Carpal Fractures in Athletes Excluding the Scaphoid

doi:10.1016/j.hcl.2009.05.013

Hand Clinics

Volume 25, Issue 3, August 2009, Pages 371-388

https://doi.org/10.1016/j.hcl.2009.05.013 Get rights and content

A wide range of hand and wrist injuries occur in today's recreational and elite athletes and account for 3% to 9% of all sports injuries. The onus is on the physician to discriminate between injuries that can be managed with an early return to sport, and those injuries that place the athlete at risk of further injury if they are not managed aggressively from the outset. The physician and the athlete must understand the balance between safe, early return to sport, and prompt surgical treatment that prevents late disability.

Section snippets

Incidence

Triquetral fractures are second only to scaphoid fractures as the most common carpal fractures, comprising 3% to 5% of all carpal fractures.5, 6, 7, 8 Two primary fracture patterns are observed; a dorsal chip or cortical fracture and triquetral body fractures. The dorsal chip fracture is much more common, reported to be as high as 93% of all triquetral fractures.⁷ Triquetral body fractures more commonly infer a high amount of energy to the wrist, and are observed with perilunate fracture

Incidence

Hamate fractures constitute approximately 2% of all carpal fractures.²⁴ The unique anatomy of the hamate hook places the bone at risk from compressive forces when the palm is struck and shear forces from the adjacent flexor tendons arise during forceful torque of the wrist.²⁵ The hamate forms the radial border of Guyon's canal and the ulnar border of the carpal tunnel (Fig. 2). Injury to the hamate can result in median and ulnar nerve dysfunction, although symptoms of median nerve dysfunction

Incidence

Trapezium fractures comprise 4% to 5% of carpal fractures.57, 58, 59 Fractures of the trapezium body are most common and described as horizontal and sagittal split, transarticular, dorsoradial tuberosity, and comminuted.⁶⁰ Sagittal split fractures are the most common. Volar trapezial ridge fractures, attachment site for the TCL, are less common. Ridge fractures have been classified as type I base fractures and type II avulsion tip fractures.⁵⁹ The association of trapezium fractures and first

Incidence

Capitate fractures comprise 1% to 2% of all carpal fractures.²⁴ The capitate is protected in the center of the hand by the surrounding carpus bones and metacarpals. A high-energy injury is typically necessary to create a fracture. In one study, capitate fractures occurred four times more commonly as part of a perilunate fracture dislocation than in isolation.⁶⁸ The combination of scaphoid waist fracture and capitate fracture with malrotation of the proximal fragment has been called the

Incidence

Trapezoid fractures constitute less than 1% of carpal fractures.²⁶ Like the capitate, the trapezoid is protected by the surrounding metacarpal and carpal bones. Fractures of the trapezoid typically result from high-energy injuries to the hand. There are no series to guide treatment.

Mechanism of Injury

The trapezoid is keystone-shaped and the dorsal surface is twice that of the volar side. This shape, coupled with stronger volar than dorsal ligaments, predisposes the trapezoid to dorsal dislocation.⁸³ An axial

Incidence

Despite its prominence at the base of the hypothenar eminence, the pisiform is fractured much less commonly than the hook of hamate, constituting about 1% of carpal fractures.²⁶ Approximately half of pisiform fractures are associated with other carpal injuries.¹⁷ In isolation, pisiform fractures can be sagittal avulsion fractures, transverse avulsion fractures, or comminuted fractures.⁹⁰

Mechanism of Injury

The anatomy and multiple structures attached to the pisiform play a role in fracture pattern and management.

Incidence

Acute fractures to the lunate are rare, constituting 1% of all carpal fractures.⁹⁹ Lunate fractures are classified into 5 subtypes based on the vascularity of the bone and location: volar pole, dorsal pole, transverse body, sagittal body, and osteochondral or chip fractures. The most common subtype is the volar pole fracture.⁹⁹

Mechanism of Injury

The lunate is compressed between the distal radius and capitate with extreme wrist hyperextension and ulnar deviation such as during a fall on an outstretched hand. In

Summary

Fractures of the carpal bones in athletes are often sport-specific injuries, which can be diagnosed with a complete clinical and radiographic examination of the patient's hand. Special radiographic views can help with the initial assessment; CT and MRI are useful for difficult diagnoses. However, the threshold for obtaining an MRI in an athlete with what seems to be a significant injury is low. The energy imparted on the hand not only creates fractures, but can injure crucial ligaments. Most

Acknowledgment

The authors would like to acknowledge Jill Clemente, MS, Research Assistant for her editorial assistance.

