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Internal fixation of a capitate fracture with Herbert screws
Internal fixation of a capitate fracture with Herbert screws A case of an isolated, displaced fracture of the capitate is described. This rare carpal injury was treated by internal hxation with two Herbert screws. The fracture united and the patient achieved an excellent range of wrist motion. The Herbert screw is useful in the treatment of displaced fractures of the capitate since the screw maintains reduction, compresses the fracture site, and allows early wrist motion. (J HAND SURC 1990;15A:885-7.)
Robin R. Richards, MD, FRCS(C), C. Bruce Paitich, MD, and Robert S. Bell, MD, FRCS(C), Toronto, ht.. Canada
I
solated fracture of the capitate is rare. Adler and Shaftan’ found 42 reported cases of isolated capitate fractures and added 6 cases of their own. In 1982, Rand and Linscheid’ reported 13 capitate fractures out of 978 carpal injuries, an incidence of 1.3%. Only 3 of the 13 were isolated fractures. We recently treated a patient with an isolated capitate fracture with two Herbert screws. We believe this method of fixation has merit in the treatment of displaced fractures of the capitate. Case report A 21-year-old, right-handed man was involved in a motorcycle accident. He sustained injuries to his right and left wrists and a fracture of the left distal femur. Both wrists were grossly swollen with intact neurovascular status. Radiographs of the right wrist showed an intraarticular fracture through the middle one third of the capitate with dorsal subluxation of the distal fragment (Fig. 1, A and B). Radiographs of the left wrist demonstrated a dorsal radiocarpal dislocation. With the patient under general anesthesia the femur was fixed internally and left wrist reduced and percutaneously pinned. A dorsal approach between the third and fourth extensor compartment was employed to expose the right
.
capitate
The proximal fragment of the capitate measured approximately 6 x 8 x 10 mm. The fragment was reduced and the
From the Upper Extremity Reconstructive Service, St. Michael’s Hospital;
and the University
Received for publication 21, 1989.
of Toronto,
Toronto, Ont., Canada.
Aug. 4, 1989; accepted in revised form Oct.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: R. R. Richards, MD, 55 Queen St. East, Suite 800, Toronto, Ont., Canada, MSC lR6. 3/l/18080
Fig. 1. A, Posteroanterior radiograph looks deceptively normal. The proximal pole of the capitate (arrow) can be seen at the junction of the lunate, triquetrum and hamate. B, Lateral radiograph shows dorsal displacement of the capitate. The proximal pole of the capitate is displaced in a palmar direction,
position secured with a Kirschner (K-)wire. Two Herbert screws were used to fix the fragment. The screw hole in the proximal fragment was over drilled. The Herbert compression clamp was not used. An intraoperative radiograph showed THE JOURNAL OF HAND SURGERY
885
886
Richards, Paitich, and Bell
The Journal of HAND SURGERY
Fig. 2. A, Postoperative posteroanterior radiograph showing anatomic reduction of the capitate fragments. The screws gave excellent fixation. The ulnar screw appears prominent although at surgery the screw head was buried beneath the articular surface. B, Postoperative lateral radiograph showing reduction of the dorsal displacement of the capitate and restoration of normal carpal alignment. anatomic reduction of the fragment. A palmar slab was applied in the operating room. After operation the wrist was immobilized in a detachable volar splint for 4 weeks to encourage capsular healing. The patient received a series of wrist range of motion exercises and grip strengthening exercises beginning 4 weeks after operation. Five months after injury the patient returned to work as an automobile mechanic. One year after injury physical examination of the wrist showed 55 degrees flexion, 40 degrees extension, 30 degrees ulnar deviation, and 10 degrees radial deviation. Grip strength measured 42 kg on the right (53 kg on the left). Radiographs showed solid union and normal carpal alignment (Fig. 2, A and B). No signs of avascular necrosis of the proximal pole fragment were observed on any of the postoperative radiographs. The patient had no complaints with regard to his right wrist even with heavy use. Two years after operation the patient continues to work fulltime as an auto mechanic. Discussion The low incidence of isolated fracture of the capitate is because of its relatively protected environment within the carpt.~s.~ The capitate articulates with the third and fourth metacarpal bones, the hamate, the lunate, the scaphoid, and the trapezoid. Different mechanisms of injury have been proposed.‘* 4 The most common is probably a fall on the palm with the wrist extended. Stein and Siegal’ showed in cadaver studies that with extreme extension the dorsal lip of the radius may strike the cap&ate, causing a fracture, often accompanied by
