Working Diagnosis:
Comminuted fracture of the Left anterior aspect of the capitate and non-displaced radial styloid fracture

Treatment:
The initial, x-rays revealed a non-displaced radial styloid fracture Case Photo #1 . The patient was placed in a short-arm fracture brace. She continued to participate in soccer activities without restrictions. Her radial wrist pain improved within 3 days, but the swelling and pain over the mid-dorsal aspect of the wrist persisted. Due to persistent pain and swelling, the patient was referred for an MRI of her wrist Case Photo #2 .

The patient's case and MRI imaging was reviewed with an orthopedic surgeon. MRI demonstrated a comminuted fracture of the capitate and non-displaced radial styloid fracture Case Photo #2 , Case Photo #3 , Case Photo #4 , Case Photo #5 , Case Photo #6 . She was transitioned into a short-arm thumb-spica splint.

The patient was seen in clinic four weeks later and repeat x-rays demonstrated a stable radial styloid fracture without evidence of healing. The capitate fracture was not visualized well on x-ray alone. The patient was subsequently referred for a CT of the wrist to better characterize the capitate fracture. CT re-demonstrated a comminuted capitate and radial styloid fractures in anatomic alignment with bridging sclerosis. Treatment using a thumb-spica splint was continued for an additional three weeks.

Outcome:
The patient did well with non-operative management. She continued unrestricted athletic participation with padding applied to the brace prior to all practices and games. She had no pain after the splint was removed. Upon discontinuation of the thumb-spica splint, she worked with physical therapy. There were no functional deficits noticed after completing physical therapy. The patient remained symptom free after removal of the splint and upon follow up. She continued to play unrestricted at the professional and national team level.

Author's Comments:
Capitate fractures account for only 1.3% of all carpal fractures (1). Only 25% of capitate fractures have a concomitant distal radius fracture (2). Isolated fractures are typically non-displaced. Non-displaced isolated capitate fractures should be treated with immobilization with a short-arm thumb-spica splint or cast for 6 to 8 weeks (3). Displaced fractures require anatomic reduction and immobilization for a minimum of 4 to 6 weeks. Treatment for comminuted fractures is based on expert opinion. The most significant complication of a capitate fracture is nonunion (4).

Editor's Comments:
Capitate fractures are a rare, but important diagnosis to be aware of in the context of a wrist pain associated with a traumatic injury. Diagnosis is often made with advanced cross-sectional imaging (i.e. MRI or CT), thus suspicion of this injury must remain high in presentation of traumatic mid-dorsal wrist pain with corresponding x-rays that may be negative for fracture (2). Isolated capitate fractures have been reported in around 20% of cases. Other common injuries reported in association with capitate fractures include most commonly scaphoid fractures. Associated distal radius, ulnar or other carpal bone fractures also have been reported though less frequently (2). Non-union is reported as one of the most common complications of this fracture, however, avascular necrosis and post-traumatic degenerative arthrosis are other complications which have also been reported (1,2,3). Literature on capitate fractures in the pediatric population is sparse. In one study, it appeared that capitate fractures occurred in isolation more frequently in the pediatric population relative to the adult population. However, this was a small study and further studies are necessary to better understand this fracture in the pediatric population (2).

References:
1. Rand JA, Linscheid RL, Dobyns JH. Capitate fractures: a long-term follow-up. Clin Orthop Relat Res. 1982;165:209-216.
2. Kadar A, Morsy M, Sur YJ. et al. Capitate Fractures: A Review of 53 Patients. J Hand Surg Am 2016; 41:e359
3. Minami M, Yamazaki J, Chisaka N et al. Nonunion of the capitate. J Hand Surg [Am] 1987; 12:pp.1089-1091.
4. Yoshihara M, Sakai A, Toba N et al. Nonunion of the isolated capitate wrist fracture. J Orthop Sci 2002; 7:pp. 578-580.

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