CARPAL BONE FRACTURES

By:
Dr. Pavan
Moderator:
Dr. Vamsi
 CARPAL BONES
Carpal bones are arranged in two rows
From lateral to medial and when viewed
from anteriorly
PROXIMAL ROW
1. the boat-shaped scaphoid;
2. the lunate, which has a 'crescent shape';
3. the three-sided triquetrum bone;
4. the pea-shaped pisiform
DISTAL ROW
1. the irregular four-sided trapezium bone;
2. the four-sided trapezoid;
3. the capitate, which has a head;
4. the hamate, which has a hook

She Looks Too Pretty Try To Catch Her

CARPAL BONES IN 3D VIEW
SOME IMPORTANT CARPAL BONES
Pisiform is a sesamoid bone in the tendon of flexor carpi
ulnaris and articulates with the anterior surface of the
Triquetrum.
Scaphoid has a prominent tubercle on its lateral palmar
surface that is directed anteriorly.
Trapezium articulates with the metacarpal bone of the thumb
and has a distinct tubercle on its palmar surface that projects
anteriorly.
LARGEST of the carpal bones, the CAPITATE, articulates
with the base of the metacarpal III.
Hamate, which is positioned just lateral and distal to the
pisiform, has a prominent hook (hook of hamate) on its
palmar surface that projects anteriorly.
CARPAL BONE OSSIFICATION CENTRES
Ossification of the carpal bones occurs in a
predictable sequence, starting with the
capitate and ending with the pisiform.

At birth, there is no calcification in the

carpal bones. Although there is great
individual variability, approximate
ossification times are as follows :
capitate: 1-3 months
hamate: 2-4 months
triquetral: 2-3 years
lunate: 2-4 years
scaphoid: 4-6 years
trapezium: 4-6 years
trapezoid: 4-6 years
pisiform: 8-12 years
 Excluding the
pisiform, a handy
way to remember
the order of
ossification is to
start at the
capitate then
move in a
counterclockwise
direction on the
volar surface of
the right carpus.

Ossification centres
of the distal radius
and ulna
distal radius: 1 year
distal ulna: 5-6 years
 The carpal bones do not lie
in a flat coronal plane;
rather, they form an arch,
whose base is directed
anteriorly .
The lateral side of this base
is formed by the tubercles of
the scaphoid and trapezium.
The medial side is formed by
the pisiform and the hook of
hamate. The flexor
retinaculum attaches to, and
spans the distance between,
the medial and lateral sides
of the base to form the
anterior wall of the so-called
carpal tunnel. The sides and
roof of the carpal tunnel are
formed by the arch of the
carpal bones.
 LIGAMENTS OF WRIST
They are divided in to
1.Extrinsic ligaments
2.Intrinsic ligaments
Extrinsic ligaments :
1. bridge carpal bones to the radius or
metacarpals
2. include volar and dorsal ligaments
Intrinsic ligaments:
1. originate and insert on carpal bones
 CHARACTERISTICS OF WRIST
LIGAMENTS
volar ligaments are secondary stabilizers of
the scaphoid
volar ligaments are stronger than dorsal ligaments
dorsal ligaments converge on the triquetrum
 EXTRINSIC LIGAMENTS
Divided into
Volar radiocarpal ligaments
Volar ulnocarpal ligaments
Dorsal ligaments
VOLAR RADIOCARPAL LIGAMENTS
Radial Collateral
Radioscaphocapitate
at risk for injury with excessively large radial styloid
from radial styloid to capitate, creating a sling to
support the waist of the scaphoid
Radioscapholunate
Ligament of Testut and Kuentz
only functions as neurovascular conduit
not a true ligament
does not add mechanical strength
Long Radiolunate
also called radiolunotriquetral or volar radiolunate
ligament
counteracts ulnar-distal translocation of the lunate
abnormal in Madelung's deformity
Short radiolunate
stabilizes lunate
VOLAR ULNOCARPAL LIGAMENTS