a fracture of the scaphoid in tension. A direct blow over the dorsum of the wrist can also fracture the capitate. Extreme flexion may cause the palmar lip of the radius to strike the capitate directly, causing a fracture. We are not certain of the mechanism of injury in our patient. As with scaphoid fractures, it may be difficult to recognize the fractured capitate radiologically. ’ Physical examination may provide the most important diagnostic information-that of localized point tenderness over the capitate.6 The implications of a displaced intraartitular fracture of the capitate are the same as fractures of other carpal bones in terms of carpal mechanics. In our case, we did not consider excising the fragment since we thought it contributed to midcarpal joint stability. Avascular necrosis and nonunion of the proximal fragment of the capitate are significant risks after this injury although they did not occur in our case. As demonstrated by Grend et a1.,7 the blood supply to the capitate is by distal-to-proximal flow across the waist. While the incidence of nonunion is not well documented, Rand et al.* reported that in their series two out of three isolated capitate fractures went on to a nonunion after treatment by cast immobilization. They further suggest that capitate fractures be treated aggressively with anatomic reduction, obtained by open techniques if necessary. Richards et al.‘. ’ have treated displaced capitellar fractures and a case of a displaced fracture of the distal
Vol. 15A, No. 6 November 1990
phalanx with Herbert screws with good results. Roth and de Lorenzi” used a Herbert screw to treat a fracture of the hamate. Ayers et al.” and Fischer et al.” have described the use of Herbert screw fixation for arthrodesis of both the proximal and distal interphalangeal joints. The Herbert screw is designed to fix and compress bone fragments while being completely buried and not requiring removal. 13,I4 The same characteristics that make the Herbert screw useful in the treatment of disorders of the scaphoid also make it useful in the treatment of displaced fractures of other carpal bones. REFERENCES 1. Adler JB, Shaftan GW. Fractures of the capitate. J Bone Joint Surg 1962;44A:1537-47. 2. Rand JA, Linscheid RL, Dobyns JH. Capitate fractures: a long term follow-up. Clin Orthop 1982;165:209-16. 3. Bryan RS, Dobyns JH. Fractures of the carpal bones other than lunate and navicular. Clin Orthop 1980;149: 107-11. 4. Vance RM, Gelberman RH, Evans EF. Scaphocapitate fractures. J Bone Joint Surg 1980;62A:271-6. 5. Stein F, Siegel MW. Naviculocapitate fracture syndrome. A case report: new thoughts on the mechanism of injury. J Bone Joint Surg 1969;51A:391-5. 6. Minami M, Yamazaki J, Chisaka N, Kato S, Ogino T,
Internal jixation of capitate fracture with Herbert screw3
7.
8.
9.
10.
11.
12.
13. 14.
887
Minami A. Nonunion of the capitate. J HAND SURG 1987;121\:1089-91. Grend RV, Dell PC, Glowczewskie F, Leslie B, Ruby LK. Interosseous blood supply of the capitate and its correlation with aseptic necrosis. J HAND SC~RG1984; 9A:677-80. Richards RR, Khoury GW, Burke FD, Waddell JP. Internal fixation of capitellar fractures using Herbert screws: a report of four cases. Can J Surg 1987;30:18891. Richards RR, Khoury G, Young MC. Internal fixation of an unstable open fracture of a distal phalanx with a Herbert screw. J HAND SURG 1988;13A:428-32. Roth JH, de Lorenzi C. Displaced intra-articular coronal fracture of the body of the hamate treated with a Herbert screw. J HAND SURG 1988;13A:619-21. Ayers J, Miller G, Dell PC. Proximal interphalangeal joint arthrodesis with the Herbert screw. J HAND SURG 1988;13A:306. Fisher TJ, Strickland JW. Distal interphalangeal joint arthrodesis using the Herbert bone screw. J HAND SURG 1988;13A:306. Herbert TJ, Fisher WE. Use of the Herbert bone screw in surgery of the wrist. Clin Orthop 1986;202:79-92. Herbert TJ. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 1984;66B: 114-23.
