Two-stage management of traumatic comminuted trapezium fracture with severe bone defect: a case report and literature review

Abstract

Background

Trapezium fractures are rare carpal injuries, and comminuted intra-articular patterns with severe bone loss are exceptionally uncommon and challenging, with no established consensus; patient-specific 3D printing may offer a reconstructive option.

Case presentation

We report a 51-year-old man who sustained a transfixing nail-gun injury, resulting in severe right wrist pain and limited thumb motion. Imaging showed a comminuted trapezium fracture with severe bone loss. The patient underwent stage I debridement, antibiotic-loaded bone cement spacer placement, and external fixation, followed by stage II implantation of a custom 3D-printed trapezium prosthesis. At the 9-month follow-up, he had satisfactory thumb and wrist motion and had resumed activities of daily living.

Discussion and conclusion

This case describes a staged reconstructive strategy for traumatic comminuted trapezium fracture with severe bone loss. This approach may be considered in carefully selected severe trapezial bone defect cases when conventional fixation or bone grafting is unlikely to restore joint congruity and thumb motion. Long-term follow-up is required to evaluate implant survival and late complications.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12891-026-10456-1.

Introduction

The trapezium is an important bony support for thumb motion. It is located on the radial side of the distal carpal row and articulates distally with the first metacarpal, proximally with the scaphoid, and medially with the trapezoid and the base of the second metacarpal [1]. Trapezium fractures are rare carpal injuries, accounting for approximately 4% of all carpal fractures [2].

The main fracture patterns include trapezial body fractures and trapezial ridge fractures. Trapezial body fractures may present as vertical split fractures or comminuted fractures, whereas comminuted trapezium fractures are particularly uncommon and have been sparsely reported in the literature [3]. These injuries are usually caused by high energy trauma and often involve the trapezial articular surface, resulting in thumb pain, restricted motion, and impaired activities of daily living. Early diagnosis and timely treatment are therefore essential. Delayed or inadequate treatment may predispose patients to thumb carpometacarpal joint degeneration or post traumatic osteoarthritis, leading to further functional limitation [4].

Three-dimensional (3D) printing has been increasingly used in orthopedic surgery for preoperative planning, intraoperative template creation, and patient-specific implant design [5]. It allows the fabrication of size-matched implants and may improve the accuracy and efficiency of complex reconstruction. In carpal surgery, 3D printing has been applied to chronic wrist bone-defect conditions, including scaphoid nonunion, distal radius reconstruction after tumor resection, and complex post-traumatic bone loss [6, 7].

The clinical presentation of trapezium fractures often mimics that of scaphoid fractures, including anatomical snuffbox pain, local swelling, hyperemia, and ecchymosis. Therefore, CT should be considered when radiographs are inconclusive. MRI may be useful when occult fracture, bone contusion, or associated ligament injury is suspected [3, 8].

Because of the rarity of this injury, no consensus has been established regarding optimal management. Here, we report a case of traumatic comminuted trapezium fracture with severe bone loss treated using a staged strategy and patient-specific 3D-printed prosthetic reconstruction, aiming to provide a reference for similar severe cases.

Case presentation

A 51-year-old man presented after a nail-gun injury to the right wrist. Physical examination revealed an open wound (~ 3 cm) over the dorsoradial wrist with local swelling and bleeding; the wound communicated with a palmar thenar laceration along the ulnar border. He reported severe wrist pain, active bleeding, and limited thumb motion. He had no relevant medical history. CT of the right wrist demonstrated a comminuted trapezium fracture(Fig. 1). Based on the clinical and imaging findings, the preliminary diagnosis was: (1) comminuted right trapezium fracture; (2) trapezoid fracture; and (3) fractures of the bases of the first and second metacarpals.

Fig. 1.

CT of the right wrist on the day of presentation. A Lateral radiograph of the right wrist; B Posteroanterior radiograph of the right wrist

On the day of injury, the patient underwent surgical debridement and wrist external fixation under brachial plexus block. Free bony and cartilaginous fragments were removed, foreign material and contamination were cleared, and devitalized tissue was excised. The injured radial artery was ligated. After thorough irrigation, the distal articular fragments of the trapezium were provisionally reassembled and reduced, then stabilized with two 1.2-mm percutaneous Kirschner wires. The wire ends were bent, cut, and left outside the skin. The osseous cavity caused by trapezial bone loss was filled with antibiotic-loaded bone cement containing vancomycin and gentamicin to control infection, obliterate dead space, and provide temporary structural support. The palmar wound was closed, a rubber drain was placed, and the skin was closed in layers.

