Trapezium and trapezoid fractures

INTRODUCTION — This topic reviews the presentation, diagnosis, and management of fractures of the trapezium and trapezoid. These two carpal bones are rarely injured in isolation, and clinicians should check carefully for additional hand and wrist injuries.

General overviews of wrist pain and carpal fractures, as well as topics devoted to other specific carpal fractures, are presented separately. (See "Evaluation of the adult with acute wrist pain" and "Evaluation of the adult with subacute or chronic wrist pain" and "Overview of carpal fractures" and "Evaluation of wrist pain and injury in children and adolescents" and "Scaphoid fractures" and "Lunate fractures and perilunate injuries" and "Capitate fractures".)

EPIDEMIOLOGY — Hand fractures are among the most common of the extremity injuries, accounting for about 18 percent of all fractures. Carpal bones fractures comprise upwards of 8 percent of hand fractures [1]. Fractures to bones of the distal carpal row (trapezium, trapezoid, capitate, and hamate) are less frequent than fractures of bones in the proximal row (scaphoid, lunate, triquetrum, and pisiform).

The trapezium is rarely injured, representing about 4 percent of all carpal fractures [1-6]. The trapezoid is the carpal bone least often fractured, comprising approximately 2 percent of all carpal fractures [1,4-6].

When present, trapezium and trapezoid fractures often occur in association with other injuries:

●For trapezium fractures, associated injuries most commonly include fracture of the first (thumb) metacarpal followed by injuries to other carpal bones and the distal radius [7].

●For trapezoid fractures, the most common associated injuries include fracture of the hamate, capitate, trapezium, or adjacent metacarpals [8]. (See 'Differential diagnosis' below.)

CLINICAL ANATOMY — Wrist anatomy and biomechanics are discussed in greater detail separately; pertinent details of trapezium and trapezoid anatomy are reviewed below. (See "Anatomy and basic biomechanics of the wrist".)

●Trapezium – The trapezium is on the radial side of the distal carpal row and articulates distally with the thumb metacarpal and proximally with the scaphoid and trapezoid (image 1 and figure 1 and figure 2 and figure 3). The trapezium forms a double saddle articulation with the base of the thumb metacarpal, giving the thumb its unique multiplanar range of motion at this first carpometacarpal (CMC) joint. The trapezium has a slightly concave articulation with the scaphoid and a flat facet articulation with the trapezoid. A longitudinal ridge is present on the volar surface, which serves as the attachment site for the transverse carpal ligament (or flexor retinaculum). The trapezium forms part of the radial aspect of the carpal tunnel, along with the scaphoid.

The trapezium is palpable at the base of the thumb on the dorsal side, just proximal to the base of the first metacarpal (picture 1 and picture 2). Having the patient repeatedly abduct and adduct the thumb makes palpation of the first CMC joint and the trapezium easier. The two tendons of the first dorsal extensor compartment (abductor pollicis longus and extensor pollicis brevis) pass directly over the bone. Having the patient abduct and extend the thumb puts these tendons under tension and can help distinguish them from the underlying trapezium. The trapezium is also palpable on the palmar side at the base of the thenar eminence just distal to the scaphoid tubercle.

●Trapezoid – The location and shape of the trapezoid convey relative protection, hence the rarity of isolated injury. The trapezoid lies in the distal carpal row and articulates distally with the second metacarpal base, radially with the trapezium, ulnarly with the capitate, and proximally with the scaphoid (image 1 and figure 1 and figure 2). It is keystone shaped, with a dorsal width twice its palmar width. It forms a stable and relatively immobile articulation with the second metacarpal and has strong ligamentous attachments to adjacent carpal bones.

The trapezoid is palpable on the dorsal wrist at the base of the second metacarpal but difficult to distinguish from this metacarpal. It can be located by starting palpation at the distal aspect of the anatomical snuffbox, then moving in an ulnar direction approximately 1 to 2 cm (picture 3).

