An unusual variety of scapho-capitate syndrome

AN UNUSUAL

VARIETY P. Y. MILLIEZ,

OF SCAPHO-CAPITATE M. DALLASERRA

SYNDROME

and J. M. THOMINE

From the Department of Orthopaedics, H6pital Charles Nicolle Rouen, France

We report a patient who sustained a displaced fracture of the lunate in association with fractures of the scaphoid and capitate. Union of the scaphoid and capitate fractures followed fixation with Herbert screws, 25 additional cases from the literature have been reviewed. Journal of Hand Surgery (British and European Volume, 1993) 18B: 53-57

stable although cornminuted. A forearm cast was worn for two months after the operation. The fractures appeared to have united by three months when the patient returned to work. At final follow-up 2.5 years after injury there was slight restriction of flexion and extension but other movements were full. Power grip was 83% of that in the left hand. The patient had some discomfort related to the weather, but no problems in working. X-ray examination showed normal density of the bones (Fig 2). The lunate appeared flattened but had healed. There was a 30”VISI angulation compared to 20” on the left.

The “scapho-capitate syndrome” has been defined by Fenton and Rosen (1950) as associated fractures of the scaphoid and capitate, with rotation of the head of the capitate through 90” or 180”. The first reports of this injury were by Lorie (1937), and Perves et al (1937).

CASE REPORT A 20-year-old right-handed male storekeeper fell downstairs probably with his right hand outstretched. Initial X-ray examination (Fig 1) showed a displaced fracture of the waist of the scaphoid, a comminuted fracture of the lunate with widening of bone, and a fracture of the waist of the capitate with rotation of the head, although this was not diagnosed. A forearm cast was applied, and the patient was referred to an orthopaedic surgeon. The true nature of the injury was realized 15 days later. Operation was carried out through a dorsal exposure. The head of the capitate was found to be free of ligamentous connections, rotated through 180” and impacted at the waist. In addition to the fractures of the scaphoid and lunate there was partial disruption of the luno-triquetral ligament, which was not repaired. The head of the capitate was reduced and internally fixed with a Herbert screw, as was the scaphoid. No attempt was made to fix the lunate because the fracture appeared

Fig 1

Initial radiograph. There is a typical “scaphocapitate syndrome”, with 180” rotation of the head of capitate, and an unusual fracture of the lunate with three fragments.

Fig 2

53

(a and b) At 2.5 years follow-up, there is union of the fractures, a 30” VISI deformity and no arthritic change.

THE JOURNAL

54

Table 1-25

cases of scapho-capitate

Author, year

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VOL. 18B No. 1 FEBRUARY

1993

syndrome reported ia the literature

Sex, age

Mechanism, side

Delay in diagnosis

Associated lesions

Treatment

Length offollow-up results

Lorie, 1937

M, 18

Fall 2 m on to left hand

1 day

0

Conservativeflate open reduction. Capitate fragment replaced + plaster 70 days

80 days, scaphoid capitate united

Perves et al, 1937

M, 20

Fall on outstretched right hand

0

Dorsal peri-lunate dislocation

Closed reduction. Failure of the reduction of the head of capitate. Plaster 1 month

1 month, cap&ate ununited in displaced position

?

?

0

Surgical. Anterior exposure, capitate reduced and pinned

No follow-up

1 month

0

Surgical. Excision of proximal capitate + plaster

No follow-up

1 year, no pain. Scaphoid united. Capitate united in displaced position.

Nicholson,

1940

?

and

Fenton and Rosen, 1950

M, 18

Jones, 1955

M, 3 1

Fall 5 m on to right hand

1 day

Possible per&lunate dislocation

Conservative. months

Fenton,

M, 31

Fall downstairs outstretched hand

0

Fracture

Surgical. Excision of proximal capitate + plaster 6 months

7 months, occasional pain. Scaphoid united

Van Cauwenberghe, 1957

M, 28

Fal15.5 mon to outstretched right hand

0

Dorsal peri-lunate dislocation

Closed reduction for dislocation. Head of capitate still inverted + 3 months plaster

10 months, occasional pain. Scaphoid and capitate ununited.

Rieder,

M, 20

Fall from a platform on right wrist

?

