Capitate Fractures: A Review of 53 Patients

Paediatric fractures of carpal bones other than the scaphoid

OBJECTIVES

Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome.

MATERIAL AND METHODS

Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study.

RESULTS

In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good.

CONCLUSION

Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation.

Outcomes of arthroscopic versus open reduction and internal fixation for the treatment of acute traumatic lunate fractures: a systematic review

The purpose of the study was to compare outcomes of fully-arthroscopic reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) to treat acute traumatic lunate fractures. A literature search was conducted using Medline and Embase. Demographic data and outcomes were extracted for included studies. The search identified 2,146 references: 17 articles were included, reporting on 20 cases (4 ARIF and 16 ORIF). No differences between ARIF and ORIF were found in rate of union (100% vs 93%, P = 1.000), grip strength (mean difference, 8%; 95%CI, -16-31; P = 0.592), rate of return to work (100% vs 100%, P = 1.000), or range of motion (mean difference, 28°; 95%CI, -25-80; P = 0.426). Lunate fractures were not identified in 6 of the 19 radiographs, but were identified in all CT scans. There were no differences in outcome between ARIF and ORIF for the treatment of fresh lunate fracture. The authors recommend surgeons to perform CT scans when diagnosing high-energy wrist trauma so as not to overlook lunate fractures. LEVEL OF EVIDENCE: Level IV.

Neglected Scaphocapitate Syndrome

Background  Scaphocapitate syndrome is a rare injury where the proximal pole of the capitate rotates 90 to 180 degrees. The proximal pole of the capitate, thought to receive its vascular supply retrograde, is rendered avascular in such cases. However, recent evidence of low rates of avascular necrosis in displaced capitate fractures, and new vascular studies of the capitate, challenge this paradigm. Case Description  We report a case of a missed and neglected scaphocapitate syndrome with more than 30 years follow-up. While the patient experienced midcarpal arthritis, the injury had not resulted in capitate proximal pole avascular necrosis as per T1 magnetic resonance imaging studies. Literature Review  Missed and chronic cases of scaphocapitate syndrome were reported previously. Successful outcomes were achieved with anatomical reduction in cases without midcarpal arthritis. Salvage procedures or arthroplasty procedures are recommended with the presence of midcarpal arthritis. However, there are no reports of a neglected case with more than 30 years follow-up with preserved vascularity of the proximal pole of the capitate. Clinical Relevance  This case illustrates that vascularity of the proximal pole of the capitate can be preserved even in longstanding displaced fractures.

Unusual capitate fracture with dorsal shearing pattern and concomitant carpometacarpal dislocation with a 6-year follow-up: A case report

BACKGROUND

Isolated capitate fractures are rare carpal fractures. Following high-energy injuries, capitate fractures are usually associated with other carpal fractures or ligament injuries. The management of capitate fractures depends on the fracture pattern. Here, we report an unusual capitate fracture with a dorsal shearing pattern and concomitant carpometacarpal dislocation, with a 6-year follow-up. To the best of our knowledge, this fracture pattern and surgical management have not been previously reported.

CASE SUMMARY

A 28-year-old man presented with left-hand volar tenderness and decreased grip strength that persisted for one month after a traffic accident. Radiography showed a distal capitate fracture with carpometacarpal joint incongruence. Computed tomography (CT) revealed a distal capitate fracture with carpometacarpal joint dislocation. The distal fragment was rotated by 90° in the sagittal plane, and an oblique shearing fracture pattern was noted. Open reduction and internal fixation (ORIF) with a locking plate were performed using the dorsal approach. The imaging studies performed 3 mo and 6 years following surgery revealed a healed fracture, and the Disabilities of the Arm, Shoulder, and Hand and visual analog scale scores were significantly improved.

CONCLUSION

CT can detect capitate fractures with dorsal shearing pattern and concomitant carpometacarpal dislocation. ORIF using a locking plate are possible.