Volar ulnocarpal
ligaments
ulnotriquetral
ulnolunate
ulnocapitate
DORSAL LIGAMENTS
Radio Triquetral (RT)
Dorsal Intercarpal (DIC)
Radio Lunate (RL)
Radio Scaphoid (RS)
 The distal portions of the
radio and ulno capitate
ligaments do not attach
to the head of the
capitate, but form a
support sling with center
of a double "V" shape
covergence of ligaments
Between these two rows
of ligaments is a thinned
area termed the Space of
Poirier
SPACE OF PORIER
Ligament free area in
palmar aspect of
capitolunate space is
area of potential
weakness
This area expands when
the wrist is dorsiflexed
and disappears in
palmar flexion.
A rent develops during
dorsal dislocations, and
it is through this
interval that the lunate
displaces into the carpal
canal.
TFCC(Triangular Fibrocartilage Complex)
Major stabilizer of the
ulnar carpus and distal
radio ulnar joint.
Absorbs 20% of the axial
load across wrist joint
Consists of
Ulnotriquetral ligament
Meniscal homologue
Articular disc
Dorsal radio ulnar ligament
Volar radio ulnar ligament
Ulnolunate ligament
Ulnar collateral ligament
INTRINSIC LIGAMENTS
The intra-articular intrinsic ligaments
connect adjacent carpal bones.
Proximal row
scapholunate ligament
lunotriquetral ligament
Distal row
trapeziotrapezoid ligament
trapeziocapitate ligament
capitohamate ligament
Palmar midcarpal
scaphotrapeziotrapezoid
scaphocapitate
triquetralcapitate
triquetralhamate
VASCULAR SUPPLY OF CARPAL BONES
The RADIAL,ULNAR and
ANTERIORINTEROSSEOUS arteries
combine to form a network of
transverse arterial arches both
dorsal and volar to the carpus.
SCAPHOID BLOOD SUPPLY:
primarily from radial artery,both
dorsally and volarly.
Volar scaphoid branch supply
distal 20%-30%
branch entering dorsal ridge
supplies proximal 70%-80%
LUNATE BLOOD SUPPLY:
recieves supply from both its
dorsal and volar surfaces.
ARTERIAL SUPPLY OF DORSUM OF WRIST.

R.radial artery
U.ulnar artery
1.dorsal branch of
anterior interosseous
artery
2.dorsal radiocarpal arch
3.branch to dorsal ridge
of scaphoid
4.dorsal intercarpal arch
5.basal metacarpal arch
6.medial branch of ulnar
artery.
ARTERIAL SUPPLY OF PALMAR ASPECT OF WRIST

R, radial artery
U, ulnar artery
1, palmar branch of anterior
interosseous artery
2, palmar radiocarpal arch
3, palmar intercarpal arch
4, deep palmar arch
5, superficial palmar arch
6, radial recurrent artery
7, ulnar recurrent artery
8, medial branch of ulnar artery
9, branch off ulnar artery
contributing to dorsal intercarpal
arch.
ARTERIAL SUPPLY OF LATERAL ASPECT OF WRIST

R, radial artery;
1, superficial palmar artery;
2, palmar radiocarpal arch;
3, dorsal radiocarpal arch;
4, branch to scaphoid tubercle and trapezium;
5, artery to dorsal ridge of scaphoid;
6, dorsal intercarpal arch;
7, branch to lateral trapezium and thumb metacarpal.
 KINEMATICS