MECHANISM OF INJURY

Trapezium — The two major types of trapezium injuries are body fractures and volar ridge avulsion fractures. Body fractures are most common and typically occur from axial loading or hyperextension of an adducted thumb. Body fractures are typically vertical (oriented roughly with the long axis of the hand) or comminuted. These fractures are intra-articular at the first carpometacarpal (CMC) joint or other neighboring joint and may be associated with a fracture of the first metacarpal base, a common pattern called a Bennett fracture (figure 4). (See "First (thumb) metacarpal fractures".)

Ridge fractures are rare and represent an avulsion of the flexor retinaculum. They result from falling onto an outstretched hand or sustaining a direct blow. They are subdivided into avulsions of the proximal base (type 1) or of the distal tip (type II) [9,10].

Trapezoid — Fractures of the trapezoid generally occur with axial loading of the second metacarpal, high-energy trauma, crush injury, or forced wrist flexion or extension [8]. In sport, such forced wrist flexion or extension can occur when a player dives for a ball or opponent with an outstretched arm. Isolated fracture of the trapezoid is unusual [8,11]. More common is dorsal dislocation or concomitant carpal or metacarpal fractures. With axial loading, the wedge-like trapezoid, with its narrowest width at the volar aspect, slips in a dorsal direction. Axial compression also transmits forces to the adjacent scaphoid [12].

SYMPTOMS AND EXAMINATION FINDINGS

Trapezium fracture — The patient with a trapezium fracture typically presents with focal tenderness over the trapezium [13,14]. Tenderness over the dorsal aspect of the bone is more likely with injury to the body of the trapezium. The trapezium is palpable at the base of the thumb on the dorsal side, just proximal to the base of the first metacarpal (picture 1 and picture 2). Palpating the anatomic snuffbox yields tenderness of not only the trapezium, which forms the distal portion of the snuffbox, but also the adjacent scaphoid. Thus, snuffbox tenderness may indicate injury to the trapezium. Having the patient repeatedly abduct and adduct the thumb makes palpation of the first carpometacarpal (CMC) joint and the trapezium easier, although compliance with this maneuver may be limited by pain.

Ecchymosis may be present. Typically, there is pain and weakness with pinching (eg, when making an "OK" sign or touching the thumb to the tip of the fifth digit). Axial loading of the thumb may elicit pain. Pain with resisted wrist flexion from a dorsiflexed (ie, extended) start position and tenderness limited to the base of the thenar eminence may indicate a fracture of the ridge [9,15].

Trapezoid fracture — The patient with a trapezoid fracture typically presents with radial-dorsal wrist pain. Patients usually have some degree of swelling, and possibly ecchymosis, along the dorsum of the hand and point tenderness dorsally just proximal to the second metacarpal base (picture 3). Resisted wrist dorsiflexion (ie, extension) may cause pain as the extensor carpi radialis longus passes over the trapezoid and inserts on the proximal aspect of the second metacarpal.

Assessment of adjacent structures and neurovascular integrity — Examination of surrounding structures is important, as concomitant injury to other bones or to ligaments, tendons, vasculature, and nerves is relatively common with either fracture.

Radial artery integrity should be evaluated with palpation of the pulse at the wrist, assessment of color and capillary refill in the fingers, and the Allen test (picture 4). Median nerve assessment should include sensation testing of the thumb, index and middle fingers, and radial aspect of the ring fingers and strength testing of thumb flexion at the interphalangeal joint, abduction, and opposition. Superficial radial nerve assessment should include testing of the sensation along the radial dorsum of the hand.

DIAGNOSTIC IMAGING

Plain radiographs — Standard wrist radiographs (anteroposterior [AP], lateral, and oblique views) of the wrist should be obtained if a trapezium or trapezoid fracture is suspected. Body fractures and dislocations may be seen on these views (image 2 and image 3 and image 4 and image 5 and image 6). The AP or oblique views may detect sagittal trapezoid fractures but should not be relied on. Overlapping shadows from other carpal bones can make detection difficult, and either fracture may be missed (image 7). Overall, given the limitations of plain radiographs, if these studies are unrevealing but clinical suspicion persists, a computed tomography (CT) or magnetic resonance imaging (MRI) study should be obtained. (See 'Advanced imaging' below.)

