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A rare coronal fracture of the medial carpal column: Case report
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ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 94–97
Clinical case
A rare coronal fracture of the medial carpal column: Case report Fracture coronale de la colonne médiale du carpe : un cas rare B. Dunet *, M. Vargas, J. Pallaro, C. Tournier, T. Fabre Orthopedic and Traumatologic Unit, Hôpital Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux cedex, France Received 9 March 2014; received in revised form 13 January 2015; accepted 13 January 2015 Available online 3 March 2015
Abstract Carpal coronal fractures are rare. We report the case of a 15 year-old male who fell from a balcony and suffered a displaced coronal fracture of the capitate, hamate and triquetrum. The diagnosis, which was initially made based on the X-rays, was confirmed by CT scan. Open reduction and internal fixation using Herbert screws was performed. To the best of our knowledge, this is the first published case of a coronal fracture of these three bones. The patient returned to normal activities after six months. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: Carpus; Hamate; Triquetrum; Capitate; Coronal fracture
Résumé Les fractures coronales du carpe sont rares. Nous rapportons le cas d’un jeune homme de 15 ans qui, dans les suites d’une chute d’un balcon, a présenté une fracture déplacée coronale du capitatum, de l’hamatum et du triquetrum. Le diagnostic, suspecté sur les radiographies initiales, a été confirmé par un scanner. Un vissage en compression de ces différentes lésions a été réalisé. Il s’agit, à notre connaissance, du premier cas rapporté associant la fracture coronale de ces trois os. Le patient a pu reprendre ses activités dans un délai de 6 mois. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Carpe ; Hamatum ; Triquetrum ; Capitatum ; Fracture coronale
1. Introduction
2. Case report
Carpal coronal fractures are rare [1–12]. The first challenge is to recognize them and the second is to select the appropriate treatment. In this report, we describe the first case of a simultaneous coronal fracture of the capitate, hamate and triquetrum bones.
A 15 year-old man who fell from a balcony presented with multiple trauma. In the emergency room, a bilateral calcaneus fracture was identified, which was fixed surgically, and two lumbar transverse process fractures were identified and were treated by casting. The patient also had a swollen, painful and weak left wrist. X-rays were taken (Fig. 1). Only the metacarpal fractures were seen initially but after specialized surgical consultation, a CT scan was ordered. This imaging assessment showed a simultaneous coronal fracture of the whole ulnar column of the wrist (capitate, hamate and triquetrum bones) associated with 3rd and 4th metacarpal base fractures (Fig. 2). The likely mechanism of injury was axial compression of the 3rd and 4th
* Corresponding author. E-mail address: [email protected] (B. Dunet). http://dx.doi.org/10.1016/j.main.2015.01.003 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved.
B. Dunet et al. / Chirurgie de la main 34 (2015) 94–97
95
Fig. 1. AP and lateral preoperative X-rays.
rays of the hand, which split the ulnar carpal column in the coronal plane. Surgical treatment was undertaken five days after the accident for these fractures. A posterior approach was used with a ‘‘Berger-like’’ capsulotomy [13], and then Herbert compression screws were used to fix the three coronal carpal fractures. Persistent posterior subluxation of the 3rd metacarpal bone required K-wire fixation (Fig. 3). The patient wore a wrist cast for one month and then was allowed to remove it gradually, as pain allowed. Active movements of metacarpophalangeal and fingers joints were allowed immediately. Fracture consolidation was confirmed by X-rays after 6 weeks and the K-wires were removed (Fig. 4).
Fig. 2. Primary CT scan. Distal row axial section (a). Proximal row axial section (b). Capitate sagittal section (c). Hamate sagittal section (d).
At 6-months follow-up, the patient recovered symmetrical range of motion with 658 extension, 708 flexion, 408 ulnar deviation, 108 radial deviation. He could carry out all of his activities without limitation. At 9-months follow-up, his PRWE total score was 9.5/100 [14], his Jamar grip strength was 50 kg in his right and 46 kg in his left hand [15]. 3. Discussion Capitate fractures represent 0.2 to 1.3% of carpal fractures, hamate fractures 2 to 4% and triquetrum fracture 18 to 30% [4,16–19]. A simultaneous coronal fracture of these three bones is extremely rare. We found no other reports of this type of injury in the scientific literature. Kang et al. reported a coronal fracture of the capitate, hamate and trapezoid bone [1], while Robinson and Kaye reported a coronal fracture of the capitate and hamate without triquetrum involvement [20]. Kessler et al. reported a triquetrum and hamate fracture [2]. Axial injury to the ulnar column of the wrist is usually associated with neck or diaphysis fractures of the 4th and 5th
Fig. 3. AP and lateral postoperative X-rays.