0

Conservative. Short arm cast 8 months

8 months, scaphoid united, capitate ununited in displaced position

Marsh and Lampros, 1959

M, 22

Fall on right wrist

1 month

M, 27

Fall on outstretched hand

0 left

Conservative cast. Diagnosis initially missed Closed reduction. Short cast 5 months

No follow-up

Adler and Shaftan, 1962

Articular fracture of radius + ulnar styloid + triquetrum Dorsal peri-lunate dislocation

Stein and Siegel, 1969

M, 28

Fall on outstretched hand

0 left

Dorsal peri-lunate dislocation+ fracture of radial styloid

Closed reduction secondary operations. Head of capitate excised. Scaphoid grafted

6 months, scaphoid necrosis and nonunion

1956

1958

Fall on outstretched hand

left

on left

of radius

Plaster 4

5 months, no pain, necrosis of proximal poles of both bones

Meyers et al, 1971

M, 25

Car crash possible hyperflexion

0

Volar peri-lunate dislocation

Surgical. Scaphoid fixed with K wire. Short cast 8 weeks

5 years, no pain, fractures healed with no necrosis

Weseley and Barenfeld, 1972

M, 19

Fall 3 m

0

Triquetral fracture Dorsal peri-lunate dislocation Humeral fracture

Surgical. Capitate and scaphoid reduced and grafted. Cast 11 weeks

2 years, no pain, fractures healed with no necrosis

Monahanand Galasko. 1972

M, 24

60 feet fall on right wrist

0

Per&lunate

Open reduction of cap&ate and scaphoid. Cast 14 weeks

5 months, no pain, fractures healed with no necrosis

dislocation

SCAPHO-CAPITATE

Table l-25

55

SYNDROME

cases of scapbo-capitate syndrome reportedin the literaturr+cmtinued

Author, year

Hohenbleicher,

1976

Vanse et al, 1980

Sex, age

Associated lesions

Delay in diagnosis

Mechanism, side

M, 16

Motor bike accident

?

Triquetral

fracture

M, 22

Right wrist Possible volar flexion stress

0

Dorsal peri-lunate dislocation

Length offollow-up results

Treatment

Open reduction and screw fixation of capitate. Cast 8 weeks

10 weeks, fractures healed

Open reduction. Capitate and scaphoid pinned grafted. Cast 3 months

9 months, pain moderate and

Vance et al, 1980

M, 22

Right wrist motor bike accident

8 weeks

0

Conservative months

Vance et al, 1980

M, 19

Left wrist fall 3 stories

0

Dorsal per&lunate dislocation (spine + pelvis + talus fractures)

Failure of closed reduction. Surgical at 6 days capitate pinned scaphoid not tIxed + cast 12 weeks

2 years, no pain, scaphoid ununited capitate united

Vance et al, 1980

M, 25

Right wrist high speed injury Possible volar flexion stress

3 weeks

Fracture of ulnar styloid + displaced distal radial fracture Possible peri-lunate dislocation (spine + femur associated fractures)

Failure of closed reduction. Surgical at 3 weeks fractures pinned + short cast 6 months

8 months, scaphoid ununited, capitate united

Vance et al, 1980

M, 21

Left wrist fall 3 m from a tree onto outstretched palm

1

Dorsal peri-lunate dislocation

Failure of closed reduction. Surgical fixation by pins

3 months, density increased on both poles

Vance et al, 1980

M, 20

Fall6 m onleft wrist

0

Dorsal per&lunate dislocation + fracture of femur

Closed reduction for dislocation. Surgical. Pin fixation failed because of comminution + cast 8 weeks

2 years, pain moderate, scaphoid ununited, dorsal subluxation of distal carpal row

Vance et al, 1980

M, 22

Left wrist, road traffic accident

3 weeks

Fractures of zygoma and femur

Surgical. Carpal tunnel release at 3 weeks, no fixation or reduction for carpal bones

9 months,

El-Khoury

M, 20

Fall 3 flights on outstretched left wrist

0

Dorsal peri-lunate dislocation

Surgical. Pin fixation of both bones

3 months, avascular necrosis of scaphoid nonunion, capitate united

Schild et al, 1983

M, 19

Left wrist

15 days

0

Conservative.

Not known

Zilch, 1986

M, 23

Left wrist

?

0

Conservative. Cast Surgical. At 6 months, grafting of scaphoid non-union

2 years, no pain, scaphoid united, capitate ununited

Sandor and Dosa, 19x7

M, 13

fall7m

?