The Bett view (AP with approximately 20 degrees of pronation) outlines the trapezium and the first metacarpal base without other structures superimposed (image 8). A ridge fracture is difficult to identify without using a carpal tunnel view (image 9) or CT (image 10). The peritrapezial view shows the joints around the trapezium, but further study is needed to determine its accuracy and utility [16].

The sensitivity and specificity of conventional plain radiographs for trapezium or trapezoid fractures are poor. One case series of 137 carpal fractures that used CT as the gold standard reported a sensitivity of 18 percent for detecting trapezium fractures with plain radiographs, while none of four trapezoid fractures were identified [5]. A similar study of 38 carpal fractures reported a sensitivity of 67 percent [4], while small retrospective case series have reported 33 [11] to 64 percent [8].

Advanced imaging — CT is highly accurate for identifying fracture or dislocation and for assessing joint surfaces when there is a question of intra-articular displacement. MRI has additional value in detecting both acute and chronic bony and soft tissue injuries [17]. If significant soft tissue injury (eg, ligament rupture or dislocation) is suspected, MRI should be obtained (image 11A-C and image 12).

Cone beam CT (CBCT) provides higher-resolution images, involves 90 percent less radiation exposure, and can be performed more quickly than conventional CT. In prospective observational case series, CBCT has demonstrated greater sensitivity than plain radiographs in detecting radiocarpal fractures. In patients with clinically suspected wrist fracture but negative plain radiographs (ie, occult fracture), CBCT detected radial or carpal fractures in 50 to 75 percent [18-21]. In two of these studies, trapezium fractures represented about 20 percent of the occult fractures, a slightly higher incidence than even scaphoid fracture [18,22]. These findings emphasize the importance of keeping a high index of suspicion for trapezium fracture in the presence of anatomic snuffbox tenderness despite negative radiographs. CBCT may be a useful tool in this setting.

DIAGNOSIS — The diagnosis of trapezium or trapezoid fracture may be made by plain radiograph in conjunction with a suggestive history and examination findings. However, as plain radiographs demonstrate poor sensitivity for both fractures, conventional computed tomography (CT), cone beam CT (CBCT), or magnetic resonance imaging (MRI) may be needed when fracture is suspected but initial radiographs are normal and a definitive diagnosis is required. Advanced imaging is useful for detecting the concomitant injuries that are frequently present.

DIFFERENTIAL DIAGNOSIS — Diagnoses that may coincide with or be confused with a trapezium or trapezoid fracture include those described below. The differential diagnosis for acute wrist pain is discussed in detail separately. (See "Evaluation of the patient with thumb pain" and "Evaluation of the adult with acute wrist pain" and "Lunate fractures and perilunate injuries".)

Fractures of the trapezium or trapezoid frequently occur along with other injuries of the wrist or hand. As an example, a large retrospective series reported that 95 percent of trapezoid fractures were associated with concurrent wrist injuries [11].

Fracture of scaphoid or other carpal bones — Radial-sided wrist pain following trauma may be due to fracture of the distal radius, scaphoid (the most commonly fractured carpal bone), capitate, lunate, or any combination of these bones. Tenderness may be diffuse at the radial aspect of the wrist. Snuffbox tenderness (figure 5 and picture 5) is suggestive but not diagnostic of scaphoid fracture; note that the trapezium also lies at the distal end of the snuffbox. Diagnostic imaging to identify such fractures should include standard wrist and scaphoid views (image 13), but advanced imaging may be required if a definitive diagnosis is needed. (See "Overview of carpal fractures" and "Scaphoid fractures" and "Capitate fractures".)