Robin R. Richards, MD, FRCS(C), C. Bruce Paitich, MD, and Robert S. Bell, MD, FRCS(C), Toronto, ht.. Canada
I
solated fracture of the capitate is rare. Adler and Shaftan’ found 42 reported cases of isolated capitate fractures and added 6 cases of their own. In 1982, Rand and Linscheid’ reported 13 capitate fractures out of 978 carpal injuries, an incidence of 1.3%. Only 3 of the 13 were isolated fractures. We recently treated a patient with an isolated capitate fracture with two Herbert screws. We believe this method of fixation has merit in the treatment of displaced fractures of the capitate. Case report A 21-year-old, right-handed man was involved in a motorcycle accident. He sustained injuries to his right and left wrists and a fracture of the left distal femur. Both wrists were grossly swollen with intact neurovascular status. Radiographs of the right wrist showed an intraarticular fracture through the middle one third of the capitate with dorsal subluxation of the distal fragment (Fig. 1, A and B). Radiographs of the left wrist demonstrated a dorsal radiocarpal dislocation. With the patient under general anesthesia the femur was fixed internally and left wrist reduced and percutaneously pinned. A dorsal approach between the third and fourth extensor compartment was employed to expose the right
.
capitate
The proximal fragment of the capitate measured approximately 6 x 8 x 10 mm. The fragment was reduced and the
From the Upper Extremity Reconstructive Service, St. Michael’s Hospital;
and the University
Received for publication 21, 1989.
of Toronto,
Toronto, Ont., Canada.
Aug. 4, 1989; accepted in revised form Oct.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: R. R. Richards, MD, 55 Queen St. East, Suite 800, Toronto, Ont., Canada, MSC lR6. 3/l/18080
Fig. 1. A, Posteroanterior radiograph looks deceptively normal. The proximal pole of the capitate (arrow) can be seen at the junction of the lunate, triquetrum and hamate. B, Lateral radiograph shows dorsal displacement of the capitate. The proximal pole of the capitate is displaced in a palmar direction,
position secured with a Kirschner (K-)wire. Two Herbert screws were used to fix the fragment. The screw hole in the proximal fragment was over drilled. The Herbert compression clamp was not used. An intraoperative radiograph showed THE JOURNAL OF HAND SURGERY
885
886
Richards, Paitich, and Bell
The Journal of HAND SURGERY
Fig. 2. A, Postoperative posteroanterior radiograph showing anatomic reduction of the capitate fragments. The screws gave excellent fixation. The ulnar screw appears prominent although at surgery the screw head was buried beneath the articular surface. B, Postoperative lateral radiograph showing reduction of the dorsal displacement of the capitate and restoration of normal carpal alignment. anatomic reduction of the fragment. A palmar slab was applied in the operating room. After operation the wrist was immobilized in a detachable volar splint for 4 weeks to encourage capsular healing. The patient received a series of wrist range of motion exercises and grip strengthening exercises beginning 4 weeks after operation. Five months after injury the patient returned to work as an automobile mechanic. One year after injury physical examination of the wrist showed 55 degrees flexion, 40 degrees extension, 30 degrees ulnar deviation, and 10 degrees radial deviation. Grip strength measured 42 kg on the right (53 kg on the left). Radiographs showed solid union and normal carpal alignment (Fig. 2, A and B). No signs of avascular necrosis of the proximal pole fragment were observed on any of the postoperative radiographs. The patient had no complaints with regard to his right wrist even with heavy use. Two years after operation the patient continues to work fulltime as an auto mechanic. Discussion The low incidence of isolated fracture of the capitate is because of its relatively protected environment within the carpt.~s.~ The capitate articulates with the third and fourth metacarpal bones, the hamate, the lunate, the scaphoid, and the trapezoid. Different mechanisms of injury have been proposed.‘* 4 The most common is probably a fall on the palm with the wrist extended. Stein and Siegal’ showed in cadaver studies that with extreme extension the dorsal lip of the radius may strike the cap&ate, causing a fracture, often accompanied by