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B. Dunet et al. / Chirurgie de la main 34 (2015) 94–97
Fig. 4. CT scan at 2 months. Triquetrum sagittal section (a). Hamate axial section (b). Capitate sagittal section (c). Coronal carpal section (d).
metacarpal or a metacarpophalangeal joint fracture. Coronal hamate fractures are caused by axial trauma to the 4th and 5th rays of the hand with ulnar deviation and palmar flexion [4]. We hypothesized that our patient sustained axial trauma with slight ulnar deviation, which induced initial contact with the 3rd and 4th rays of the hand. The mechanical energy directed to the ulnar column resulted in a coronal fracture of the three bones. Furthermore, wrist extension, without a palmar flexion, can explain the impaction of the posterior radius cortex [2]. The full diagnosis is based on a complete clinical examination and standard X-rays. Posterior subluxation of the 4th and 5th metacarpals on the lateral view should lead one to suspect a capitate and/or hamate injury [4]. We think that additional X-rays with ulnar deviation or stress X-rays could be painful for the patient and that a CT scan could be more helpful. Indeed, a CT scan should be systematic if there is any doubt, to ensure that the fractures are not missed [3,4,19–22]. The CT scan images can help to determine the type of lesion, detect fracture displacement, and provide information about potential associated ligament lesions. Sonography may help to diagnose any intrinsic ligament lesions also [23]. Surgical treatment through a posterior approach provides a good view of the intra-articular reduction, which must be perfect to avoid early arthritis and be fixed rigidly in compression with a Herbert screw [1,5,8,10,24]. Kang et al. performed closed reduction and fixation with a percutaneous compression screw, while respecting the dorsal metacarpal ligaments and keeping with the ligamentotaxis principle [1]. In our opinion, arthroscopy has no place in the treatment of complex carpal fractures affecting both carpal rows but may be an option in cases of isolated fractures of the proximal row to verify reduction and determine if the ligaments are intact [25,26]. This is the first published case report describing a coronal fracture of the ulnar column. The mechanism of injury is hypothesized to be axial compression of the 3rd and 4th rays of the hand (the two tallest), more or less associated with ulnar deviation and wrist extension. A CT scan must be performed systematically to quickly and correctly treat the various injuries present. We believe that open reduction and internal fixation with a compression screw is needed to obtain the best results.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Kang SY, Song KS, Lee HJ, Lee JS, Park YB. A case report of coronal fractures through the hamate, the capitate, and the trapezoid. Arch Orthop Trauma Surg 2009;129:963–5. [2] Kessler T, Köpke J, Gebert L. Simultaneous corpus fractures of the os triquetrum and os hamatum diagnosed by magnetic resonance tomography. A case report. Handchir Mikrochir Plast Chir 1996;28:50–2. [3] Langenhan R, Hohendorff B, Probst A. Coronal fracture dislocation of the hamate and the base of the fourth metacarpal bone: a rare form of carpometacarpal injury. Handchir Mikrochir Plast Chir 2011;43:140–6. [4] Cano Gala C, Pescador Hernández D, Rendón Díaz DA, López Olmedo J, Blanco Blanco J. Fracture of the body of hamate associated with a fracture of the base of fourth metacarpal: a case report and review of literature of the last 20 years. Int J Surg Case Rep 2013;4:442–5. [5] Schädel-Höpfner M, Prommersberger KJ, Eisenschenk A, Windolf J. Treatment of carpal fractures. Recommendations of the Hand Surgery Group of the German Trauma Society. Unfallchirurg 2010;113:741–54. [6] Binhammer P, Born T. Coronal fracture of the body of the trapezium: a case report. J Hand Surg Am 1998;23:156–7. [7] Suresh S. Isolated coronal split fracture of the trapezium. Indian J Orthop 2012;46:99–101. [8] Wharton DM, Casaletto JA, Choa R, Brown DJ. Outcome following coronal fractures of the hamate. J Hand Surg Eur Vol 2010;35:146–9. [9] Vidil A, Dumontier C. Coronal fractures of scaphoid. Chir Main 2004;23:157–63. [10] Thomsen NO. A dorsally displaced capitate neck fracture combined with a transverse shear fracture of the triquetrum. J Hand Surg Eur Vol 2013;38:210–1. [11] Hofmeister EP, Faruqui S. Two unusual cases of coronal lunate fracture. Orthopedics 2009;32:4 [pii: orthosupersite.com/view.asp?rID=38068]. [12] Christodoulou L, Palou CH, Chamberlain ST. Proximal row transcarpal fracture from a punching injury. J Hand Surg Br 1999;24:744–6. [13] Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg 1995;35:54–9. [14] MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma 1998;12:577–86. [15] Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am 1984;9:222–6. [16] Ong JC, Devitt BM, O’Sullivan ME. Impaction-fracture of the capitate and lunate: a case report. J Orthop Surg (Hong Kong) 2012; 20:243–5.
