Working Diagnosis:
Left Trapezium Stress Fracture

Treatment:
Initially treated with wrist splint and non-steroidal anti-inflammatory medication as needed for approximately 2 weeks, she was then placed in a cast for 3 weeks. After removal of the cast and gradual return to gymnastics, the patient returned to clinic because of pain. After MRI results, she was placed in a removable cast for an additional 6 weeks.

Outcome:
After 6 weeks in the removable cast, she was no longer having pain at rest and slowly progressed back into activity including weight bearing activities without impact. Patient was subsequently cleared for gymnastics and acrobatics.

Author's Comments:
Trapezium fractures and stress fractures are seemingly rare and unrecognized with limited information. The information available suggests that trapezium fractures have two potential mechanisms. The first is through indirect axial overload; fall on an outstretched hand with hyperextension and radial deviation which results in the trapezium being compressed between the base of the 1st metacarpal and the radial styloid process. The second is through direct trauma to the base of the ridge of the trapezium. Recognized complications of trapezium fractures include carpometacarpal joint stiffness, contractures of the 1st web space, and loss of pinch strength and function. In this particular case the indirect axial overload with the wrist in hyperextension and radial deviation is likely what led to the injury. In gymnastics when learning a backbend, young gymnasts are often taught to make a triangle with their thumbs and index fingers. Then as they begin to do the backbend, they are instructed to look at the triangle as they continue into back extension and until their hands touch the floor. Creating this triangle with their fingers helps teach gymnasts to keep their arms close to their ears as well as their neck in a neutral position. These two things help ensure their hands hit the floor first protecting their head and neck. The triangle position could create the radial deviation of the wrist along with the hyperextension of the wrist required to do a backbend leading to such an injury. One speculation regarding why these injuries may be rare and unrecognized is our current treatment of scaphoid fractures. The trapezium lies just distal to the scaphoid making it somewhat difficult to differentiate from the scaphoid. Pain in the area of the scaphoid typically results in use of a thumb spica cast even with negative x-rays. Typically, MRIs are not performed unless there is lingering pain. As the treatment for a scaphoid fracture would be the same for a trapezium fracture, the true number of trapezium fractures may not be well documented.

Editor's Comments:
Patients with trapezium fractures may present with symptoms consistent with scaphoid fractures and are initially managed the same. Notably, this fracture would normally be diagnosed only if there is persistent pain after conservative management leading to advanced imaging (MRI/CT). The trapezium receives its blood supply from two separate systems and with anastomoses of these supplies, there is significantly reduced concern for nonunion (1).

References:
1. Beekhuizen SR, Quispel CR, Jasper J, Deijkers RLM. The Uncommon Trapezium Fracture: A Case Series. Journal of Wrist Surgery. 2019;09(01):063-070.

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