The global motion of the wrist is composed of flexion, extension,

radioulnar deviation at the radiocarpal joint, and axial rotation
around the distal radioulnar joint (DRUJ)
The radiocarpal articulation acts as a universal joint allowing a small
degree of intercarpal motion around the longitudinal axis related to
the rotation of individual carpal bones.
forearm accounts for about 140 degrees of rotation.
Radiocarpal joint motion is primarily flexion and extension of nearly
equal proportions (70 degrees) and radial and ulnar deviation of 20
degrees and 40 degrees, respectively.
The scaphoid rests on the radioscaphocapitate ligament at its
waist.using this ligament as axis it rotates from volar flexed
perpendicular position to dorsiflexed longitudnal position.
Wrist in radial deviation scaphoid flexes and in ulnar deviation
scaphoid extends.
 Conjunct rotation of the
entire proximal row occurs
in flexion during radial
deviation (upper left).
The axes of the radius and
carpal rows are collinear in
neutral (middle left), and
the proximal row extends
with ulnar deviation (lower
left).
Angulatory excursions of
the proximal and distal rows
are essentially equal in
amplitude and direction
during extension (upper
right) and flexion (lower
right). This has been
described as synchronous
angulation.
 WRIST BIOMECHANICS
Biomechanic concepts that have been proposed for
better understanding of functioning,movements and
various types of forces acting.some of them are:
1. LINK CONCEPT
2. COLUMN CONCEPT
3. ROWS CONCEPT
4. TALEISNIKS CONCEPT
5. LICHTMANS RING CONCEPT
LINK CONCEPT
three links in a chain composed of
radius, lunate and capitate
head of capitate acts as center of
rotation
proximal row (lunate) acts as a unit and
is an intercalated segment with no
direct tendon attachments
distal row functions as unit
advantage
efficient motion (less motion at each
link)
strong volar ligaments enhance stability
disadvantage
more links increases instability of the
chain
scaphoid bridges both carpal rows
resting forces/radial deviation push the
scaphoid into flexion and push the
triquetrum into extension
ulnar deviation pushes the scaphoid
into extension
COLUMN CONCEPT
lateral (mobile) column
comprises scaphoid, trapezoid and trapezium
scaphoid is center of motion and function is
mobile
central (flexion-extension) column
comprises lunate, capitate and hamate
luno-capitate articulation is center of motion
motion is flexion/extension
medial (rotation) column
comprises triquetrum and distal carpal row
motion is rotation
ROWS CONCEPT
comprises proximal and
distal rows
scaphoid is a bridge
between rows
motion occurs within
and between rows
TALEISNIKS CONCEPT
Taleisniks concept of
central (flexion-
extension) column
involves entire distal
row and lunate
Scaphoid (S) is lateral
(mobile) column, and
Triquetrum (Tq) is rotary
medial column.
LICHTMANS RING CONCEPT
proximal and distal rows are
semirigid posts stabilized by
interosseous ligaments;
Normal controlled mobility
occurs at scaphotrapezial
and triquetrohamate joints.
Any break in ring, either
bony or ligamentous
(arrows), can produce
dorsal intercalated
segmental instability or
volar intercalated segmental
instability deformity.
 PATHOMECHANICS
The Radius, Lunate and Capitate have been
described as a central link that is colinear in
sagittal plane
The Scaphoid serves as a connecting
STRUT.Any flexion moment transmitted across
the scaphoid is balanced by an extension at
the triquetrum.
CARPAL INSTABILITY
Scaphoid instability by fracture or
scapholunate ligament disruption
,the lunate and triquetrum
assume a position of excessive
dorsiflexion(DISI-Dorsal
Intercalated Segmental
Instability) scapholunate angle
becomes abnormally (high>70
degrees)

