Fractures of the Carpal Bones Excluding the Scaphoid

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FRACTURES OF THE CARPAL BONES EXCLUDING THE SCAPHOID

BY MUNIR A. SHAH, MD, AND STEVEN F. VIEGAS, MD

Carpal fractures excluding the scaphoid can cause morbidity that is disproportionate to their incidence because they are easily overlooked and are often harbingers of a wider wrist injury. Failure to recognize a more global injury pattern can result in undertreatment and permanent wrist dysfunction. Diagnosis requires a high index of suspicion,familiarity with carpal topography to guide the physical examination,and judicious use of specialized radiographic views and ancillary imaging techniques. Copyright © 2002 by the American Society for Surgery of the Hand

racture of the carpal bones, excluding the topography to guide the physical examination and scaphoid, account for approximately 40% of judicious use of specialized radiographic views and Fall carpal fractures.1 Paradigms for evaluation ancillary imaging techniques based on clinical sus- and treatment of the fractured scaphoid are well picion. Second, such fractures are often harbingers delineated in the literature. The less common frac- of signiﬁcant ligamentous disruption or associated tures of other carpal bones have received consider- carpal fractures. Failure to recognize a more global ably less attention. However, these injuries can injury pattern can result in undertreatment and produce morbidity that is disproportionate to their permanent wrist dysfunction. incidence for several reasons. First, carpal fractures We examine the incidence, mechanisms of injury, excluding the scaphoid may have a subtle clinical associated osseous and ligamentous injuries, physical and radiographic presentation and are easily over- examination ﬁndings, useful radiographic views, and looked. Diagnosis requires familiarity with carpal ancillary imaging techniques and management prin- ciples of these often overlooked carpal fractures.

From the Division of Hand Surgery,Department of Orthopaedics and Rehabilitation,University of Texas Medical Branch,Galveston, TRIQUETRUM TX. Address reprint requests to Munir A. Shah,MD,Department of Orthopaedics,Rebecca Sealy Hospital,Room 2.616,301 University riquetral fractures are probably the most com- Blvd,Galveston,TX 77555-0165. E-mail: [email protected] Tmon carpal fracture excluding the scaphoid. In a population-based study conducted in Bergen, Nor- Copyright © 2002 by the American Society for Surgery of the Hand 1531-0914/02/0203-0003$35.00/0 way, triquetral fractures comprised 31% of all carpal doi:10.1053/jssh.2002.34795 fractures.1

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND ⅐ VOL. 2,NO. 3,AUGUST 2002 129 130 CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS

Triquetral fractures can involve the dorsal rim or body.2 Fractures of the dorsal rim can result from avulsion of the dorsal intercarpal, dorsal radiocarpal, or lunotriquetral ligaments during a hyperﬂex- ion/radial deviation injury to the wrist. Alterna- tively, hyperextension/ulnar deviation injuries can produce an impaction fracture when the ulnar styloid or hamate chisel into the dorsal triquetral rim (Fig 1).3,4 Triquetral body fractures most commonly involve the medial tuberosity, typically caused by a direct blow to the ulnar border of the wrist. Other fracture patterns involving the body include comminuted, transverse, or sagittal fractures and are commonly associated with higher energy mechanisms of injury. Triquetral body fractures may be the sole radiographic manifestation of a more global wrist injury including axial disruption of the carpus secondary to severe dorsopalmar crush or a perilunate greater arc injury (Fig 2).5,6 Physical examination reveals dorsoulnar wrist tenderness over the triquetrum. Standard wrist radiographs are typically diagnostic. The oblique view is the most useful for visualizing dorsal rim fractures.2 Occasionally, bone scan or computed tomography (CT) may be necessary to corroborate clinical suspicion. Cast immobilization is sufﬁcient for dorsal avulsion/chisel fractures and nondisplaced fractures of the triquetral body if carpal instability has been excluded. Patients should be counseled that dorsal rim fractures may produce prolonged soreness.2 In addition, pro- gression to symptomatic nonunion may occur and can be treated with fragment excision and ligament repair. Isolated, nondisplaced body fractures can be treated with cast immobilization. Triquetral body fractures that are displaced or are part of a broader ligamentous insult require surgical treatment to reduce and stabilize the fracture and, when necessary, address carpal instability.6-8

