast immobilization when feasible

›Surgical strategy selection

›Fragment size determines fixation approach

›Large T- or Y-pattern fragments: ORIF with lag screws and buttress plate

›Small comminuted fragments: external fixation via ligamentotaxis

›Severely comminuted with multiple tiny fragments: external fixation alone

›Ligamentotaxis principle

›Joint distraction recruits soft tissue tension to reduce and hold fragments

›Does not require direct fixation of small fragments

›Mean fixator duration approximately 28 days

›Rehabilitation timeline

›Hand therapy initiated 2–6 weeks post-operatively

›Occupational therapy for opposition, grip, and pinch restoration

›Splinting between therapy sessions initially

›Return to sports or manual work

›Typically 3–6 months depending on fixation type and healing

›Grip strength recovery may take 6–12 months

›Long-term outcomes and salvage

›Post-traumatic CMC arthritis

›Leading long-term complication after Rolando fracture

›Trapeziometacarpal arthroplasty or arthrodesis as salvage options

›Osteoarthritis management

›Intra-articular corticosteroid injections for symptom control

›Splinting with a thumb CMC orthosis for activity modification

11Patient Discharge Instructions/pdi39

copy discharge instructions

›Rolando fracture home care

›Splint care and protection

›Keep the thumb spica splint clean and dry at all times

›Cover splint with a plastic bag when showering or washing

›Do not remove or modify the splint yourself

›Ice and elevation

›Ice pack wrapped in a cloth over the splint for 20 minutes every 2 hours for the first 48 hours

›Keep the hand elevated above heart level as much as possible

›Use a sling when walking to maintain elevation

›Activity restrictions

›No use of the injured hand for gripping, pinching, or lifting

›No sports, driving, or heavy work until cleared by hand surgeon

›School or desk work with the non-injured hand is permitted

›Medications at home

›Ibuprofen 400–600 mg every 6–8 hours with food as needed for pain

›Do not use if you have kidney problems, stomach ulcers, or if you are pregnant

›Acetaminophen 500–1000 mg every 4–6 hours as needed for pain

›Do not exceed 4000 mg per day total

›If prescribed opioid pain medication

›Take only as directed for severe pain

›Do not drive, operate machinery, or drink alcohol while taking opioids

›Do not share with others

›Warning signs to return to the emergency department

›Increased numbness or tingling in the thumb or fingers

›Thumb becomes cold, pale, blue, or capillary refill does not return after pressing

›Severe increase in pain inside or around the splint despite pain medication

›Swelling of the thumb or hand that is severe and not improving with elevation

12References/r21

Guidelines and key sources

›Primary references for Rolando fracture management

›Rolando S (1910). Fracture de la base du premier metacarpe. Presse Med 1910

›Original description of the comminuted intra-articular fracture pattern

›Jupiter JB, Axelrod TS, Belsky MR. Fractures and dislocations of the hand. In: Browner BD, ed. Skeletal Trauma. Philadelphia: WB Saunders; 2008

›American Society for Surgery of the Hand clinical practice guidelines

›Intra-articular fractures of the thumb metacarpal base

›Kjaer-Petersen K, Langhoff O, Andersen K. Bennett's fracture. J Hand Surg (Br). 1990;15:58–61

›Comparative outcomes for Bennett versus Rolando fracture patterns

›Langhoff O, Andersen K, Kjaer-Petersen K. Rolando's fracture. J Hand Surg (Br). 1991;16:454–459

›Largest series reporting on Rolando fracture outcomes including external fixation

›Evidence levels and surgical guidelines

›ACEP Clinical Policy on hand trauma

›Supports plain radiography as first-line imaging (Level B recommendation)

›Supports CT for surgical planning when operative fixation anticipated (Level C recommendation)

›Orthopaedic Trauma Association guidelines for intra-articular fracture reduction

›Articular step-off reduction to < 1 mm as quality standard

›ICD-10 coding reference

›S62.201A — fracture of base of thumb, unspecified side, initial encounter

›S62.201D — fracture of base of thumb, unspecified side, subsequent encounter

›S62.211 — Bennett fracture, right thumb (for differential coding comparison)

›SNOMED CT concept: comminuted intra-articular fracture of base of first metacarpal bone

Evidence & Review

Evidence & Review