Peri-lunate

Clos,ed reduction of dislocation. Surgical. Mini-plate with compression for both bones + cast 10 weeks

1 year, not known

Authors

M, 20

Fall downstairs outstretched right hand

15 days

Fracture

Surgical. At 17 days Herbert screws for scaphoid and capitate

2.5 years, no pain scaphoid capitate and lunate united

et al, 1982

case, 1992

on

dislocation

of lunate

cast 3

Cast

15 months, no pain, scaphoid united, capitate ununited

no pain

THE

56

REVIEW OF THE LITERATURE AND DISCUSSION Only 25 cases that satisfy Fenton and Rosen’s definition of the scapho-capitate syndrome have been reported since 1937 (Table 1). The injury always occurs in young men, with an average age of 22 (range 13-31) years. Both sides are equally affected. Most injuries are due to falls from height8 or vehicle accidents. In only eight cases was the mechanism clearly defined as a fall on the outstretched hand. In nearly one-third of cases there was a delay of more than 15 days in diagnosis. In 13 cases there was an initial peri-lunate dislocation, which was dorsal in 11. Eight patients had other carpal or wrist fractures (four of the radius, two of the ulnar styloid, and two of the triquetrum). Other major fractures occurred in seven as a result of the high-energy injury. Treatment was conservative in nine cases, and surgical in the other 17. In seven of them operation was required because of the failure of the conservative treatment. It is difficult to analyse the results of treatment because of inadequate information and short follow-up in many cases. The results of conservative treatment in the six cases in which there was adequate information are given in Table 2. Malunion was obvious in the only capitate that united. Five different types of surgical procedure were used and the results are given in Table 3. Although numbers are small it is interesting to note that with open reduction alone, union was obtained in three out of four scaphoids, and in all three capitate bones. Overall, five out of 14 scaphoids and eight out of 15 capitate bones failed to unite with surgical treatment. The mechanism of the injury is debatable. Stein and Siegel (1969) suggested that the fracture of the capitate Table 2-Results of conservativetreatment 6 cases Scaphoid Capitate

Non-union

Union

Necrosis

1 4

4 1

1 1

Table 3-Results of surgical treatment Procedure

Excision

Open rfu;iuztn

Pins fixation

Bone graft +pins

Plate or screw compression

1

1 2 1

1

fiwation Scaphoid Union Non-union Necrosis Unknown Capitate Union Non-union Necrosis Unknown

0

4 3 1

5 1 3 1

3

3 3

5 3

4 2 1 1 1 2 1

1 1

1

3

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was caused by impaction on the dorsal lip of the radius, when the wrist was dorsiflexed, a view that was supported by Monahan and Galasko (1972). However, Aitken and Nalebuff (1960) stressed that hyperflexion could produce peri-lunate dislocation, and this mechanism was thought to be important in three of the cases reported by Vance et al (1980). Whatever the mechanism, most authors think that the scapho-capitate syndrome is a variety of trans-scaphoid trans-capitate per&lunar fracture dislocation which has usually reduced spontaneously. The associated wrist fractures reported in the literature would tend to support this view and suggest that ligamentous injuries are frequently underestimated. An understanding of the injury will help in choosing the best treatment. Although union may occur with conservative treatment in a cast, the head of the capitate will still be displaced. Simple excision of the head of capitate will shorten the height of the carpus and predispose to arthritis (Vance et al, 1980; Allieu, 1984). Open reduction without internal fixation has been successful but there is still a risk of non-union. Open reduction and internal fixation using compression screws is probably most reliable in obtaining primary bony union but there is still a risk of avascular necrosis of the head of capitate because of the anatomy of its blood supply (Gelberman et al, 1983; Vander Grend et al, 1984). If there is a deficiency in the bone it may be necessary to consider cancellous grafting or partial carpal arthrodesis as recommended by Razemon (1984).