References (103)

K. Hocker et al.
Chip fractures of the triquetrum
J Hand Surg Br
(1994)
M.J. Botte et al.
Fractures of the carpus, excluding the scaphoid
Hand Clin
(1987)
M.S. Cohen
Fractures of the carpal bones
Hand Clin
(1997)
M. Garcia-Elias
Dorsal fractures of the triquetrum—avulsion or compression fractures?
J Hand Surg Am
(1987)
J.K. Mayfield et al.
Carpal dislocations: pathomechanics and progressive perilunar instability
J Hand Surg Am
(1980)
M. Vigler et al.
Carpal fractures excluding the scaphoid
Hand Clin
(2006)
R.W. Culp et al.
Complications of common carpal injuries
Hand Clin
(1994)
S. Papp
Carpal bone fractures
Orthop Clin North Am
(2007)
W.B. Geissler
Carpal fractures in athletes
Clin Sports Med
(2001)
T. Suzuki et al.
Osteochondral fracture of the triquetrum: a case report
J Hand Surg Am
(2002)

H. Aiki et al.

Pisotriquetral arthrosis after triquetral malunion: a case report

J Hand Surg Am

(2006)

J.J. Walsh et al.

Diagnosis and management of hamate hook fractures

Hand Clin

(2000)

K.D. Polivy et al.

Fractures of the hook of the hamate—a failure of clinical diagnosis

J Hand Surg Am

(1985)

A.P. Thomas et al.

An unusual hamate fracture

Hand

(1983)

A.T. Bishop et al.

Fracture of the hamate hook

J Hand Surg Am

(1988)

P.R. Manske

Fracture of the hook of the hamate presenting as carpal tunnel syndrome

Hand

(1978)

J.D. Papilion et al.

Radiographic evaluation of the hook of the hamate: a new technique

J Hand Surg Am

(1988)

A.E. Freeland et al.

Displaced dorsal oblique fracture of the hamate treated with a cortical mini lag screw

J Hand Surg Am

(1986)

J.L. Whalen et al.

Nonoperative treatment of acute hamate hook fractures

J Hand Surg Am

(1992)

M.E. Rettig et al.

Distal radius and carpal fractures

Clin Sports Med

(1998)

F. Demirkan et al.

Biomechanical evaluation of flexor tendon function after hamate hook excision

J Hand Surg Am

(2003)

P.S. Konig et al.

Variations of the ulnar nerve and ulnar artery in Guyon's canal: a cadaveric study

J Hand Surg Am

(1994)

J.S. Panagis et al.

The arterial anatomy of the human carpus. Part II: the intraosseous vascularity

J Hand Surg Am

(1983)

J.M. Failla

Hook of hamate vascularity: vulnerability to osteonecrosis and nonunion

J Hand Surg Am

(1993)

R.E. Van Demark et al.

Avascular necrosis of the hamate: a case report with reference to the hamate blood supply

J Hand Surg Am

(1992)

P. Smith et al.

Excision of the hook of the hamate: a retrospective survey and review of the literature

J Hand Surg Br

(1988)

M. Garcia-Elias et al.

Bennett's fracture combined with fracture of the trapezium. A report of three cases

J Hand Surg Br

(1993)

A.K. Palmer

Trapezial ridge fractures

J Hand Surg Am

(1981)

F.X. McGuigan et al.

Surgical treatment of intra-articular fractures of the trapezium

J Hand Surg Am

(2002)

P. Binhammer et al.

Coronal fracture of the body of the trapezium. A case report

J Hand Surg Am

(1998)

A.J. Checroun et al.

Radial artery injury in association with fractures of the trapezium

J Hand Surg Br

(1997)

A.G. Volk et al.

Unusual capitate fracture: a case report

J Hand Surg Am

(1995)

J.H. Calandruccio et al.

