Arch Orthop Trauma Surg DOI 10.1007/s00402-011-1301-x
HANDSURGERY
Successful delayed surgical treatment of a scaphocapitate fracture Benedikt Schliemann · M. Langer · C. Kösters · M. J. Raschke · S. Ochman
Received: 11 February 2011 © Springer-Verlag 2011
Abstract The scaphocapitate fracture syndrome is a rare entity of a perilunate fracture-dislocation. The diagnosis is frequently missed at initial presentation to a physician. Usually, a CT scan is required to reveal the extent of the lesion. Operative treatment consists of open reduction and internal Wxation with screws (e.g. headless compression screw) or Kirschner wires. We report on a case of a 19year-old man who presented to our hospital 2 months after he fell on his left wrist. He complained about persistent pain and a decreased range of motion after conservative treatment in a short arm cast. The diagnosis was Wnally made by a CT scan and the patient was treated operatively using headless compression screws in both the capitate and the scaphoid. After 12 weeks, fractures were completely healed radiographically and the patient returned to work. At follow-up 16 months after trauma, the patient had no further complaints. Range of motion increased and no avascular necrosis could be observed. Keywords Fenton syndrome · Scaphocapitate fracture · Greater arc injury · Perilunate fracture dislocation · Carpal instability
B. Schliemann (&) · M. Langer · C. Kösters · M. J. Raschke · S. Ochman Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Waldeyerstraße 1, 48149 Münster, Germany e-mail:
[email protected] URL: http://www.traumacentrum.de
Introduction The combination of a fracture of the scaphoid and the capitate is not very common. In 1956, Fenton [1] described a special type of a scaphocapitate fracture which he deWned as a combination of a fracture of the scaphoid in its middle third and a capitate fracture with 90° to 180° rotation of the proximal capitate pole in the frontal plane. There are only approximately 40 cases reported in international literature [2–5]. The rarity of this lesion is supposedly the main reason why it is commonly underdiagnosed at initial presentation to a physician. Furthermore, on plain X-rays the fracture pattern is hardly identiWable. An early CT scan is required to conWrm the diagnosis of a scaphocapitate fracture syndrome and in addition, it helps the surgeon to identify any irregularities in the alignment of the two carpal rows. Once the diagnosis is established, treatment consists of open reduction and internal Wxation by either screws, e.g. Herbert or headless compression screw (HCS), or Kirschner wires (K-wire). Anatomy of the carpus should be restored and temporary K-wire transWxation may be required because of collateral intercarpal ligament lesions. There are only few descriptions of associated lesions. Nagai et al. [6] found a lesion of the median nerve associated with a scaphocapitate fracture (traumatic carpal tunnel syndrome). Scaphocapitate fractures are also observed in patients with multiple injuries [7].
Case report We report on a 19-year-old man who presented to our hospital 2 months after he fell on his left wrist. He complained about persistent wrist pain and swelling as well as a decreased range of motion. After the initial presentation to
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an orthopaedic surgeon, the wrist was immobilized in a cast for 4 weeks and physiotherapy was started afterwards. Because of persistent wrist pain throughout the physiotherapeutic treatment, the joint was immobilized in the cast again. After all, a CT scan was taken and the patient was referred to our hospital. Clinical examination showed a swollen left wrist with a range of motion of 20° of Xexion, 10° of extension and 10° of ulnar and radial deviation. We did not determine any signs of a lesion of the median nerve. The computed tomography revealed a lesion of the scaphoid waist and a fracture of the capitate with rotation and a palmar dislocation of the proximal pole (Fig. 1). Operative treatment The young man was admitted to the hospital and because of fracture dislocation and carpal instability, we decided to operate 60 days after trauma. Open reduction was performed through a dorsal approach. The proximal pole of the capitate was found to be approximately 90° rotated transversely and dislocated palmarly. It was reduced and Wxed with a 1.5 and a 3.0 mm HCS (Fig. 2a, b). Fixation of the scaphoid was equally accomplished using a 3.0 mm HCS. To restore carpal integrity, the lunotriquetral ligament was repaired using a palmar approach and protected by K-wire transWxation. Intraoperative Xuoroscopy showed anatomic reduction of the fractures and a regular alignment of the carpus (Fig. 3). The wrist was immobilized in a short arm cast for another 4 weeks. Fig. 2 Intraoperative Wndings: palmar dislocation of the proximal capitate fragment (a). Reduction of the capitate fracture using K-wires and Wxation with headless compression screws (b)
Fig. 1 Preoperative CT scan showed a fracture of the scaphoid waist and a fracture of the capitate
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Fig. 3 Postoperative X-ray (Stecher view) showed anatomic reduction of the fractures and restored anatomy of the carpus
Arch Orthop Trauma Surg Fig. 4 Computed tomography 14 months after trauma showed complete union of the fractures with no signs of avascular necrosis
Fig. 5 Range of motion of the aVected wrist at follow-up 1 year after surgery
Follow-up Six weeks after surgery, the K-wires were removed and physiotherapy was initiated again. Plain radiographs 3 months after surgery showed a union of both the scaphoid and the capitate fracture, and the patient was able to return to work. Range of motion was 30° of extension and 45° of Xexion. A CT scan at follow-up 14 months after surgery showed a complete consolidation of the fractures with no signs of avascular necrosis neither of the scaphoid nor the capitate (Fig. 4a, b). There was a considerable increase in the range of motion to a Xexion of 60° and an extension of 45° (Fig. 5a, b). Ulnar and radial deviations were 35°, pronation and supination 80°, respectively. The patient was free of pain and reported no further swelling.