Fractura aislada del hueso grande asociada a quiste traumático sinovial: presentación de un caso en un niño

Introducción: Las fracturas aisladas del hueso grande son muy infrecuentes en los niños y se producen por traumatismos de alta energía. Pueden pasar desapercibidas en la valoración inicial y las radiografías solo permiten identificar las lesiones en huesos osificados, por lo que son necesarias pruebas complementarias, como la resonancia magnética, para descartar posibles lesiones del carpo asociadas, sobre todo en menores de 10 años. Se presenta el caso de una fractura aislada del hueso grande con aparición de quiste sinovial por causa traumática en un paciente pediátrico, tratado mediante inmovilización con yeso antebraquial durante cuatro semanas, con buena evolución. Conclusión: El manejo de estos casos depende de la gravedad de la lesión y, aunque por lo común evolucionan bien con un tratamiento conservador, su diagnóstico precoz permite elegir la mejor opción yevitar posibles complicaciones, como la falta de consolidación o la necrosis avascular.Nivel de Evidencia: IV

Avascular Necrosis of Capitate and Other Uncommon Presentations of Carpal Avascular Necrosis

Outside of Preiser and Kienbock disease, avascular necrosis (AVN) of the remaining carpal bones is a rare cause of wrist pain and disability with a natural history that is incompletely understood. At present, much of the available clinical information exists in the form of isolated case reports or small case series. Although reported surgical treatment options are numerous, there is a dearth of comparative studies and long-term outcomes data with which to guide management.

Arthroscopic Treatment of Capitate Nonunion: A New Technique

Isolated fractures of the capitate are very rare which means that their nonunion is even rarer. Repair techniques have always been performed by open surgery which may result in loss of mobility due to the capsulotomy. The typically used surgical techniques such as arthrodesis of the carpal or wrist bones can have irreversible consequences on range of motion. No arthroscopic technique has ever been described for this condition. Here, we describe a case of isolated capitate nonunion without ligament tears or other carpal fractures in a 21-year-old male, following a capitate fracture 10 years prior. We describe our arthroscopic treatment technique for this capitate nonunion.

Capitate fracture nonunion in association with triquetrum avulsion fracture: Rare injury with massive effect on hand function, a case report

Introduction and importance

Capitate fractures are rare and usually occur due to high-energy trauma. They are often associated with other wrist injuries or dislocations. An isolated occurrence of capitate and triquetral fractures due to high-energy trauma is rarely reported in the literature. This rare injury pattern has a significant effect on wrist function, as presented in this case.

Case presentation

A 19-year-old male manual worker, presented with persistent right wrist pain and progressive loss of function after sustaining motor vehicle collision 5 months prior. The patient had major concerns regarding the return of wrist function.

Clinical discussion

A diagnosis of collapsed capitate fracture nonunion associated with a triquetral avulsion fracture was made based on radiography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Treatment with internal fixation and strut corticocancellous autograft to restore capitate height resulted in substantial improvement in wrist function and alleviation of pain. The Mayo wrist score increased from 15/100 to 90/100 at the 6-year follow-up visit.

Conclusion

Capitate fractures can occur in association with triquetral fractures in the absence of dislocation or greater arch injuries. Nonunion is a common complication, and internal fixation with bone graft is the gold standard for the treatment of capitate fracture nonunion, resulting in excellent outcomes and return of function.

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Capitate fracture nonunion with triquetral avulsion is a rare injury pattern with only 8 cases reported in literature.

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Capitate nonunion is a common complication that can lead to massive wrist and hand dysfunction.

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Open reduction and internal fixation with cannulated screw and bone graft is recommended for treating capitate nonunion.

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Restoration of capitate height enhances hand function and significantly improves wrist range of motion.

Evaluation and Management of Carpal Fractures Other Than the Scaphoid

Fractures of the carpus can be debilitating injuries and often lead to chronic pain and dysfunction when not properly treated. Although scaphoid fractures are more common, fractures of the other carpal bones account for nearly half of all injuries of the carpus. Often missed on initial presentation, a focused physical examination with imaging tailored to the suspected injury is needed to identify these fractures. In addition to plain radiographs, advanced imaging such as CT and MRI are helpful in diagnosis and management. Treatment of carpal fractures is based on the degree of displacement, stability of the fracture, and associated injuries. Those that require surgical fixation often affect the congruency of the articular surfaces, are unstable, are at risk for symptomatic nonunion, are associated with notable ligamentous injury, or are causing nerve or tendon entrapment. Surgical strategies involve percutaneous Kirschner wires, external fixation, screws and/or plates, excision, or fusion for salvage. Owing to the intimate articulations in the hand, small size of the carpal bones, and complex vascular supply, carpal fracture complications include symptomatic nonunion, osteonecrosis, and posttraumatic arthritis.

