Trapezium Fracture

Rare fracture - approximately ~1% of all carpal fractures
Often occurs from axial loading mechanism to the 1st metacarpal or wrist
Vast majority of these fractures can be immobilized in an thumb spica splint and discharged with orthopaedic follow up

Mechanism

Axial loading of the thumb
Axial loading of the wrist

Timing of injury
Other locations of pain/Associated injuries

Often accompanied by fracture at the base of the 1st metacarpal
May co-occur with scaphoid, captitate, and trapezoid fracture

Numbness/tingling
Hand dominance
Profession

Vitals

Swelling about the volar base of the thumb
Pain with palpation and axial loading of the first metacarpal
Poke holes or punctate wounds → open injuries

Dorsal wounds are commonly open fractures

Do not miss this; if seen, give IV cefazolin (2-3g) immediately

Motor Exam:

Median Nerve/ Anterior interosseous nerve (AIN)

Opposition of the thumb

Opponens innervated by the median nerve - helpful to assess if concern for acute carpal tunnel syndrome

Flexion of wrist, fingers, thumb
“A-OK sign” = AIN

Tests flexion of thumb IP joint (FPL) and flexion of index DIP joint (FDP)

Radial nerve/ Posterior interosseous nerve (PIN)

Extension of wrist, fingers, thumb

“Thumbs up” = PIN

Tests extension of thumb IP and MCP joints (EPL))
Palm on flat surface and lifting/extending thumb off the surface is also a good test for PIN (tests extension of thumb MCP joint (EPL))

Ulnar nerve

Finger abduction (spread fingers, “peace sign”), finger adduction, cross fingers (“promise”)

Sensory Exam:

Median, Radial, Ulnar nerve distributions

Radial: Dorsal first web space
Median: Volar distal index finger
Ulnar: Volar distal small finger
Distal sensation on ulnar and radial sides of the affected ray
Two point discrimination

Vascular exam:

Radial artery, Ulnar artery

If having difficulty with palpation radial artery, find a doppler
Pulse decreased - Obtain noninvasive vascular imaging and consult vascular surgery if abnormal

Capillary refill to digits

Will likely be pain limited
Extension of DIPJ, PIPJ, MCPJ, Wrist
Flexion of the DIPJ, PIPJ, MCPJ, Wrist

Pronated PA/Lateral/Oblique of involved wrist and hand

Injuries rarely happen in isolation, be aware of other potential carpal bone injury

CT scan

Helpful to delineate multiple carpal bone injuries
Helpful for comminuted, intraarticular fracture patterns

MRI - rarely needed in the ED

Can be useful if there is questions about wrist instability
Orthopaedics to order if need be

Medical Decision Making

Closed trapezium fracture :

*** is a *** y/o ***-hand dominant ***M/F with hx of *** who presents with an injury to the ***R/L hand which occurred while mechanism***, found to have a closed trapezium fracture. On exam, the patient is neurovascularly intact with well perfused digits. The injury was closed with no poke holes or punctate wounds. Radiographs reveal ***. The fracture was immobilized in a thumb spica splint. The patient will follow up in a hand clinic within one week.

Open trapezium fracture :

*** is a *** y/o ***-hand dominant ***M/F with hx of *** who presents with an injury to the ***R/L hand which occurred while mechanism***, found to have an open trapezium fracture. On exam, the patient is neurovascularly intact with well perfused digits. There was noted to be an open wound on the ***dorsal/volar aspect of the radial hand which probes to fracture. The patient was given an immediate dose of IV ancef (2/3g***). Radiographs reveal ***. Orthopaedics was consulted and the patient was made an NPO. The patient last ate ***. Orthopaedics to provide further recommendations.

Open fracture:

Consult hand surgery (plastics vs. orthopaedics) immediately
NPO, preop labs (type and screen, INR, aPTT, CBC, BMP)
Ensure IV cefazolin (2-3g) were given

Gustillo-Anderson chart for antibiotic type and dose

Depending on the size of the soft tissue defect may require gentamicin as well

All other trapezium fractures:

Consult orthopaedic surgery immediately
NPO, preop labs

All other isolated ulnar shaft fractures:

WB status: Non-weight-bearing injured hand; keep arm elevated
Diet: Regular
Analgesia: short course of narcotic pain medication, tylenol (scheduled)

Ex: 5mg oxycodone q4 - 15 pills

Immobilization

Thumb Spica

Maintain thumb in soda can holding position

Disposition: Home with follow up in orthopaedic surgery clinic in 1 week

Procedure Walkthroughs:

Position: thumb in abduction as if holding a can of soda
Apply soft padding liberally over the thumb, wrist, and distal forearm

Split the plaster/orthoglass longitudinal with its length on one side

After wetting, use the split end to cocoon the first ray with the hand in the position as if holding a can of soda
Make sure to keep plaster/Ortho-Glass off skin

Procedure Notes:

PROCEDURE NOTE Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone

PRE-PROCEDURE DIAGNOSIS: fracture of the ***R/L trapezium

POST-PROCEDURE DIAGNOSIS: Same (refer above)

PROCEDURALIST: ***

ANESTHESIA: None

NAME OF PROCEDURE: Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone

PROCEDURE IN DETAIL:
The risks and benefits of the procedure were discussed at length with the patient. Risks discussed included but were not limited to post-procedural pain, stiffness, numbness, and tingling. Following informed verbal consent after discussion of risks and benefits, the patient agreed to proceed with the procedure. A timeout was performed.

A well-padded thumb spica splint was applied to the injured hand. The patient's neurovascular status was consistent with baseline.

COMPLICATIONS: ***

DISPOSITION:Discharged home with follow up with orthopaedic surgery in 1 week for repeat evaluation

Common ICD-10 Codes	Brief Description
S62.17**	Fracture of trapezium [larger multangular]
S62.171*	Displaced, right
S62.172*	Displaced, left
S62.174*	Nondisplaced, right
S62.175*	Nondisplaced, left