External fixator pins were inserted percutaneously through small incisions into the distal first metacarpal and the mid-diaphysis of the radius. Two clamps and connecting rods were then mounted. The wrist was maintained in extension, and the first metacarpal was maintained in abduction before the construct was tightened. Intraoperative fluoroscopy confirmed satisfactory pin placement and fixation. This staged management helped reduce infection risk, preserve the defect space, and provide immediate structural support for subsequent reconstruction. Postoperative imaging confirmed satisfactory positioning of the bone cement spacer (Fig. 2). The early postoperative course was uneventful, with good wound healing, no signs of infection or osteomyelitis, and no adverse reaction to the cement. However, thumb motion remained limited, requiring continued follow-up and consideration of definitive reconstruction.

Fig. 2.

Stage I: (A) preoperative clinical appearance; (B) intraoperative view showing a clearly defined fracture; (C) postoperative imaging. Stage II: (D) preoperative imaging; (E–F) postoperative imaging; (G–H) imaging at 3 months postoperatively

After 2 months of rehabilitation, the patient underwent the second-stage procedure. Bilateral trapezium CT scans were obtained, and the DICOM data were used to design a patient-specific 3D-printed trapezium prosthesis. The prosthesis was designed to be 5% smaller than the contralateral trapezium (Fig. 3). To improve durability and biocompatibility, the prosthesis was coated with niobium titanium nitride (NbTiN) for long-term use under high mechanical load. The implant was anatomically matched to the defect, and a dedicated screw-hole design allowed rigid fixation to the adjacent trapezoid to provide stable anchorage. In addition, the microporous architecture allowed fixation of the surrounding ligamentous tissues, thereby improving local carpal stability.

Fig. 3.

3D-printed trapezium prosthesis

During the second stage procedure, a radial longitudinal incision was made at the wrist. After incision of the skin and fascia, the soft tissues were carefully separated to expose the antibiotic loaded bone cement spacer in the trapezial region. The surrounding tissues were released, and the cement spacer was removed. Residual bone fragments and remaining bone cement were debrided, followed by repeated wound irrigation. The 3D printed trapezium prosthesis was then implanted into the defect for trapezium replacement. Under repeated intraoperative fluoroscopic guidance, the position of the prosthesis was adjusted until satisfactory alignment was achieved. The prosthesis was then fixed to the trapezoid with one screw. The surrounding capsuloligamentous tissues were sutured through the reserved holes of the prosthesis. Final intraoperative fluoroscopy confirmed satisfactory replacement and fixation of the trapezium prosthesis. The wound was irrigated again, closed layer by layer, dressed, and immobilized with a plaster splint. Postoperative imaging confirmed correct placement of the prosthesis within the defect (Fig. 2).

At the 3-month follow-up, the implant was accurately positioned (Fig. 2) and remained well fixed, with near-complete restoration of a painless range of motion of the thumb and wrist. At 6 months, the patient achieved a full painless range of motion and was able to perform all activities of daily living without difficulty. Thumb CMC abduction exceeded 40°, maximal thumb MCP flexion was approximately 60°, and IP flexion was approximately 80°. The VAS pain score was 0. The ARAT score (maximum 57) improved from 22 preoperatively to 57 postoperatively, and the Kapandji opposition score (maximum 10) increased from 6 to 10. At the 9-month postoperative follow-up (Fig. 4), bilateral grip strength and key pinch strength were measured. Grip strength was 25.6 kg in the injured right hand and 28.4 kg in the contralateral left hand, corresponding to 90.1% of the unaffected side. Key pinch strength was 7.3 kg in the injured right hand and 8.1 kg in the contralateral left hand, also corresponding to 90.1% of the unaffected side. In addition, ROM images and videos obtained during follow-up were added to the supplementary materials.Follow-up imaging demonstrated satisfactory implant position with no evidence of displacement or loosening.

Fig. 4.

A–B CT examination after the initial treatment; (C–F) imaging examination at 9 months postoperatively

Discussion

The complex anatomy of the trapezium and its location on the radial side of the distal carpal row underpin its critical role in thumb and overall hand function. In particular, its distal articulation with the base of the first metacarpal forms a biconcave–convex (saddle) configuration, enabling multiplanar motion at the first carpometacarpal (CMC) joint. In addition, the volar surface bears a longitudinal ridge that serves as the radial attachment of the transverse carpal ligament (flexor retinaculum) [9].This case is clinically relevant because open comminuted trapezium fractures with severe bone loss are exceedingly rare. Management is challenging and requires meticulous, staged reconstruction to restore carpal integrity and functional stability of the wrist and thumb [10, 11].