Isolated nondisplaced capitate waist fracture diagnosed by magnetic resonance imaging

J Hand Surg Am

(1999)

R.R. Richards et al.

Internal fixation of a capitate fracture with Hebert screws

J Hand Surg Am

(1990)

R.H. Gelberman et al.

The arterial anatomy of the human carpus. Part I: the extraosseous vascularity

J Hand Surg Am

(1983)

R. Vander Grend et al.

Intraosseous blood supply of the capitate and its correlation with aseptic necrosis

J Hand Surg Am

(1984)

W.E. Lowry et al.

Traumatic avascular necrosis of the capitate bone-case report

J Hand Surg Am

(1981)

R.B. Kimmel et al.

Surgical treatment of avascular necrosis of the proximal pole of the capitate-case report

J Hand Surg Am

(1982)

A.S. Lapinsky et al.

Avascular necrosis of the capitate: a case report

J Hand Surg Am

(1992)

A.A. Rico et al.

Peudoarthrosis of the capitate

J Hand Surg Br

(1999)

M. Garcia-Elias et al.

Traumatic dislocations of the carpus

J Hand Surg Am

(1989)

M.A. Meyn et al.

Isolated dislocation of the trapezoid bone

J Hand Surg Am

(1980)

Y. Yasuwaki et al.

J Hand Surg Am

(1994)

P. Cuenod et al.

Open dislocation of the trapezoid

J Hand Surg Br

(1995)

B. Helal

Racquet player's pisiform

Hand

(1978)

R.E. Carroll et al.

Dysfunction of the pisotriquetral joint: treatment by excision of the pisiform

J Hand Surg Am

(1985)

H. Teisen et al.

Classification of fresh fractures of the lunate

J Hand Surg Br

(1988)

J.A. Bergfeld et al.

Soft playing splint for protection of significant hand and wrist injuries in sports

Am J Sports Med

(1982)

K.E. DeHaven et al.

Athletic injuries: comparison by age, sport, and gender

Am J Sports Med

(1986)

H. Krahl et al.

Stimulation of bone growth through sports: a radiologic investigation of the upper extremities in professional tennis players

Am J Sports Med

(1994)

Cited by (27)