HAMATE FIGURE 1. Mechanisms of triquetral avulsion fractures.

amate fractures constitute approximately 7% of (CMC) joints (Fig 3).9 The typical mechanism is axial Hcarpal fractures and can involve the hamular loading of the ﬂexed CMC joints (eg, striking an process (hook) or, more commonly, the body.1 Body unyielding object with a clenched ﬁst), that produces fractures are typically associated with a broader hand a coronally oriented fracture of the dorsal, distal and/or wrist injury, most commonly dorsal fracture hamate with variable degrees of comminution.10 Body dislocation of the 4th and/or 5th carpometacarpal fractures also may be associated with greater arc peri- CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS 131

FIGURE 2. (A) Anteroposterior wrist radiograph shows a seemingly isolated triquetral fracture (arrow). However, there is disruptions of Gilula’s arcs, a minute fleckavulsion from the radial styloid and palmar flexion of the lunate as evidenced by its triangular radiographic appearance. (B) Lateral wrist radiograph shows a dorsal perilunate dislocation. Triquetral fractures can represent an osseous component of a wider ligamentous injury. lunate injuries or axial carpal dislocations.8 The latter often, over the dorsal aspect of the hamate.12-14 Pain injury is associated with dorsopalmar crush and flat- can be elicited with resisted ring and small finger tening of the carpal arch, which produces sagittal- distal interphalangeal joint flexion when the wrist is oblique hamate body fracture.5 in ulnar deviation (Fig 4). Pain is relieved when the Fractures of the hamular process are typically iso- test is performed with the wrist in radial deviation.15 lated injuries. The mechanism of injury is classically Patients with delayed presentation may have flexor direct trauma to the patient’s nondominant hand by tendon rupture that should be specifically excluded the base of a golf club, bat, or racquet.10-13 Falls on an during the initial examination. Patients with hamular outstretched hand can also produce hook fractures, process and hamate body fractures require a thorough either by direct trauma or flattening of the carpal arch evaluation of ulnar nerve function, particularly the with avulsion by the transverse carpal ligament. The deep motor branch, because both injuries can be as- hook of the hamate may fracture at the tip, waist, or sociated with ulnar neuropathy. Associated carpal tun- base. nel syndrome has also been reported.12,13 Physical examination of the typical body fracture Hamate body fractures are usually apparent on (CMC joint fracture dislocation) reveals dorsoulnar standard wrist radiographs, particularly the oblique wrist swelling. Tenderness is well localized to the and lateral views.16 When associated with a fracture CMC joints. Loss of knuckle prominence from abnor- dislocation of the CMC joints, the metacarpals are mal flexion of the metacarpal(s) or abrasions over the usually flexed, with their bases residing in an abnor- metacarpal heads may be present. Poorly localized mal dorsal position and relative to the intact carpus tenderness should alert suspicion for additional liga- and adjacent metacarpals. Hamular process fractures mentous disruptions, particularly in patients with are notoriously difficult to visualize with standard a history of high-energy injury (eg, dorsopalmar radiographs. The carpal tunnel and 30° supinated crush).5 oblique views are valuable additional radiographic In contrast, patients with hook of the hamate frac- projections that may visualize hook of hamate fractures may have a subtle initial presentation, and the tures (Fig 5).13,17 Transverse CT images or bone scan injury can be easily overlooked. Diagnosis requires a should be obtained if the diagnosis remains in ques- high index of suspicion. Patients may complain of tion.18 poorly localized palmar wrist pain aggravated by Nondisplaced, isolated hamate body fractures may power grip.13 Examination reveals tenderness over the be treated with immobilization. More commonly, hamular process (radial and distal to the pisiform) and, these fractures are part of a larger injury, and surgical 132 CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS

FIGURE 3. Fracture-dislocations of the 4th and 5th CMC joints often have minimal findings on the (A) anteroposterior wrist radiograph except increased overlap of the 5th metacarpal and hamate. The (B) oblique and (C) lateral views show a flexed posture of the 5th metacarpal, abnormal dorsal prominence of the metacarpal bases and a coronally oriented fracture of the dorsal, distal hamate (C, arrow). Postoperative (D) anteroposterior and (E) lateral wrist radiographs show reduction of the CMC joints and restoration of hamate articular congruity. A dorsal, coronally oriented capitate fracture resulted from this injury because the capitate has a facet for articulation with the 4th metacarpal. This patient had a complete, preoperative motor palsy of the ulnar-innervated intrinsic hand muscles that resolved over 8 weeks. treatment is usually required to reduce and stabilize flexor tendon rupture.11 Others recommend open re- the hamate fracture and to address carpal or carpo- duction and internal fixation of nonunion based on the metacarpal instability.8 Acute, nondisplaced hamular possible functional importance of the hamular process process fractures may be treated with cast immobili- as a pulley for the digital flexors.20 zation.19 Symptomatic nonunion has been reported, particularly in fractures adjacent to the hamular pro- TRAPEZIUM cess base. Excision of the ununited fragment pro- vides reliable symptomatic and functional improve- rapezial fractures comprise approximately 3% of ment.13,17 Certain investigators recommend excision Tcarpal fractures and can involve the body or of asymptomatic nonunions to minimize the risk for ridge.1,21 Ridge fractures are typically isolated injuries CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS 133

resisted wrist flexion by producing apposition of the flexor carpi radialis against the trapezial ridge.23 Car- pal tunnel syndrome is a common comorbid condition and should be excluded specifically.22 Body fractures may show abnormal dorsoradial prominence of the thumb metacarpal base.25 Tenderness is localized to the CMC joint and/or the distal aspect of the anatomic snuffbox.27 Radiographic evaluation of suspected trapezial ridge fractures should include a carpal tunnel view.22 Occasionally, CT may be required to delineate an acute or chronic ridge fracture. Body fractures, espe- cially if associated with concomitant thumb CMC joint dislocation, are often distinguishable on standard wrist radiographs, although CT is sometimes required to visualize the fracture.28 An oblique lateral, with the ulnar aspect of the hand down and the forearm in 20° of pronation, may reveal more subtle body fractures by decreasing the radiographic overlap between the trapezoid and trapezium.26 Trapezial ridge fractures can be treated with cast immobilization. Symptomatic nonunions may be treated with fragment excision.22,23 Body fractures with intra-articular displacement should be reduced FIGURE 4. Resisted flexor digitorum profundus flexion of the anatomically and rigidly fixed.29 ring and small fingers with the wrist in ulnar deviation will commonly elicit pain at the hookof the hamate if a fracture exists. PISIFORM

isiform fractures account for approximately 2% of caused by direct trauma or avulsion by the transverse Pall carpal fractures.1,21 The pisiform is a sesamoid carpal ligament during a fall on an outstretched attached to the flexor carpi ulnaris tendon proximally, hand.22,23 Palmar classified ridge fractures based on and to the pisohamate, pisometacarpal, and pisotrique- location and propensity for healing. Type I fractures tral ligaments distally. Additional soft-tissue attach- involve the base of the ridge and typically heal with ments include the abductor digiti minimi and the trans- immobilization. Type II fractures involve the tip of the ridge and can progress to symptomatic nonunion.23 Trapezial body fractures may occur during extreme wrist dorsiflexion and radial deviation, effectively crushing the trapezium between the base of the thumb metacarpal and the radial styloid. Vertical transarticular body fractures may be the most common type. This fracture pattern may be associated with fracture dislocation of the 1st CMC joint and a thumb metacarpal Bennett’s fracture secondary to a direct blow to the adducted and flexed thumb.24-27 Physical examination of patients with trapezial ridge fractures show tenderness localized just distal to FIGURE 5. This carpal tunnel view shows a hamular process the scaphoid tuberosity.28 Pain can be elicited with fracture that was missed on standard wrist radiographs. 134 CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS

FIGURE 6. (A) Anteroposterior wrist radiograph of a patient with ulnar-sided wrist pain shows a possible fracture of the pisiform. (B) Carpal tunnel view clearly shows a displaced parasagittal pisiform fracture. verse carpal ligament.30 The ulnar nerve and artery are with minimal adverse sequellae.33-35 Fractures that immediately radial to the pisiform in Guyon’s canal. have a transverse, as opposed to longitudinal, orien- The typical history is a fall on an outstretched hand tation functionally disrupt the flexor carpi ulnaris that most often produces a transverse pisiform fracture function and have a more guarded prognosis.5 by a combination of both direct and indirect mechanisms. The pisiform becomes fixed at the pisotriquetral LUNATE joint when the outstretched hand strikes the ground; forceful contraction of the flexor carpi ulnaris then pro- unate fractures comprise approximately 1% of all duces a transversely oriented avulsion fracture. Other Lcarpal fractures.1,21 Their incidence may have injury patterns include comminuted, parasagittal, and been previously overestimated because some investi- osteochondral impaction fractures (Fig 6).5,31 gators included fractures that occurred in the setting Physical examination reveals tenderness over the of Kienbock’s disease, and others have probably as- pisiform. Examination should exclude other wrist in- cribed dorsal triquetral fractures to the lunate.5 In 1 juries (eg, perilunate dislocation, distal radius or ad- series, only 17 cases of lunate fracture were collected ditional carpal fracture) that can occur in up to 50% over a 31-year period.21 of pisiform fractures.32 The ulnar nerve requires eval- Lunate fractures can involve the dorsal or palmar uation, particularly in patients with comminuted frac- poles or the lunate body.21 Dorsal pole fractures may tures that result from a direct blow and those with result from scapholunate or lunotriquetral interosse- established posttraumatic pisotriquetral osteoarthri- ous or dorsal radiocarpal ligament avulsion. Alterna- tis.33,34 Pisiform fractures are poorly visualized on tively, impingement of the dorsal pole between the anteroposterior and oblique wrist radiographs but radius and capitate during extreme wrist dorsiflexion may be visualized on the lateral view. Additional can produce an impaction fracture. Palmar pole frac- projections that bring the pisiform and pisotriquetral tures may result from avulsion by the long and short joint into profile are the carpal tunnel view and the radiolunate ligaments.15 Body fractures occur second- 30° supinated lateral radiograph.32,33 Occasionally, ary to axial loading of the lunate between the capitate CT or bone scan may be required to corroborate head and lunate fossa. clinical suspicion. Examination reveals painful wrist motion and lo- Most pisiform fractures can be treated with splint calized tenderness when the fracture is dorsal. Frac- immobilization. Symptomatic posttraumatic osteoar- tures of the lunate may be the radiographic harbinger thritis or nonunion can be treated with pisiform enu- of a more global carpal injury (eg, perilunate disloca- cleation and reconstruction of the flexor carpi ulnaris tion) and demand rigorous evaluation of the wrist. CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS 135

FIGURE 7. A minimally displaced fracture of the (A) lunate volar pole was treated with cast immobilization. The patient developed signiﬁcant displacement of the (B) volar lunate fragment (arrow) and midcarpal collapse with severe lunate ﬂexion and palmar subluxation of the capitate. (C, D) Open reduction of the volar pole, with its attached long and short radiolunate ligaments, and the midcarpal joint restored carpal alignment.