When triquetrum is destabilized

(disruption of the lunotriquetral
ligament complex) the opposite
pattern (VISI-Volar Intercalated
Segment Instability) is seen as the
intercalated lunate segment volar
flexes
LOAD-CARRYING STRUCTURES (WEBER AND CHAO)
.
These forces are related to fixed coordinate system
(XYZ) and to vector representation of applied load
(P).
Four ligamentous components (cb, ed, ih, kj)
potentially transmit tensile loads when wrist is in
strong dorsiflexion.
Dorsal ligamentous structures eliminated from
analysis because in dorsiflexion structures would
be lax.
Articular surface between radius and scaphoid and
between radius and lunate potentially transmit
compressive forces Ff and Fg.
cb, radiocollateral ligament complex;
ed, radiocapitate ligament;
Ff, radioscaphoid contact force;
Fg, radiolunate contact force;
ih, radiolunate ligament;
kj, ulnar capsular ligament;
XYZ, cartesian coordinate system.
 MECHANISM OF INJURY
The most common mechanism of carpal injury is a
fall onto the outstreched hand, resulting in an axial
compressive force with wrist hyperextension. The
volar ligaments are placed under tension with
compression and shear forces applied dorsally,
especially when the wrist is extended beyond its
physiological limits.
Excessive ulnar deviation and intercarpal supination
result in predictable pattern of perilunate injury,
progressing from the radial side of the carpus to the
mid carpus and finally to the ulnar carpus.
 Relative Incidence of Carpal Bone
Fractures
Scaphoid 68.2%
Triquetrum 18.3%
Trapezium 4.3%
Lunate 3.9%
Capitate 1.9%
Hamate 1.7%
Pisiform 1.3%
Trapezoid 0.4%
 CLINICAL EVALUATION
HISTORY
age,
hand dominance,
occupation,
hobbies,
date of injury or onset of symptoms,
correlation of symptoms with activities
modifying factors
LOCAL EXAMINATION
Well localised tenderness
Deformity
Mechanical symptoms, such as clicking, popping, snapping, and
grating
Provocative test
 RADIOGRAPHIC TECHNIQUES
Various radiographic techniques useful in
evaluating a painful wrist include
routine radiographic series consisting of four
views
1. posteroanterior,
2. lateral,
3. oblique, and
4. ulnardeviated posteroanterior scaphoid view
spot views of the carpal bones for detail (carpal
tunnel view)
fluoroscopic spot views of the wrist;
GILULA'S LINES.
A. PA views show three smooth Gilula arcs in a normal wrist. These arcs outline
proximal and distal surfaces of the proximal carpal row and the proximal cortical
margins of capitate and hamate.
B. Arc I is broken, which indicates an abnormal lunotriquetral joint due to a
perilunate dislocation. Additional findings are the cortical ring sign produced by
the cortical outline of the distal pole of the scaphoid and a trapezoidal shape of
the lunate.
Carpal tunnel view shows avulsion fracture of hamate hook (arrow) and trapezium
(arrowheads).
fluoroscopic spot views of the wrist
A, Posteroanterior view of capitate shows no definite abnormality.
B, On angled view, cystic defect with fracture is seen in capitate waist (arrows).
 series of views for instability
1. anteroposterior clenched fist;
2. posteroanterior in neutral, radial, and ulnar
deviation;
3. lateral in neutral and full flexion and
extension;
4. semipronated oblique 30 degrees from the
posteroanterior
5. semisupinated oblique 30 degrees from the
lateral
Diagnostic ultrasound
Cine or Video Fluoroscopy
Bone Scanning
Arthrography of the wrist (triple injection
when indicated)
CT
MRI.
 OTHER DIAGNOSTIC TECHNIQUES
1. differential local anesthetic injection,
2. wrist arthroscopy, and
3. various other operative procedures.
 A, Standard radiocarpal portals.
Positioning of patient B, Standard midcarpal portals.
SCAPHOID FRACTURES
SCAPHOID FRACTURES
irregularly shaped tubular bone, twisted and bent into an
S-shape
resembles a deformed peanut or a boat (from the Greek
word for boat, skaphos).
more than 80% of its surface being covered by articular
cartilage
The scaphoid receives most of its blood supply from two
major vascular pedicles .
One enters the scaphoid tubercle and supplies its distal
20% to 30% and the other arises from the dorsal scaphoid
branch of the radial artery .
The dorsal ridge vessels enter through numerous small
foramina along the spiral groove and dorsal ridge. This
source accounts for about 80% of the blood supply.
unusual retrograde vascular supply, the scaphoid has a
high risk of nonunion and Osteonecrosis after fracture.
Temporary interruption of the blood supply to the
proximal fragment is virtually certain with proximal pole
fractures.
 EPIDEMIOLOGY