Trapezial body fractures and trapezial ridge fractures are the two principal categories of trapezium fractures. Body fractures are often associated with radial deviation and varying degrees of thumb abduction, and include horizontal fractures, intra-articular vertical fractures, dorsoradial tubercle fractures, and comminuted patterns. In contrast, ridge fractures typically result from wrist hyperextension or a direct volar impact to the trapezium [12]. Palmer et al. classified ridge fractures into type I base fractures and type II smaller avulsion fractures [10].Another commonly used system is the Walker classification, which is based on the fracture line orientation and articular involvement: type I, horizontal fracture; type IIa, radial tubercle fracture with CMC joint involvement; type IIb, radial tubercle fracture extending into the scaphotrapezial (ST) joint; type III, ulnar tubercle fracture; type IV, vertical fracture; and type V, comminuted fracture [13].Given the rarity of trapezium fractures, no specific treatment consensus has been established. Most authors agree that nondisplaced or minimally displaced (< 2 mm) fractures can usually be managed nonoperatively. In more displaced fractures, associated tears of the surrounding ligaments and dorsal capsule are common and may lead to joint instability. Even after reduction and fixation, concomitant soft-tissue repair may be required, and reconstruction of the volar ligaments and capsular structures should be considered when indicated [14–16].Because intra-articular fractures generally require anatomic restoration of the joint surface, most authors recommend operative management [17].Operative management primarily aims at anatomic reduction and stable fixation, using techniques such as Kirschner-wire (K-wire) fixation, transmetacarpal cross-pinning between the first and second metacarpals, headless compression screw fixation, or plate fixation [16, 18, 19].For large defects or substantial bone loss, bone grafting can be added to fixation to reconstruct the osseous defect [20–22].Reported techniques have yielded favorable outcomes in the available literature, and the optimal approach largely depends on the fracture pattern. With recent technological advances, synthetic implants have also been explored for the management of these injuries [23].

Erdoğan and Karaduman [16]reported a motorcycle-related Walker type V comminuted trapezium fracture with concomitant base fractures of the first and second metacarpals and articular surface depression. The injury was managed with traction-assisted closed reduction and percutaneous fixation, followed by short-term cast immobilization. At 1-year follow-up, imaging demonstrated osseous union with normal range of motion; however, grip and pinch strength remained inferior to the contralateral side.

Shen et al. [20]reported a high-energy injury resulting in severe comminution of the trapezium with substantial bone loss. A staged approach was adopted: stage I debridement with a temporary bone-cement spacer for support, followed by stage II reconstruction using a patient-specific prosthesis. At 24-month follow-up, the patient was pain-free with satisfactory functional recovery, and imaging confirmed a stable implant without loosening or displacement.

Eiras et al. [9]reported a motorcycle-related, highly comminuted trapezium fracture with substantial bone loss, involving both the scaphotrapezial (ST) and trapeziometacarpal (TMC) articular surfaces. Within 1 week of injury, the patient underwent open reduction and internal fixation (ORIF) with elevation of the depressed articular surface, followed by ~ 6 weeks of immobilization. At 6 weeks, 3 months, and 12 months, follow-up demonstrated fracture union with restored alignment and near-complete functional recovery, with only mild residual TMC subluxation and slight discomfort during strenuous activity.

Ohno et al. [24]reported two cases of isolated intra-articular comminuted/depressed trapezium fractures in athletes. Both were treated with arthroscopy-assisted reduction and fixation, followed by brief immobilization and early rehabilitation. The athletes returned to preinjury competitive level at approximately 2 months.

Eda et al. [4]reported a motor vehicle–related comminuted trapezium fracture with articular surface depression, accompanied by other carpal fractures. The patient underwent open reduction and internal fixation (ORIF) with filling of the subchondral bone defect, supplemented by temporary intermetacarpal fixation to prevent secondary collapse. At 6-month follow-up, osseous union was achieved with overall functional recovery.

Spielman and Sankaranarayanan [25]reported a patient who developed pain and swelling at the thumb base after a fall; CT confirmed a comminuted trapezium fracture with first CMC subluxation. The patient underwent open reduction and internal fixation (ORIF), followed by brief immobilization and early rehabilitation. At 3-month follow-up, imaging showed fracture union, with full restoration of thumb range of motion and return to sports.

Kohyama et al. [22]reported three cases of trapezium fractures associated with thumb CMC dislocation, including comminuted/depressed (Walker type V) patterns. All patients underwent reduction and fixation; cases with collapse and/or bone loss additionally received defect filling and temporary intermetacarpal fixation. At 6 months to 2 years, all achieved fracture union with well-aligned, painless CMC joints and no clinically significant instability.