Radiographs frequently fail to visualize or underesti- functional loss of the dorsal component of the scapholu- mate the size or displacement of fracture fragments. nate interosseous, the dorsal radiocarpal and lunotrique- Therefore, CT is invaluable to evaluate lunate injuries, tral ligaments. Loss of dorsal constraints can lead to particularly body fractures. dorsiflexion and volar translation of the lunate and Lunate fractures should be approached with caution secondary arthritis. Occasionally, dorsal lunate avul- because even seemingly innocuous, isolated fractures sion fractures are limited to the attachment of the may functionally detach critical wrist ligaments and scapholunate interosseous ligament (Fig 8). This fracture lead to profound malalignment of the carpus.36 Alter- pattern requires reduction and fixation to prevent dorsal natively, lunate fractures may be part of a larger intercalated collapse instability of the wrist. Axial com- ligamentous insult.37,38 Patients whose fractures do pression injuries with displacement and/or articular im- not appear to warrant surgical intervention require paction require reduction and fixation (Fig 9). Neutral- meticulous follow-up care to ensure that wrist mal- ization of axial loads with an external fixator may assist in alignment does not develop. maintaining the reduction. Patients should be counseled Palmar pole fractures require reduction and fixation that lunate fractures can be complicated by avascular because they produce functional loss of the long and necrosis, nonunion, and carpal malalignment.39 short radiolunate ligaments. Untreated, this fracture may produce profound volar flexion and dorsal translation of CAPITATE the lunate. Failure to recognize and treat this injury can produce chronic palmar subluxation of the capitate and he capitate is central and well protected within the midcarpal arthritis (Fig 7).15,36 Conversely, large dorsal Tcarpus and infrequently injured. Capitate fractures pole fractures require fixation because they can produce comprise approximately 1% of all carpal fractures.1,21 136 CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS

FIGURE 8. (A) Anteroposterior radiograph of a patient who sustained a fall on an outstretched hand shows a radial styloid (arrow) and 5th metacarpal fracture. A subtle abnormality is evident at the radial aspect of the lunate. Examination revealed tenderness over the scapholunate ligament and a positive Watson’s maneuver during examination under anesthetic. (B) A dorsal wrist approach conﬁrmed lunate avulsion fracture of the scapholunate ligament. (D) The scapholunate joint and lunate avulsion fracture (arrow) were reduced and secured with (C, D) K-wires. CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS 137