Discussion Fractures of the scaphoid account for approximately 80% of all carpal fractures and usually aVect young male patients. In contrast, capitate fractures are rare (1–2%) and frequently associated with the perilunate fracture-dislocation. Delayed diagnosis and treatment may result in non-unions
with subsequent carpal arthrosis and a carpal collapse (SNAC wrist). Furthermore, osteonecrosis of the proximal pole of the scaphoid and the head of the capitate may occur due to the speciWc blood supply of these bones [8]. The body and the head of the capitate are usually supplied by distally entering vessels that course proximally within the bone [8, 9]. Considering the degree of dislocation in our case, it is remarkable that the proximal fragment of the capitate survived 2 months of being without blood supply from these arteries. Presumably, blood supply of the proximal part was assured by smaller vessels that occasionally enter more proximally and by an intact extraosseous vascularity. Nevertheless, the proximal parts of both the scaphoid and the capitate are at risk of avascular necrosis in case of fractures due to the retrograde pattern of blood supply. Early detection of dislocated fractures is essential to prevent necrosis. Therefore, we strongly advocate a CT scan at an early stage if a complex lesion of the carpus is assumed and cannot be excluded from plain radiographs. A combination of both a scaphoid and a capitate fracture with rotation of the proximal capitate pole was Wrst described by Fenton as a particular type of carpal injuries [1]. Only around 40 cases have been described in literature since that early presentation [2, 4, 7, 10, 11]. Most authors consider it to be a variety of perilunate fracture-dislocation
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Arch Orthop Trauma Surg Fig. 6 Postulated mechanism of the injury in our patient: Axial loading leads to a fracture of the capitate (a). Additional radial deviation causes the scaphoid fracture (b)
as a Wnal stage of a greater arc injury with the potential of spontaneous reduction [11–13]. According to Johnson, we characterize the fracture pattern in our patient as a stage III injury of the greater arc [12]. With respect to the classiWcation of MayWeld et al., it appears as a stage III lesion as well, because the scaphoid, the capitate and the triquetrum have been aVected by instability [14, 15]. Yet, the mechanism of the injury remains controversial: Fenton [1] assumed that a fall on the dorsoradially Xexed wrist causes the radial styloid process to hit the scaphoid and capitate. Thirteen years later, Stein and Siegel reported a diVerent mechanism. Hyperextension without radial deviation results in a fracture of the capitate from its contact to the dorsal lip of the radius. The proximal capitate fragment rotates 90° owing to the force of extension, and return of the hand to neutral position completes the 180° [16]. Based on the patient’s history and the intraoperative Wndings in our case, we presume the following mechanism of the injury: The patient fell on the dorsiXected wrist and the axial loading resulted in a fracture of the capitate bone (Fig. 6a). With additional radial deviation, the scaphoid collides with the radial styloid process which leads to a fracture of its proximal pole (Fig. 6b). The energy is then transmitted through the triquetrum, causing a lesion of the intercarpal ligaments. The fracture pattern varies between the diVerent reports. Whereas Fenton [1] observed a rotation of the proximal pole of the capitate in the frontal plane, other authors described palmar dislocations of the capitate [6]. In our case, the proximal fragment of the capitate was found to be dislocated palmarly and rotated by approximately 90° in the transverse plane. Vance et al. [17] reviewed previously presented cases, reported seven own cases and detected six diVerent patterns of fracture-dislocation. Palmar dislocation appears to increase the susceptibility to a lesion of the median nerve [6, 18, 19]. In contrast, we did not Wnd such a
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lesion despite a palmar dislocation of the proximal capitate fragment in our patient. Presumably, the diagnosis of a scaphocapitate fracture is frequently missed at the initial presentation to a physician. There are several reports of delayed diagnosis of this injury pattern [10, 20, 21]. Plain radiographs may not show the extent of the lesion and, therefore, treatment remains conservative initially. Furthermore, the surgeon may not bear this speciWc injury in mind because of its rarity. In those cases, only persistent pain and a decreased wrist function result in additional imaging which Wnally leads to the right diagnosis. DiVerent treatment options for scaphocapitate fractures have been described. In due times, Fenton [1] removed the proximal fragment of the capitate because he considered an osteonecrosis as unavoidable. Nowadays, anatomic reconstruction by either K-wire or screw Wxation is state of the art in displaced fractures of the carpus [17, 22]. In case of non-displaced fractures, conservative treatment may be applied. However, Schädel-Höpfner et al. [23] showed in a controlled multicenter cohort study, that patients treated operatively for a non-displaced scaphoid fracture returned signiWcantly earlier to work and had a better functional outcome compared to patients immobilized in a cast until fracture union was achieved. Yet, the complication rate including non-unions of the fractures was higher in the operative group. In our patient, both fractures were Wxed by HCS and radiographically healed within 12 weeks. No complications were observed.
Conclusion The present case revealed a good clinical result despite a considerably delayed diagnosis 2 months after trauma. Perilunate fracture-dislocations remain a diagnostic challenge
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and should always be taken into consideration if clinical and radiographic Wndings remain unclear. Careful examination and a forceful use of additional imaging such as CT scans are essential to establish an early diagnosis and to achieve the best functional outcome. By this means, the risk of complications, e.g. pseudarthrosis or avascular necrosis of the carpal bones, can be decreased. Nevertheless, satisfying results may be achieved even if the patient was underdiagnosed initially. Consistent with previously described cases, open reduction and internal Wxation with Herbert or headless compression screws is the treatment of choice. Intensive postoperative rehabilitation is required to restore the range of motion of the aVected wrist and prevent stiVness.
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