Distal radius fracture — Distal radius fractures are the most common fracture of the wrist and hand. They are typically caused by a fall onto an outstretched hand. Tenderness at the distal radius is often accompanied by some degree of deformity and ecchymosis. Diagnosis is generally made by plain radiograph (image 14). Approximately 7 percent of distal radial fractures involve a concomitant carpal fracture, so a careful search for such injuries should be performed [23]. (See "Distal radius fractures in adults".)

Metacarpal fractures and fracture-dislocations — Trapezium fractures may be associated with first metacarpal fractures. Pain, dorsal swelling over the base of the first metacarpal, and difficulty with motion at the first carpometacarpal (CMC) joint suggest possible fracture of the first metacarpal. These injuries are often intra-articular, with Bennett fracture (includes dislocation (figure 4)) and Rolando fracture (comminuted but without dislocation (image 15)) being common patterns.

Fracture or dislocation of the trapezoid may be associated with fracture of the second metacarpal. Pain and dorsal swelling over the base of the second metacarpal along its dorsal aspect suggest the presence of a fracture.

Standard views of the thumb (anteroposterior [AP], lateral, and oblique), with possible addition of a Bett view, are generally sufficient to diagnose these injuries, but computed tomography (CT) can be useful to determine the extent of injury and position of fragments. (See "Evaluation of the patient with thumb pain" and "First (thumb) metacarpal fractures" and "Overview of metacarpal fractures".)

Less common injuries

●First CMC dislocation – Dislocation of the first CMC joint rarely occurs in isolation. Crush injury is the most common cause. Typical findings include swelling and pain at the base of the thenar eminence and possibly gross deformity. Joint instability may be detectable. Plain radiographs are sufficient for diagnosis. A careful search for concomitant fractures should be performed, as such injuries are common.

●First CMC osteoarthritis – Degenerative arthritis at the base of the thumb (first CMC joint) is a chronic condition with insidious onset, but flares can cause acute exacerbation of pain and may be associated with minor thumb trauma. Tenderness is localized to the first CMC joint, and small bony osteophytes may be palpable at the joint line. Pain can be reproduced with axial loading or circular motion of the first metacarpal. Diagnosis is confirmed with plain radiographs (image 16). (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Carpal metacarpal osteoarthritis'.)

●de Quervain (radial styloid) tendinopathy – Overuse of the abductor pollicis longus and extensor pollicis brevis tendons within the first extensor compartment of the hand can cause de Quervain tendinopathy or tenosynovitis. Pain may acutely flare up following heavy use of the affected hand. Typically, tenderness is present over the radial styloid, and the Finkelstein test is positive (pain with thumb clenched and ulnar deviation of wrist (picture 6)). Radiographs are normal, but ultrasound may show thickening of the tendon sheath and/or tendons. (See "de Quervain tendinopathy".)

●Dislocation of the trapezoid – Isolated trapezoid dislocation is rare. Due to the wedge shape of the trapezoid and its wider dorsal dimension, when it occurs, dislocation is usually dorsal. Dislocation causes swelling and possibly gross deformity at the dorsal wrist and pain at the base of the second metacarpal. Plain radiographs detect some dislocations, but CT may be required. A careful search for concomitant fracture should be performed, as such injury is likely. In addition, a careful neurovascular examination should be performed. Any diminished or absent radial pulse or signs of impaired circulation to the hand should prompt immediate surgical referral for reduction [12].

INDICATIONS FOR SURGICAL REFERRAL — Open fractures and those associated with neurovascular compromise require emergency (ie, immediate) surgical consultation. Additional indications for each fracture are reviewed below. In summary, indications include:

●Comminution

●Significant displacement

●Associated dislocation

Most trapezium and trapezoid fractures are associated with other wrist injuries. If such injuries are identified, the clinician must consider whether other, related indications for referral are present. The presence of multiple injuries lowers the threshold for referral substantially.