Alonso and Couceiro [21]reported a fall-related comminuted trapezial body fracture with concomitant thumb CMC dislocation. The injury was treated emergently with closed reduction and percutaneous fixation, followed by short-term external fixation. At 6-month follow-up, pain had resolved and thumb function recovered satisfactorily.

Gvozdenovic and Soelberg Vadstrup [26]reported a motorcycle-related injury with multiple carpometacarpal (CMC) joint dislocations, accompanied by a comminuted trapezium fracture and adjacent carpal injuries. Because the trapezium was severely comminuted and could not be reliably stabilized, surgery focused on restoring alignment and stability of the involved joints with fixation. At 4 months, the patient had resumed activities of daily living and returned to work; at 1 year, overall hand function was good, although grip and pinch strength remained inferior to the contralateral side.

Matzon et al. [27]reported two high-energy injuries causing severely comminuted trapezium fractures with articular depression and radiographic evidence of bone loss. Both patients underwent open reduction and internal fixation (ORIF) with autologous cancellous bone grafting to fill the defect, followed by brief immobilization and progressive rehabilitation. Radiographic union was achieved at approximately 8–10 weeks, with good functional recovery; some patients were pain-free and returned to work by around 4 months.

Shenouda et al. [28]reported a high-energy injury resulting in a severely comminuted trapezium fracture that was not amenable to conventional internal fixation. In addition to treating the associated fractures, thumb–metacarpal suspension/stabilization was used to maintain first-ray length and effectively unload the trapezium. At 6-month follow-up, radiographic healing and functional recovery were good, with return to daily activities and work.

McGuigan and Culp [14]reviewed surgically treated intra-articular trapezium fractures, including comminuted patterns. Most resulted from high-energy trauma, and some were associated with thumb-base fractures. The authors recommended reduction and fixation for fractures with significant articular displacement or concomitant CMC subluxation. At a mean follow-up of approximately 48 months, most patients reported only mild or activity-related pain, with range of motion and grip/pinch strength approaching the contralateral side. Imaging demonstrated degenerative changes in a subset, but overall functional impact was limited.

Walker et al. [13]summarized trapezial body fractures and proposed a classification system, noting that comminuted/displaced or intra-articular fractures often require anatomic reduction and fixation to restore the articular surface. At 3–24 months of follow-up, most patients achieved painless or near-full range of motion; however, high-energy comminuted injuries more frequently resulted in reduced grip strength and/or residual articular incongruity (Table 1).

Table 1.

Literature summary of comminuted trapezium fractures

Study (author, year)	Number of cases	Mechanism of injury	Management	Reported results
Erdoğan et al. (2026) [16]	1	Motorcycle accident–related comminuted trapezium fracture (Walker type V).	CRIF with K wire	At 12 months postoperatively, bony union and normal ROM; reduced grip/key pinch strength vs. contralateral side.
Fengjing Shen et al. (2025) [20]	1	High-energy impact caused severe comminution of the trapezium with bone loss, resulting in a bone defect.	3D-printed trapezoid implant	At 24 months postoperatively, full recovery
Eiras et al. (2025) [9]	1	Motor vehicle accident–related severe trapezium comminution with marked bone loss.	ORIF with K-wire and screw	At 12 months postoperatively, only mild residual TMC subluxation and mild discomfort with strenuous activity.
Ohno et al. (2024) [24]	2	Isolated intra-articular comminuted/depressed trapezium fracture.	Arthroscopy-assisted reduction and fixation	At 2 months postoperatively, full recovery.
Eda et al. (2022) [4]	1	Motor vehicle accident–related comminuted trapezium fracture.	ORIF	At 6 months postoperatively, full recovery.
Spielman et al. (2021) [25]	1	Comminuted trapezium fracture	ORIF with K-wire and screw	At 3 months postoperatively, full recovery.
Kohyama et al. (2018) [22]	3	Trapezium fracture with thumb CMC dislocation, including comminuted/depressed (Walker type V).	ORIF with bone defect filling	At 24 months postoperatively, full recovery.
Alonso et al. (2018) [21]	1	Fall-related comminuted trapezium body fracture with thumb CMC dislocation.	CRIF with K wire	At 6 months postoperatively, full recovery.
Gvozdenovic et al. (2015) [26]	1	Motor vehicle accident–related multiple carpometacarpal dislocations with a comminuted trapezium fracture	ORIF with K wire	At 12 months postoperatively, largely satisfied; grip and pinch strength remained lower than the contralateral side.
Matzon et al. (2015) [27]	2	High-energy trauma–related severe comminution of the trapezium with articular surface depression	ORIF with bone defect filling	At 4 months postoperatively, largely fully satisfied.
Shenouda et al. (2014) [28]	1	High-energy injury–related severe trapezium comminution	Percutaneous scaphoid screw fixation	At 6 months postoperatively, full recovery.
McGuigan et al. (2002) [14]	5	High-energy trauma–related comminuted trapezium fracture	ORIF with K wire	At 48 months postoperatively, Occasional mild activity-related pain with largely satisfactory function.
Walker et al. (1988) [13]	2	Motor vehicle accident–related comminuted trapezium fracture	ORIF with K-wire	At 48 months postoperatively, full recovery.