Isolated Trapezoid Fracture in Adolescent Goalkeepers: A Scoping Review of the Literature and a Report of Two Cases
2024, Journal of Hand Surgery Global Online
Isolated trapezoid fractures are rare injuries, particularly among adolescents, constituting only 0.4% of all carpal bone fractures. This study aims to present two cases of isolated trapezoid fracture in adolescent goalkeepers and a scoping review of the literature to provide guidelines for the management of this injury.
Following PRISMA-ScR guidelines, a scoping review of reported cases was conducted. Two hundred and twenty articles were found using PubMed and Google Scholar. After full-text review, a total of 30 cases from 22 articles along with our 2 cases were analyzed based on demographics, injury mechanism, method/timing of diagnosis, prognosis, and time to recovery.
Thirty-two reported cases of trapezoid fractures with a mean age of 26.7 years (75% male) were found, with pain as the most common presenting symptom. A majority (78%) had initial negative findings on radiography, and the diagnosis was primarily established through computed tomography (59%; n = 19) or magnetic resonance imaging (50%; n = 16). There was a substantial delay in diagnosis (mean 26 days), primarily because computed tomography/magnetic resonance imaging was frequently ordered late. The majority of cases (78%) were managed conservatively, with immobilization periods ranging from 4 to 12 weeks. The average duration for full recovery was 4.5 months, with operative management taking 7.3 months and conservative management taking 3.5 months.
Trapezoid fractures, though rare, are often not promptly diagnosed on initial plain radiographs, leading to a potential underreporting of cases. Because of the risk of complications associated with this type of injury, clinicians should maintain a high level of vigilance and consider trapezoid fracture as a possible differential diagnosis when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents. Further research and guidelines are needed to enhance our understanding and management of this uncommon injury in the future.
Differential diagnosis/symptom prevalence IIIb.
Imaging of the Hand and Wrist
2020, Clinics in Sports Medicine
Citation Excerpt :
Fractures of the trapezium occur most commonly in the body and typically are identified on standard views of the wrist.29 A pronated anteroposterior (AP) view, or Bett view, can be used to improve visualization of the trapeziometacarpal articulation.29 CT may be useful to identify more unusual fractures, such as occult trapezial ridge and coronal fractures.29
Carpal Fractures Other than Scaphoid in the Athlete
2020, Clinics in Sports Medicine
Citation Excerpt :
Midcarpal arthritis is a common consequence, and cases of transcaphoid, transcapitate perilunate injuries requiring ORIF are often season-ending injuries for athletes.16 Once union is achieved with anatomic alignment, good outcomes along with return to all activities are noted.16,64–66 As noted earlier, an MRI is helpful to evaluate the vascular supply of the proximal pole of the capitate, which has a retrograde interosseous blood supply similar to the scaphoid.
Return to Play and Complications After Hook of the Hamate Fracture Surgery
2017, Journal of Hand Surgery
The purpose of this study was to evaluate the efficacy of hook of the hamate excision for fracture in a large cohort of patients to better understand recovery time and complications.
We retrospectively reviewed the medical records of patients treated with surgical excision for hook of the hamate fractures at 2 different centers. We collected information on demographics, clinical presentation, and postoperative complications. Continuous outcome variables included time to surgery, return to play, and return to activity.
Our cohort of 81 patients had a median age of 22 years and was composed of 74 athletes including 57 baseball players and 8 golfers. The median time to return to play was 6 weeks (range, 1–36 weeks) after surgery; 11 patients (14%) had a return at 12 weeks or longer. Seventy-eight patients returned to preinjury activity levels. Twelve patients with a full recovery continued to experience some level of intermittent, nonspecific pain in the affected hand, although this was not severe enough to require additional treatment. We observed a 25% incidence of postoperative complications with the majority consisting of transient ulnar nerve dysfunction. Complications were more common among nonathletes, those presenting with nonunions, and those experiencing longer intervals between injury and surgery.
In most cases, surgical excision as treatment for hook of the hamate fractures is safe and allows a relatively rapid return to play. However, we found a higher incidence of complications, including transient ulnar nerve dysfunction, than has been previously reported. In addition, there is a group of patients with delayed return to play and continued discomfort after surgery. These findings should inform the discussion with surgical candidates.
Therapeutic IV.
Hamate Hook and Pisiform Fractures
2016, Operative Techniques in Sports Medicine
Though rare, hook of hamate (hamulus) fractures and pisiform fractures are serious injuries in the athlete that should not be missed or underestimated. Failure to promptly diagnose and treat these fractures may lead to serious complications including avascular necrosis, nonunion, tendon rupture, carpal instability, neurovascular compression, and arthritis. Hamulus fractures should be suspected in the athlete with persistent hypothenar hand, particularly those who use a bat, racket, or club. Complete hamulus excision after fracture has been shown to provide consistent pain relief and return to sport. Pisiform fractures are uncommon. Excision may provide benefit in the setting of a displaced fracture. Return to sport after any carpal fracture should focus primarily on the future health of the athlete, with future play only as a secondary aim.
Carpal Fractures Other than Scaphoid
2015, Clinics in Sports Medicine
Citation Excerpt :
Horizontal fractures, caused by a horizontal shear load, are rare.22 Athletes present with focal tenderness and a painful, weakened pinch.12 Ridge fractures cause localized pain at the base of the thenar eminence.7

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Carpal Fractures in Athletes Excluding the Scaphoid

Section snippets

Incidence

Incidence

Incidence

Incidence

Incidence

Mechanism of Injury

Incidence

Mechanism of Injury

Incidence

Mechanism of Injury

Summary

Acknowledgment

J Hand Surg Br

Hand Clin

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J Hand Surg Am

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Orthop Clin North Am

Clin Sports Med

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Hand Clin

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Clin Sports Med

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J Hand Surg Am

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J Hand Surg Am

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J Hand Surg Br

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J Hand Surg Am

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J Hand Surg Am

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J Hand Surg Am

J Hand Surg Am

J Hand Surg Br

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Br

Hand

J Hand Surg Am

J Hand Surg Br

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Am J Sports Med

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Am J Sports Med

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Am J Sports Med