Dorsal distal articular margin fractures of the capitate occur as part of the 3rd CMC joint fracture dislocation.9 The mechanism of injury is axial loading combined with a flexion moment applied to the long finger metacarpal. Occasionally, such fractures are produced during fracture dislocations of the 4th CMC joint because the capitate typically has a facet for articulation with and ligamentous attachment to the 4th metacarpal (Fig 2).44 Fractures of the 3rd metacarpal base should be distinguished from an os styloi- deum, a common accessory bone that resides within the extensor carpi radialis brevis at the level of the CMC joint. Roughly one half of capitate fractures are associated with additional osseous and/or ligamentous injuries (eg, dorsal fracture dislocation of the CMC joint or transscaphoid perilunate injury), and the other one- half are isolated.40 Physical examination may reveal localized tenderness for isolated capitate fractures or more diffuse swelling and tenderness if the fracture is part of a wider wrist injury. Standard wrist radiographs may not reveal isolated body or dorsal articular margin fractures. CT in the coronal plane for transverse fractures and in the parasagittal plane for articular margin FIGURE 9. Lunate body fracture (arrow) produced by an axial fractures can show fractures that do not manifest on loading injury. A CT scan should be obtained because dis- plain radiographs. Magnetic resonance imaging is use- placement and articular impaction are difficult to discern on ful to predict healing potential of transverse body plain radiographs. fractures by visualizing the vascular status of the capitate head.5 Nondisplaced, isolated, capitate fractures can be Capitate fractures can involve the body or the distal treated with cast immobilization.15 Capitate fractures dorsal articular margin. Body fractures are usually that are part of a larger wrist injury should be fixed transverse and may result from a direct blow that along with associated osseous/ligamentous inju- causes multiple carpal bone fractures or as part of an ries.42,43 The seemingly isolated but displaced capitate incomplete or self-reduced perilunate injury.15,40 The fracture requires meticulous evaluation because dis- scaphocapitate syndrome is a manifestation of the placement occurs with concomitant osseous or liga- perilunate injury pattern.41-43 Wrist extension results mentous injuries (Fig 11). Patients with capitate frac- in scaphoid fracture and, with further extension, the tures should be counseled that functional limitation is capitate impacts on the dorsal lip of the radius. A common secondary to nonunion, avascular necrosis of transverse fracture of the capitate body occurs, and its the proximal pole, capitate collapse, symptomatic proximal fragment can rotate 180° in the sagittal midcarpal arthrosis, or associated injuries.45 Painful plane as the hand returns to a neutral position. The midcarpal arthrosis can be treated with midcarpal articular cartilage of the capitate head then faces dis- arthrodesis. tally in opposition to the fracture surface of the distal capitate fragment (Fig 10). Transscaphoid, transcapi- TRAPEZOID tate, perilunate injuries can also occur without mal- rotation of the capitate head. Avascular necrosis of the he trapezoid is well protected by the osseous proximal fragment is possible because the head has no Tarchitecture of the 2nd CMC joint. The base of soft-tissue attachments.40,42 the 2nd metacarpal is fish tailed and interlocks with 138 CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS

FIGURE 10. Mechanism of proximal capitate fragment rotation in the scaphocapitate syndrome. Note the 180° rotation of the proximal fragment. the trapezium, capitate, 3rd metacarpal, and trape- month period. Most reports are limited to individual zoid. The inherently stable joint geometry is rein- cases.47 forced by strong ligaments and explains why the Most trapezoid fractures occur during CMC joint trapezoid is the least common carpal fracture.46 Hove1 dislocation, either isolated or in association with frac- reported no cases of trapezoid fracture in an analysis of ture dislocations of multiple CMC joints.9,48 The 183 consecutive carpal fractures collected over a 10- usual mechanism is high-energy axial loading of the index or adjacent metacarpals. Physical examination reveals tenderness and swelling localized to the involved CMC joints. The 2nd CMC joint is notoriously difficult to visualize on routine radiographs. Mehara and Bhan49 described a radiographic view that brings the 2nd CMC joint into profile. The thumb is positioned in maximal palmar abduction, and the radial border of the hand and thumb are placed flat against the cassette by hyper- pronating the forearm. The radiograph beam is di- rected 30° off of the vertical line, toward the palm. CT in the parasagittal plane is often necessary to visualize fracture dislocations of the 2nd CMC joint. Nondisplaced fractures can be treated with cast immobilization. Displaced fractures require reduction and fixation of the trapezoid and metacarpal. Adjacent FIGURE 11. A displaced capitate fracture (solid arrow) CMC joint injuries should be addressed at the same should prompt a meticulous search for a wider wrist injury. This patient sustained a transcapitate, transtriquetral (hollow setting. Symptomatic chronic injuries can be treated arrow) greater arc injury. with CMC joint arthrodesis. CARPAL FRACTURES (EXCLUDING SCAPHOID) ⅐ SHAH & VIEGAS 139

SUMMARY views and ancillary imaging techniques, and an under- standing of commonly associated patterns of osseous and arpal fractures can cause disproportionate morbidity ligamentous injury. Patients should be counseled that Crelative to their incidence. Timely diagnosis and even with ideal treatment, these fractures can produce effective treatment of these injuries requires a high index signiﬁcant morbidity that requires additional treatment of suspicion, judicious use of specialized radiographic to improve wrist function.

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