●Trapezium fracture – All trapezium body fractures displaced more than 2 mm, distal ridge fractures (type II), and any fracture associated with injury to contiguous bones or with carpometacarpal (CMC) subluxation should be referred to a hand surgeon [7,9,10,24]. Nearly all body fractures are intraarticular, and therefore, the clinician should carefully assess the joint spaces adjacent to the trapezium in all imaging studies.

Displaced fractures and all comminuted fractures should be referred. Type II (distal) trapezium ridge fractures are associated with a higher risk of symptomatic nonunion, hence the recommendation by some authors for surgical management [9,25,26].

●Trapezoid fracture – Any trapezoid fracture associated with comminution, displacement, or dislocation should be referred to a hand surgeon [9,26,27]. What constitutes significant displacement remains unclear. While one case report describes a fracture with up to 2 mm displacement that was successfully treated nonoperatively [28], another describes a coronal fracture with 1 mm displacement that failed conservative treatment [11]. We suggest referral to a hand surgeon for any degree of fracture displacement.

Dislocations increase the risk of neurovascular injury and long-term complications, and fractures associated with a dislocation should be urgently referred. Even if the hand surgeon cannot see the patient immediately, the case should be discussed with the consulting surgeon by phone as soon as the dislocation is recognized. Primary care clinicians skilled in reducing dislocations may attempt reduction of a dorsally dislocated trapezoid prior to referral. (See 'Initial treatment' below.)

INITIAL TREATMENT — Standard acute fracture care, including analgesia, is provided to all patients and discussed separately. (See "General principles of acute fracture management".)

Primary care clinicians with experience managing fractures may elect to manage the patient with any of the following injury types:

●Isolated, uncomplicated, nondisplaced trapezium body fracture

●Isolated, nondisplaced trapezium ridge base (type I) fracture

●Isolated, noncomminuted, nondisplaced trapezoid fracture

Treatment of trapezium and trapezoid fractures is based on expert opinion, as studies of these fractures are scant and largely limited to case reports and small case series. Initial treatment is as follows:

●Trapezium fracture – Nonoperative treatment consists of immobilization for four to six weeks [9,10,26,29]. Given that swelling is usually minimal, a short arm thumb spica cast can typically be applied at initial presentation. If marked swelling is present, a thumb spica splint can be applied for three to five days (figure 6) while ice and elevation are used to reduce swelling. (See "Basic techniques for splinting of musculoskeletal injuries".)

●Trapezoid fracture – Isolated, nondisplaced sagittal or coronal linear fractures can be treated conservatively with immobilization in a short arm cast (picture 7), once initial swelling has subsided, for four to six weeks [9,26,30-32]. If marked swelling is present initially, a volar splint can be applied for three to five days (figure 7) while ice and elevation are used to reduce such swelling. (See "Basic techniques for splinting of musculoskeletal injuries" and "General principles of definitive fracture management", section on 'Casting'.)

Clinicians skilled in reducing dislocations may attempt reduction of a dorsally dislocated trapezoid (an uncommon injury) prior to surgical referral. Reduction can be performed by applying gentle traction to the second metacarpal, followed by simultaneously flexing the wrist and placing direct pressure on the dorsal side of the trapezoid [27]. Following reduction, a volar splint should be applied. If the reduction cannot be maintained, the patient is referred.

FOLLOW-UP CARE — The patient should be assessed for cast integrity after approximately three weeks or as needed for symptoms of poor cast fit. Biweekly cast checks may be prudent in active patients. When the cast is removed, healing should be confirmed clinically by the absence of point tenderness. A careful neurovascular examination should be performed at each visit.

Plain radiographs should be repeated after cast removal following four to six weeks of immobilization. Displacement can occur following the initial visit, so careful reassessment is important. If pain persists with an avulsion or ridge fracture after appropriate treatment, refer the patient to a hand surgeon for possible excision.