Nonunion of the Capitate due to Delayed Diagnosis of an Isolated Fracture: A Case Report

CASE

A 14-year-old girl was diagnosed with nonunion of an isolated capitate fracture 5 months after she first presented to the emergency department. The fracture of the capitate was treated by cancellous proximal bone graft and screw fixation. This current case provides details of the surgical fixation method and long-term functional outcome after nonunion of an isolated capitate fracture after a follow-up of 18 months following fixation.

CONCLUSIONS

Persisting localized tenderness over the capitate should be an indication to perform an additional computed tomography or magnetic resonance imaging scan. Nonunion of isolated capitate fractures can be treated by means of open reduction and internal fixation, with autologous bone grafting.

Retro-lunar dislocation of carpal bones with trans-capitate, trans-lunate fractures and intact scaphoid. What if Bain was right?

We report the case of retro-lunar dislocation of carpal bones detaching the proximal pole of the capitate with intact scaphoid, associated with lunate fracture. A rare case where the pathomechanics of the lesion has not yet been precisely identified. We present our conservative approach in the treatment of the capitate fracture and propose a theory-based explanatory pattern that combines the ligaments injuries sequences described by Mayfield from lateral to medial (corresponding to Johnson's lesser arc injuries), and the displacement of the transmitted force along Wagner's dislocation line from medial to lateral, causing bones injuries, following Johnson's greater arc injuries and Bain's translunate arc. Our management after closed reduction of the dislocation was surgical through dorsal approach and fixation of the proximal pole of the capitate. 25 months after surgery, despite the installation of early osteoarthritis, the functional outcome is satisfactory.

Isolated Treatment of a Comminuted Capitate Fracture: A Case Report

CASE

Comminuted fractures of the capitate, in the absence of associated carpal injuries, are exceedingly rare. Treatment of this complex injury is not well-documented in the literature. We describe the case of a comminuted capitate fracture that was successfully managed with Kirschner wire fixation.

CONCLUSION

Based on this case and a review of the literature, management of a comminuted capitate fracture with Kirschner wire fixation can lead to successful treatment and positive patient outcomes.

Treatment of Acute Carpal Bone Fractures

Carpal bone fractures are common hand fractures that can be complicated by concomitant damage to surrounding structures, chronic comorbidities, or delays in diagnosis. This article provides an overview of wrist anatomy, an expedited review of the athlete's presenting condition, and a systematic approach to the evaluation of the wrist. Recommended treatment plans are based on a review of the literature and an evidence-based approach to imaging studies. It is imperative that sports medicine providers be aware of current literature for carpal bone fractures and collaborate with other medical subspecialties and the athlete to provide recommendations for a safe return to play.

The Vascular Anatomy of the Capitate: New Discoveries Using Micro-Computed Tomography Imaging

PURPOSE

To study the intraosseous 3-dimensional microvasculature of the capitate bone using a novel high-resolution micro-computed tomography (μCT) imaging technology, and to examine the blood supply as it relates to the most common fracture types.

METHODS

Ten cadaveric wrists were injected with a lead-based contrast agent. The capitates were harvested and imaged using a μCT scanner. The intraosseous vascularity was incorporated into a 3-dimensional image. We measured the vascular pattern as well as the vessels' cross-sectional area, number, and distribution. An average capitate fracture line was calculated using clinical data from 22 patients with capitate fractures. The fracture line was projected on the representative capitate to assess its relation with the nutrient vessels' entry points.

RESULTS

The capitate is a well-vascularized carpal supplied by dorsal and volar vascular systems that anastomose in 30% of cases. There was no predominance of one vascular system over the other. Most vessels enter the capitate at the distal half and supply the proximal pole in a retrograde fashion. In addition, most specimens (70%) also had at least one vessel entering the proximal pole through the volar capitate ligaments and supplying the proximal pole directly. The average fracture line had an oblique orientation, and 90% of the specimens had a blood vessel entering proximal to that line.

CONCLUSIONS

This μCT vascular study further verifies that the capitate receives most of its vasculature in a retrograde fashion, but the study also shows that most capitates have vessels supplying the proximal pole directly. These findings might explain why most capitate waist fractures do not progress to proximal pole avascular necrosis.

CLINICAL RELEVANCE

This study characterizes the microvasculature of the capitate and might shed light on processes involved in bone healing and the etiology of capitate avascular necrosis.