References ADLER, J. B. and SHAFTAN, G. W. (1982). Fracturesof the capitate. Journal ofBone and Joint Surgery, 44A:S :1537-1547. AITKEN, A. P. and NALEBUFF, E. A. (1960). Volar transnavicular perilunar dislocation of the carpus. Journal of Bone and Joint Surgery, 42A:6: 10511057. ALLIEU, Y. (1984). Instabilite du carpe: Principes thCrapeutiques gCnCraux. Annales de Chirurgie de la Main. 3 :4 :364367. EL-KHOURY, G. Y., USTA, H. Y. andBLAIR, W. F. (1982). Naviculocapitate fracture-dislocation. American Journal of Roentgenology, 139:385-386. FENTON, R. L and ROSEN, H. (1950). Fracture of the capitate bone-report of two cases. Bulletin of the Hospital for Joint Diseases Orthopaedic Institute, 11:134-139. FENTON, R. L. (1956). The naviculo-capitate fracture syndrome. Journal of Bone and Joint Surgery, 38A:3:681-684. GELBERMAN, R. H., PANAGIS, J. S., TALEISNIK, J. and BAUMGAERTNER, M. (1983). The arterial anatomy of the carpus, part I & II. Journal of Hand Surgery, 8 :367-382. HOHENBLEICHER, R. (1976). Das “naviculo-capitate fracture” syndrom. Unfallheilkunde, 79:281-283. JONES, G. B. (1955). An unusual fracture-dislocation of the carpus. Journal of Bone and Joint Surgery, 37B: 1: 146-147. LORIE, J. P. (1937). Un case de fractura de1 escafdides carpiano y de1 hueso grande. Cirugia Ortopkdica y Traumatologia Habana: 5 : 125-130. MARSH, A. P. and LAMPROS, P. J. (1959). The naviculo-capitate fracture syndrome. American Journal of Roentgenology, 82: 255-256. MEYERS, M. H., WELLS, R. and HARVEY, J. P. (1971). Naviculo-capitate fracture syndrome. Journal of Bone and Joint Surgery, 53A:7: 1383-1386. MONAHAN, P. R. W. and GALASKO, C. S. B. (1972). The scapho-capitate fracture syndrome. Journal of Bone and Joint Surgery, 54B: 1: 122-124. NICHOLSON, C. B. (1940). Fracture dislocation of the OS magnum. Journal of the Royal Naval Medical Service, 26:289-291.

SCAPHO-CAPITATE

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SYNDROME

PERVeS, .I., RIGAUD, A. andBADELON, L. (1937). Fracturepard6capitation du grand OSavec dtplacement dorsal du corps de l’os simulant une dislocation carpienne. Revue d’OrthopMie, 24:3:251-253. RAZEMON, J. P., Fractures des OS du Carpe. In Tubiana R., Trairt! de Chimrgie de la Main, Vo12. Paris, Masson: 1984:667-692. RIEDER, J. J. (1958). Fracturesofthecapitate bone. U.S. ArmedForces Medical Joumal,9:10:1513-1516. SANDOR, L. and DOSA, G. (1987). Das “scapho-capitate-fracture”-Syndrom (Fenton). Unfallchirurgie, 90: 547-549. SCHILD,H.,MUELLER,H.A.andKLOTTER,H. J.(1983).TransskaphoIdale, transkapitale Luxationsfraktur (“naviculo-capitate fracture syndrome”) *ine seltene Handwurzel-kombinationsverletmng. R6ntgen-Blatter, 36 :9 :299-302. STEIN, F. and SIEGEL, M. W. (1969). Naviculocapitate fracture syndrome: A case report: New thoughts on the mechanism of injury. Journal of Bone and Joint Surgery, 51A:2:391-395. VAN CAUWENBERGHE, R. (1957). Un cas rare de fracture-luxation du carpe. Acta Orthopaedica Belgica, 23 :79-84.

VANCE, R. M., GELBERMAN, R. H. and EVANS, E. F. (1980). Scaphocapitate fractures: Patterns of dislocation, mechanismsof injury, and preliminary results of treatment. Journal of Bone and Joint Surgery, 62A :2: 271-276. VANDER GREND, R., DELL, P. C., GLOWCZEWSKIE, F., LESLIE, B. and RUBY, L. K. (1984). Intraosseous blood supply of the capitate and its correlation with aseptic necrosis. Journal of Hand Surgery, 9A :5 :677-680. WESELEY, M. S. and BARENFELD, P. A. (1972) Trans-scaphoid, transcapitate, transtriquetral perilunate fracture dislocation of the wrist: A case report. Journal of Bone and Joint Surgery, 54A:5: 1073-1078. ZILCH, H. (1986). Das “scapho-capitate-fracture”-Syndrom. Handchirurgie Mikrochimrgie Plastische Chirurgie, 18 :59-60.

Accepted: 8 May 1992 Dr P. Y. Milliez, Department of Orthopaedics, HBpital Charles Nicolle, 76031 Rouen Cedex, 0 1993 The British

France. Society

for Surgery of the

Hand

1 Rue de Gemmnt,