Given that the trapezium has three joint faces with articular surfaces, fractures may lead to late arthrosis that may require surgical intervention. Arthritic changes may not become evident on plain radiographs for several years. Arthritic changes appear to develop more frequently after comminuted fractures, while collapse of the bone is more frequent after horizontal fractures or injuries with three or more parts [33,34].

For patients who sustained a fracture-dislocation of the trapezoid, it is important to assess for signs of osteonecrosis from disruption of the blood supply. Signs may consist of persistent pain and changes in the appearance of the bone on plain radiograph, which may not be apparent for several weeks to a few months after the injury. Such findings warrant referral to a hand surgeon. (See 'Indications for surgical referral' above.)

After four to six weeks of casting, the wrist will have lost strength and mobility. Depending on the clinical circumstances, formal physical therapy or a home exercise program can be used to help the patient regain full function. The patient can stop the program once full mobility and strength are regained.

A basic home exercise program might consist of the following:

●Perform passive stretches twice daily, holding each stretch for 30 seconds. Stretch the wrist in flexion, extension, ulnar deviation, and radial deviation. The hand and wrist can be soaked in very warm water for five minutes prior to stretching to facilitate motion.

●Perform motion and strength exercises after stretching. Exercises should include active wrist circles 10 times in each direction followed by two sets of 15 repetitions using appropriate resistance (eg, elastic band, dumbbell) for each of the following: wrist flexion, wrist extension, ulnar deviation, and radial deviation.

The patient's pain, motion, and function should be assessed about two weeks after cast removal. Those who are having persistent, significant pain and/or functional impairment may benefit from a referral to physical therapy.

COMPLICATIONS

●Trapezium fracture – Nonunion of distal trapezium ridge (type II) fractures can lead to chronic wrist tenderness and sometimes median nerve irritation, as the fracture fragment is attached to the flexor retinaculum (roof of the carpal tunnel). There are rare reports of radial artery damage in association with trapezium fractures [35].

Other potential complications may include first carpometacarpal (CMC) joint stiffness and arthritis, carpal tunnel syndrome, flexor carpi radialis tendinopathy (possibly including late tendon rupture), and loss of pinch strength and function associated with pain [9,26].

●Trapezoid fracture – Delayed union, nonunion, and post-traumatic arthritis are possible complications of trapezoid fracture, especially if diagnosis is delayed. Dorsal dislocations may disrupt the dorsal blood supply to the trapezoid, possibly resulting in osteonecrosis [9,26,27]. As trapezoid fractures are uncommon, data pertaining to their complications are limited, but they appear to be uncommon.

RECOMMENDATIONS FOR RETURN TO SPORT OR WORK — If the patient can perform their work or sport while wearing rigid cast protection, they may proceed with their activities as tolerated during immobilization. Semirigid protection in a brace should be continued for four weeks after rigid immobilization is completed. Unprotected return to full sport or heavy physical labor requires full thumb and wrist range of motion and at least 80 percent strength compared with the uninjured extremity in all planes of motion at these joints. If operative treatment is required, sport and work may resume at approximately 12 weeks postoperatively.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of definitive fracture management".)

●(See "General principles of acute fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fractures of the skull, face, and upper extremity in adults" and "Society guideline links: Acute pain management".)

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Isolated fractures of the trapezium or trapezoid are uncommon. When present, fractures of either bone are usually associated with other injuries to the thumb, wrist, or hand. (See 'Epidemiology' above and 'Clinical anatomy' above.)

●Fracture types and mechanisms – Fracture of the trapezium most often involves the body or avulsion of the volar ridge. Extension of the wrist rotates the radius and scaphoid, making the trapezium more prone to injury. Distal radius and scaphoid fractures, and proximal first metacarpal fracture dislocations, can be associated with trapezium fractures. Fractures of the trapezoid generally occur with axial loading of the second metacarpal, high-energy trauma, crush injury, or forced wrist flexion or extension. In sport, such forced wrist flexion or extension can occur when a player dives for a ball or opponent with an outstretched arm. (See 'Mechanism of injury' above and 'Differential diagnosis' above.)