incidence
accounts for up to 15% of acute wrist injuries
location
incidence of fracture by location
o waist -65%
o proximal third - 25%
o distal third - 10%
distal pole is most common location in kids due to
ossification sequence
 CLINICAL EVALUATION OF SCAPHOID
FRACTURE
complain of wrist pain after a fall on the outstretched hand
Minimal or gross swelling
snuffbox tenderness
scaphoid tubercle tenderness
Palpable deformity distal to radial styloid
pain with longitudinal axial compression/tension
Pain with dorsiflexion, radial deviation
pain with resisted pronation
PROVOCATIVE TESTS
THE SCAPHOID SHIFT TEST: Reproduction of pain with dorsal-volar shifting
of scaphoid.
THE WATSON TEST: Painful dorsal scaphoid displacement as the wrist is
moved from ulnar to radial deviation with palmar pressure on the
tuberosity.
 PATHOANATOMY

most common mechanism of injury is axial load

across hyper-extended and radially deviated wrist
common in contact sports
transverse fracture patterns are considered more
stable than vertical or oblique oriented fractures
 SCAPHOID FRACTURE IMAGING
Radiographs
Recommended views
AP and lateral
scaphoid view
30 degree wrist
extension, 20 degree
ulnar deviation
45 pronation view
Findings
if radiographs are
negative and there is a
high clinical suspicion
should repeat
radiographs in 14-21
days
The four scaphoid views
(PA, true lateral, radial
oblique, ulnar oblique)
detect most of carpal
fractures.
A fisted PA view can be
helpful in detecting
scaphoid fractures.
 UNSTABLE FRACTURE
Greater than 1
mm stepoff
Lunocapitate
angulation > 15
degrees (lateral)
Scapholunate
angulation > 45
degrees (lateral)
 Bone scan
effective to
diagnose occult
fractures at 72
hours
specificity of
98%, and
sensitivity of
100%, PPV 85%
to 93% when
done at 72 hours
.
 MRI
most
sensitive method to
diagnose of occult
fractures within 24
hours
allows immediate
identification of
fractures and
ligamentous injuries
in addition to
assessment of
vascular status of
bone (vascularity of
proximal pole)
 CT scan with 1mm
cuts
less effective than
bone scan and MRI
to diagnose occult
fracture
can be used to
evaluate location
of fracture, size of
fragments, extent
of collapse,
andprogression of
nonunion or union
after surgery
The MRI scan demonstrates a clear fracture line of the scaphoid (proximal pole). B. It is
difficult to identify the proximal fracture by native x-rays.
 MRI is useful for diagnosis of occult
scaphoid fractures (A) and for evaluation of
vascularity of fractured scaphoid(B).
CLASSIFICATION OF SCAPHOID
FRACTURES
HERBERT AND FISHER'S CLASSIFICATION OF
FRACTURES OF THE SCAPHOID
 NONDISPLACED, STABLE SCAPHOID FRACTURES
NONOPERATIVE
THUMB SPICA CAST IMMOBILIZATION
INDICATIONS
stable nondisplaced fracture (majority of fractures)
Tuberosity fracture
Patient with injury and positive examination findings but normal x-rays, immobilize
for 1-2 weeks.
TECHNIQUE
start immobilization early (nonunion rates increase with delayed immobilization of
> 4 weeks after injury).
long arm spica vs short arm casting is controversial
with no consensus
duration of casting depends on location of fracture
distal-third for 6-8 weeks
mid-third for 8-12 weeks
proximal third for 12-24 weeks
athletes should not return to play until imaging shows a healed fracture
may opt to augment with pulsed electomagnetic field (studies show beneficial in
delayed union)
OUTCOMES
scaphoid fractures with <1mm displacement have union rate of 90%
 THUMB SPICA CAST IMMOBILIZATION