B. Dunet et al. / Chirurgie de la main 34 (2015) 94–97 [17] Kaewlai R, Avery LL, Asrani AV, Abujudeh HH, Sacknoff R, Novelline RA. Multidetector CT of carpal injuries: anatomy, fractures and fracturedislocations. Radiographics 2008;28:1771–84. [18] Höcker K, Menschik A. Fracture of the triquetrum. Pathomechanics, classification, treatment and results within the scope of follow up. Handchir Mikrochir Plast Chir 1994;26:207–12. [19] Hey HW, Chong AK, Murphy D. Prevalence of carpal fracture in Singapore. J Hand Surg Am 2011;36:278–83. [20] Robison JE, Kaye JJ. Simultaneous fractures of the capitate and hamate in the coronal plane: case report. J Hand Surg Am 2005;30:1153–5. [21] Gella S, Borse V, Rutten E. Coronal fractures of the hamate: are they rare or rarely spotted? J Hand Surg Eur Vol 2007;32:721–2.
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[22] Suh N, Ek ET, Wolfe SW. Carpal fractures. J Hand Surg Am 2014;39:785–91. [23] Karabay N. US findings in traumatic wrist and hand injuries. Diagn Interv Radiol 2013;19:320–5. [24] Porter ML, Seehra K. Fracture-dislocation of the triquetrum treated with a Herbert screw. J Bone Joint Surg Br 1991;73:347–8. [25] Dana C, Doursounian L, Nourrissat G. Arthroscopic treatment of a fresh lunate bone fracture detaching the scapholunate ligament. Chir Main 2010;29:114–7. [26] Slutsky DJ, Trevare J. Use of arthroscopy for the treatment of scaphoid fractures. Hand Clin 2014;30:91–103.
ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 94–97
Clinical case
A rare coronal fracture of the medial carpal column: Case report Fracture coronale de la colonne médiale du carpe : un cas rare B. Dunet *, M. Vargas, J. Pallaro, C. Tournier, T. Fabre Orthopedic and Traumatologic Unit, Hôpital Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux cedex, France Received 9 March 2014; received in revised form 13 January 2015; accepted 13 January 2015 Available online 3 March 2015
Abstract Carpal coronal fractures are rare. We report the case of a 15 year-old male who fell from a balcony and suffered a displaced coronal fracture of the capitate, hamate and triquetrum. The diagnosis, which was initially made based on the X-rays, was confirmed by CT scan. Open reduction and internal fixation using Herbert screws was performed. To the best of our knowledge, this is the first published case of a coronal fracture of these three bones. The patient returned to normal activities after six months. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: Carpus; Hamate; Triquetrum; Capitate; Coronal fracture
Résumé Les fractures coronales du carpe sont rares. Nous rapportons le cas d’un jeune homme de 15 ans qui, dans les suites d’une chute d’un balcon, a présenté une fracture déplacée coronale du capitatum, de l’hamatum et du triquetrum. Le diagnostic, suspecté sur les radiographies initiales, a été confirmé par un scanner. Un vissage en compression de ces différentes lésions a été réalisé. Il s’agit, à notre connaissance, du premier cas rapporté associant la fracture coronale de ces trois os. Le patient a pu reprendre ses activités dans un délai de 6 mois. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Carpe ; Hamatum ; Triquetrum ; Capitatum ; Fracture coronale
1. Introduction
2. Case report
Carpal coronal fractures are rare [1–12]. The first challenge is to recognize them and the second is to select the appropriate treatment. In this report, we describe the first case of a simultaneous coronal fracture of the capitate, hamate and triquetrum bones.