a fracture of the scaphoid in tension. A direct blow over the dorsum of the wrist can also fracture the capitate. Extreme flexion may cause the palmar lip of the radius to strike the capitate directly, causing a fracture. We are not certain of the mechanism of injury in our patient. As with scaphoid fractures, it may be difficult to recognize the fractured capitate radiologically. ’ Physical examination may provide the most important diagnostic information-that of localized point tenderness over the capitate.6 The implications of a displaced intraartitular fracture of the capitate are the same as fractures of other carpal bones in terms of carpal mechanics. In our case, we did not consider excising the fragment since we thought it contributed to midcarpal joint stability. Avascular necrosis and nonunion of the proximal fragment of the capitate are significant risks after this injury although they did not occur in our case. As demonstrated by Grend et a1.,7 the blood supply to the capitate is by distal-to-proximal flow across the waist. While the incidence of nonunion is not well documented, Rand et al.* reported that in their series two out of three isolated capitate fractures went on to a nonunion after treatment by cast immobilization. They further suggest that capitate fractures be treated aggressively with anatomic reduction, obtained by open techniques if necessary. Richards et al.‘. ’ have treated displaced capitellar fractures and a case of a displaced fracture of the distal
Vol. 15A, No. 6 November 1990
phalanx with Herbert screws with good results. Roth and de Lorenzi” used a Herbert screw to treat a fracture of the hamate. Ayers et al.” and Fischer et al.” have described the use of Herbert screw fixation for arthrodesis of both the proximal and distal interphalangeal joints. The Herbert screw is designed to fix and compress bone fragments while being completely buried and not requiring removal. 13,I4 The same characteristics that make the Herbert screw useful in the treatment of disorders of the scaphoid also make it useful in the treatment of displaced fractures of other carpal bones. REFERENCES 1. Adler JB, Shaftan GW. Fractures of the capitate. J Bone Joint Surg 1962;44A:1537-47. 2. Rand JA, Linscheid RL, Dobyns JH. Capitate fractures: a long term follow-up. Clin Orthop 1982;165:209-16. 3. Bryan RS, Dobyns JH. Fractures of the carpal bones other than lunate and navicular. Clin Orthop 1980;149: 107-11. 4. Vance RM, Gelberman RH, Evans EF. Scaphocapitate fractures. J Bone Joint Surg 1980;62A:271-6. 5. Stein F, Siegel MW. Naviculocapitate fracture syndrome. A case report: new thoughts on the mechanism of injury. J Bone Joint Surg 1969;51A:391-5. 6. Minami M, Yamazaki J, Chisaka N, Kato S, Ogino T,
Internal jixation of capitate fracture with Herbert screw3
7.
8.
9.
10.
11.
12.
13. 14.
887
Minami A. Nonunion of the capitate. J HAND SURG 1987;121\:1089-91. Grend RV, Dell PC, Glowczewskie F, Leslie B, Ruby LK. Interosseous blood supply of the capitate and its correlation with aseptic necrosis. J HAND SC~RG1984; 9A:677-80. Richards RR, Khoury GW, Burke FD, Waddell JP. Internal fixation of capitellar fractures using Herbert screws: a report of four cases. Can J Surg 1987;30:18891. Richards RR, Khoury G, Young MC. Internal fixation of an unstable open fracture of a distal phalanx with a Herbert screw. J HAND SURG 1988;13A:428-32. Roth JH, de Lorenzi C. Displaced intra-articular coronal fracture of the body of the hamate treated with a Herbert screw. J HAND SURG 1988;13A:619-21. Ayers J, Miller G, Dell PC. Proximal interphalangeal joint arthrodesis with the Herbert screw. J HAND SURG 1988;13A:306. Fisher TJ, Strickland JW. Distal interphalangeal joint arthrodesis using the Herbert bone screw. J HAND SURG 1988;13A:306. Herbert TJ, Fisher WE. Use of the Herbert bone screw in surgery of the wrist. Clin Orthop 1986;202:79-92. Herbert TJ. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 1984;66B: 114-23.