ORIF Open Reduction and Internal Fixation, CRIF Closed Reduction and Internal Fixation

Conventional open reduction and internal fixation may have limited efficacy in comminuted trapezium fractures with severe bone loss and may predispose patients to complications such as post traumatic osteoarthritis. Fengjing et al. reported successful treatment of a complex comminuted trapezium fracture with bone loss using a 3D printed trapezium prosthesis [20], supporting the potential role of 3D printed reconstruction in selected severe cases. For trapezium fractures with reconstructible fragments, restorable articular surfaces, and limited bone defects, ORIF, K-wire or screw fixation, and bone grafting remain reasonable and preferred treatment options. However, the present case involved an open high energy injury with severe trapezial comminution, substantial bone loss, and insufficient residual osteochondral support. Therefore, conventional fixation or bone grafting was unlikely to reliably restore the three dimensional morphology of the trapezium and joint congruity. Although arthrodesis could provide stability and pain relief, it would sacrifice motion of the thumb CMC joint and may impair thumb abduction, opposition, and pinch function. Considering the patient’s functional need to preserve thumb motion, patient specific 3D printed prosthetic reconstruction was selected.

The main novelty of this case lies in the staged reconstructive strategy. In stage I, debridement, antibiotic loaded cement spacer placement, and temporary external fixation were performed to control infection risk, maintain thumb column length, and preserve the space for subsequent reconstruction. In stage II, after improvement of the soft tissue condition, a patient specific 3D printed trapezium prosthesis was used for anatomical reconstruction, with the aim of restoring trapezial height, the thumb CMC joint space, and thumb mobility as much as possible.

At the 9 month follow up, the patient demonstrated good thumb and wrist range of motion, and imaging confirmed stable implant position, indicating a favorable short term outcome. Previous reports have shown that although bony union, pain relief, and satisfactory range of motion can be achieved after ORIF, K-wire fixation, bone grafting, or other reconstructive procedures, grip or pinch strength on the injured side may remain lower than that on the contralateral side. Similarly, in the present case, grip strength and key pinch strength of the injured hand were mildly lower than those of the unaffected hand during short term follow up. Nevertheless, pain relief, thumb motion, opposition function, and recovery of daily hand use were satisfactory.

A custom made 3D printed prosthesis also has several limitations, including higher cost, longer design and manufacturing time, dependence on engineering support and institutional resources, and limited reproducibility. Therefore, it should not be considered a routine treatment for all trapezium fractures. Although the short term outcome in this case was encouraging, the long term risks of implant wear, loosening, and secondary thumb CMC arthritis remain unclear. Longer follow up and more cases are needed to further evaluate its safety and effectiveness.

Given the extreme rarity of comminuted trapezium fractures with severe bone loss, heightened clinical awareness is warranted. When encountered, this staged treatment strategy may represent a useful reconstructive option in carefully selected patients.

Conclusion

This report describes the staged management of a traumatic comminuted trapezium fracture with severe bone loss. Stage I debridement, antibiotic-loaded cement spacer placement, and external fixation provided infection control and temporary stabilization, while stage II reconstruction with a patient-specific 3D-printed trapezium prosthesis achieved favorable short-term pain relief and functional recovery. This strategy may be considered in carefully selected severe trapezial bone defect cases when conventional fixation or bone grafting is unlikely to restore joint congruity and thumb motion. However, long-term follow-up is still required to evaluate implant survival and late complications.

Authors' contributions

L.C, C.Y.T drafted the manuscript, and data analysis played a significant role. C.J.X, W.Z.T collected patient data and contributed to the process of summarizing the literature review. Z.L.R was responsible for the overall study design, manuscript review, and revision, ensuring the integrity and coherence of the research.

Funding

Not applicable.

Data availability

The data utilized and/or analyzed in this study can be obtained from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The patient’s informed consent has been obtained, and our hospital’s ethics committee has confirmed it.

Consent for publication

The patient has provided written informed consent, including consent for the use of personal information, clinical data, and imaging images included in this study.

Competing interests

The authors declare no competing interests.