A 15 year-old man who fell from a balcony presented with multiple trauma. In the emergency room, a bilateral calcaneus fracture was identified, which was fixed surgically, and two lumbar transverse process fractures were identified and were treated by casting. The patient also had a swollen, painful and weak left wrist. X-rays were taken (Fig. 1). Only the metacarpal fractures were seen initially but after specialized surgical consultation, a CT scan was ordered. This imaging assessment showed a simultaneous coronal fracture of the whole ulnar column of the wrist (capitate, hamate and triquetrum bones) associated with 3rd and 4th metacarpal base fractures (Fig. 2). The likely mechanism of injury was axial compression of the 3rd and 4th
* Corresponding author. E-mail address: [email protected] (B. Dunet). http://dx.doi.org/10.1016/j.main.2015.01.003 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved.
B. Dunet et al. / Chirurgie de la main 34 (2015) 94–97
95
Fig. 1. AP and lateral preoperative X-rays.
rays of the hand, which split the ulnar carpal column in the coronal plane. Surgical treatment was undertaken five days after the accident for these fractures. A posterior approach was used with a ‘‘Berger-like’’ capsulotomy [13], and then Herbert compression screws were used to fix the three coronal carpal fractures. Persistent posterior subluxation of the 3rd metacarpal bone required K-wire fixation (Fig. 3). The patient wore a wrist cast for one month and then was allowed to remove it gradually, as pain allowed. Active movements of metacarpophalangeal and fingers joints were allowed immediately. Fracture consolidation was confirmed by X-rays after 6 weeks and the K-wires were removed (Fig. 4).
Fig. 2. Primary CT scan. Distal row axial section (a). Proximal row axial section (b). Capitate sagittal section (c). Hamate sagittal section (d).
At 6-months follow-up, the patient recovered symmetrical range of motion with 658 extension, 708 flexion, 408 ulnar deviation, 108 radial deviation. He could carry out all of his activities without limitation. At 9-months follow-up, his PRWE total score was 9.5/100 [14], his Jamar grip strength was 50 kg in his right and 46 kg in his left hand [15]. 3. Discussion Capitate fractures represent 0.2 to 1.3% of carpal fractures, hamate fractures 2 to 4% and triquetrum fracture 18 to 30% [4,16–19]. A simultaneous coronal fracture of these three bones is extremely rare. We found no other reports of this type of injury in the scientific literature. Kang et al. reported a coronal fracture of the capitate, hamate and trapezoid bone [1], while Robinson and Kaye reported a coronal fracture of the capitate and hamate without triquetrum involvement [20]. Kessler et al. reported a triquetrum and hamate fracture [2]. Axial injury to the ulnar column of the wrist is usually associated with neck or diaphysis fractures of the 4th and 5th
Fig. 3. AP and lateral postoperative X-rays.
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B. Dunet et al. / Chirurgie de la main 34 (2015) 94–97
Fig. 4. CT scan at 2 months. Triquetrum sagittal section (a). Hamate axial section (b). Capitate sagittal section (c). Coronal carpal section (d).
metacarpal or a metacarpophalangeal joint fracture. Coronal hamate fractures are caused by axial trauma to the 4th and 5th rays of the hand with ulnar deviation and palmar flexion [4]. We hypothesized that our patient sustained axial trauma with slight ulnar deviation, which induced initial contact with the 3rd and 4th rays of the hand. The mechanical energy directed to the ulnar column resulted in a coronal fracture of the three bones. Furthermore, wrist extension, without a palmar flexion, can explain the impaction of the posterior radius cortex [2]. The full diagnosis is based on a complete clinical examination and standard X-rays. Posterior subluxation of the 4th and 5th metacarpals on the lateral view should lead one to suspect a capitate and/or hamate injury [4]. We think that additional X-rays with ulnar deviation or stress X-rays could be painful for the patient and that a CT scan could be more helpful. Indeed, a CT scan should be systematic if there is any doubt, to ensure that the fractures are not missed [3,4,19–22]. The CT scan images can help to determine the type of lesion, detect fracture displacement, and provide information about potential associated ligament lesions. Sonography may help to diagnose any intrinsic ligament lesions also [23]. Surgical treatment through a posterior approach provides a good view of the intra-articular reduction, which must be perfect to avoid early arthritis and be fixed rigidly in compression with a Herbert screw [1,5,8,10,24]. Kang et al. performed closed reduction and fixation with a percutaneous compression screw, while respecting the dorsal metacarpal ligaments and keeping with the ligamentotaxis principle [1]. In our opinion, arthroscopy has no place in the treatment of complex carpal fractures affecting both carpal rows but may be an option in cases of isolated fractures of the proximal row to verify reduction and determine if the ligaments are intact [25,26]. This is the first published case report describing a coronal fracture of the ulnar column. The mechanism of injury is hypothesized to be axial compression of the 3rd and 4th rays of the hand (the two tallest), more or less associated with ulnar deviation and wrist extension. A CT scan must be performed systematically to quickly and correctly treat the various injuries present. We believe that open reduction and internal fixation with a compression screw is needed to obtain the best results.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Kang SY, Song KS, Lee HJ, Lee JS, Park YB. A case report of coronal fractures through the hamate, the capitate, and the trapezoid. Arch Orthop Trauma Surg 2009;129:963–5. [2] Kessler T, Köpke J, Gebert L. Simultaneous corpus fractures of the os triquetrum and os hamatum diagnosed by magnetic resonance tomography. A case report. Handchir Mikrochir Plast Chir 1996;28:50–2. [3] Langenhan R, Hohendorff B, Probst A. Coronal fracture dislocation of the hamate and the base of the fourth metacarpal bone: a rare form of carpometacarpal injury. Handchir Mikrochir Plast Chir 2011;43:140–6. [4] Cano Gala C, Pescador Hernández D, Rendón Díaz DA, López Olmedo J, Blanco Blanco J. Fracture of the body of hamate associated with a fracture of the base of fourth metacarpal: a case report and review of literature of the last 20 years. Int J Surg Case Rep 2013;4:442–5. [5] Schädel-Höpfner M, Prommersberger KJ, Eisenschenk A, Windolf J. Treatment of carpal fractures. Recommendations of the Hand Surgery Group of the German Trauma Society. Unfallchirurg 2010;113:741–54. [6] Binhammer P, Born T. Coronal fracture of the body of the trapezium: a case report. J Hand Surg Am 1998;23:156–7. [7] Suresh S. Isolated coronal split fracture of the trapezium. Indian J Orthop 2012;46:99–101. [8] Wharton DM, Casaletto JA, Choa R, Brown DJ. Outcome following coronal fractures of the hamate. J Hand Surg Eur Vol 2010;35:146–9. [9] Vidil A, Dumontier C. Coronal fractures of scaphoid. Chir Main 2004;23:157–63. [10] Thomsen NO. A dorsally displaced capitate neck fracture combined with a transverse shear fracture of the triquetrum. J Hand Surg Eur Vol 2013;38:210–1. [11] Hofmeister EP, Faruqui S. Two unusual cases of coronal lunate fracture. Orthopedics 2009;32:4 [pii: orthosupersite.com/view.asp?rID=38068]. [12] Christodoulou L, Palou CH, Chamberlain ST. Proximal row transcarpal fracture from a punching injury. J Hand Surg Br 1999;24:744–6. [13] Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg 1995;35:54–9. [14] MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma 1998;12:577–86. [15] Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am 1984;9:222–6. [16] Ong JC, Devitt BM, O’Sullivan ME. Impaction-fracture of the capitate and lunate: a case report. J Orthop Surg (Hong Kong) 2012; 20:243–5.
B. Dunet et al. / Chirurgie de la main 34 (2015) 94–97 [17] Kaewlai R, Avery LL, Asrani AV, Abujudeh HH, Sacknoff R, Novelline RA. Multidetector CT of carpal injuries: anatomy, fractures and fracturedislocations. Radiographics 2008;28:1771–84. [18] Höcker K, Menschik A. Fracture of the triquetrum. Pathomechanics, classification, treatment and results within the scope of follow up. Handchir Mikrochir Plast Chir 1994;26:207–12. [19] Hey HW, Chong AK, Murphy D. Prevalence of carpal fracture in Singapore. J Hand Surg Am 2011;36:278–83. [20] Robison JE, Kaye JJ. Simultaneous fractures of the capitate and hamate in the coronal plane: case report. J Hand Surg Am 2005;30:1153–5. [21] Gella S, Borse V, Rutten E. Coronal fractures of the hamate: are they rare or rarely spotted? J Hand Surg Eur Vol 2007;32:721–2.
97
[22] Suh N, Ek ET, Wolfe SW. Carpal fractures. J Hand Surg Am 2014;39:785–91. [23] Karabay N. US findings in traumatic wrist and hand injuries. Diagn Interv Radiol 2013;19:320–5. [24] Porter ML, Seehra K. Fracture-dislocation of the triquetrum treated with a Herbert screw. J Bone Joint Surg Br 1991;73:347–8. [25] Dana C, Doursounian L, Nourrissat G. Arthroscopic treatment of a fresh lunate bone fracture detaching the scapholunate ligament. Chir Main 2010;29:114–7. [26] Slutsky DJ, Trevare J. Use of arthroscopy for the treatment of scaphoid fractures. Hand Clin 2014;30:91–103.