●Trapezium fracture presentation and examination – Trapezium fracture typically presents with minimal swelling, but there may be ecchymosis and significant discomfort. Often, there is pain and weakness with pinching (eg, making an "OK" sign or touching the thumb to the tip of the fifth digit). Focal tenderness over the dorsal aspect of the bone is more likely with injury to the body (picture 1 and picture 2). Snuffbox tenderness may be present (picture 8 and picture 5). Examination of surrounding structures (eg, distal radius, scaphoid, first metacarpal, median nerve) is important, as concomitant injury is common. (See 'Symptoms and examination findings' above and 'Assessment of adjacent structures and neurovascular integrity' above.)

●Trapezoid fracture presentation and examination – Trapezoid fracture typically presents with radial-dorsal wrist pain following trauma. Patients usually have some degree of swelling, and possibly ecchymosis, along the dorsum of the hand and point tenderness dorsally just proximal to the second metacarpal base (picture 3). Resisted wrist extension may cause pain, as the extensor carpi radialis passes over the trapezoid. (See 'Symptoms and examination findings' above.)

●Diagnostic imaging – Trapezium and trapezoid fractures can be difficult to visualize with standard radiographic views, in part due to overlapping shadows from other carpal bones. A true anteroposterior (AP) or Bett view and a carpal tunnel view provide better visualization in some instances, but a computed tomography (CT) or magnetic resonance (MRI) scan may be necessary to make the diagnosis. (See 'Diagnostic imaging' above and 'Diagnosis' above.)

●Differential diagnosis – Relatively common injuries that present in a similar fashion include fractures of the scaphoid or other carpal bones, distal radius fracture, and metacarpal fractures and fracture-dislocations. (See 'Differential diagnosis' above.)

●Indications for surgical referral

•Emergency referral to a specialist should be obtained for any open fracture or fracture associated with a neurologic or vascular deficit. Associated injuries (eg, scaphoid or displaced distal radius fracture) may warrant referral. (See "Scaphoid fractures" and "Distal radius fractures in adults" and "First (thumb) metacarpal fractures".)

•All trapezium body fractures displaced more than 2 mm, distal ridge fractures (type II), comminuted fractures, and any fracture associated with injury to contiguous bones or carpometacarpal (CMC) subluxation should be referred to a hand surgeon. (See 'Indications for surgical referral' above.)

•Any trapezoid fracture associated with comminution, any degree of displacement, or dislocation should be referred to a hand surgeon. (See 'Indications for surgical referral' above.)

●Management of nondisplaced, uncomplicated fractures

•Isolated, uncomplicated, nondisplaced trapezium body fractures and isolated, nondisplaced trapezium ridge base (type I) fractures can be treated effectively with four to six weeks of immobilization, typically in a short arm thumb spica cast. (See 'Initial treatment' above.)

•Isolated, nondisplaced sagittal or coronal linear fractures of the trapezoid can be treated conservatively with immobilization in a short arm cast (picture 7), once initial swelling has subsided, for four to six weeks. If marked swelling is present initially, a volar splint can be applied for three to five days (figure 7). (See 'Indications for surgical referral' above.)

•Regular follow-up is needed to ensure proper cast fit and to check fracture alignment. Details of management are provided in the text. (See 'Initial treatment' above and 'Follow-up care' above.)

●Follow-up care and complications – Return to sport or heavy physical labor requires full thumb and wrist range of motion and at least 80 percent strength compared with the uninjured extremity in all planes of motion at these joints. Involvement of one of the three articular surfaces of the trapezium in the fracture may lead to late arthrosis that requires surgical intervention. Other possible long-term complications include carpal tunnel syndrome, arthritis, flexor carpi radialis tendinopathy, loss of pinch strength, and nonunion. (See 'Follow-up care' above and 'Complications' above and 'Recommendations for return to sport or work' above.)