Forearm cast from just

below the elbow
proximally to the base of
the thumbnail and the
proximal palmar crease
distally (thumb spica) with
the wrist in slight Radial
deviation and in Dorsi
flexion. The thumb is
maintained in a functional
position, and the fingers
are free to move from the
metacarpophalangeal
joints distally.
 Using nonoperative casting techniques, the
expected rate of union is 90% to 95% within 10 to
12 weeks.
During this time, the fracture is observed
radiographically for healing.
If collapse or angulation of the fractured
fragments occurs, surgical treatment usually is
required.
Surgery may be considered if new healing activity
is not evident and if union is not apparent after a
trial of cast immobilization for about 20 weeks.
 DISPLACED, UNSTABLE SCAPHOID
FRACTURES
Displaced,unstable fracture in which the
fragments are offset more than 1 mm in the
anteroposterior or oblique view, or
lunocapitate angulation is > 15 degrees, or the
scapholunate angulation is > 45 degrees in the
lateral view (range 30 to 60 degrees).
 OPERATIVE
ORIF vs percutaneous screw fixation
INDICATIONS
in unstable fractures as shown by
proximal pole fractures
displacement > 1 mm
15 scaphoid HUMPBACK DEFORMITY
radiolunate angle > 15 (DISI)
intrascaphoid angle of > 35
scaphoid fractures associated with perilunate dislocation
comminuted fractures
unstable vertical or oblique fractures
in non-displaced waist fractures
to allow decreased time to union, faster return to work/sport,
similar total costs compared to casting
OUTCOMES
union rates of 90-95% with operative treatment of scaphoid fractures
CT scan is helpful for evaluation of union
HUMPBACK DEFORMITY
Humpback deformity of the
scaphoid results from angulation
of the proximal and distal parts
of a scaphoid in the setting
of scaphoid fracture through the
waist .
It can result in progressive
collapse of the scaphoid with
non-union and destabilisation of
the wrist.
Associated with a Dorsal
Intercalated Segment
Instability(DISI).
Managed operatively with
internal fixation + / - bone
grafting.
TECHNIQUE
ORIF vs percutaneous screw fixation
Approach
Dorsal approach
indicated in proximal pole fractures
care must be taken to preserve the blood supply when entering the dorsal
ridge by limiting exposure to the proximal half of the scaphoid
percutaneous has higher risk of unrecognized screw penetration of
subchondral bone
Volar approach
indicated in waist and distal pole fractures and fractures with humpback
flexion deformities
allows exposure of the entire scaphoid
uses the interval between the FCR and the radial artery
Arthroscopic assisted approach
has also been described
Fixation
rigidity is optimized by long screw placed down the central axis of the
scaphoid
Radial styloidectomy
should be performed if there is evidence of impaction osteoarthritis
between radial styloid and scaphoid
 OPEN REDUCTION AND INTERNAL FIXATION OF ACUTE
DISPLACED FRACTURES OF THE SCAPHOIDVOLAR APPROACH
 OPEN REDUCTION AND INTERNAL FIXATION OF ACUTE
DISPLACED FRACTURES OF THE SCAPHOIDDORSAL APPROACH
 EXPOSURE AND INTERNAL FIXATION OF SCAPHOID
FRACTURES THROUGH A DORSOLATERAL APPROACH

A: Skin incision.
B: Exposure of the
dorsal radiocarpal joint
capsule after isolating
and protecting the
superficial radial nerve
and radial artery.
C: Scaphoid exposure
through dorsal
radiocarpal
capsulotomy.
D:Reduction of
scaphoid fracture.
E:Use of double-
guidewire technique
for placement of screw
and counter-rotation.
The second guidewire
is removed after
placement of the
screw.
PERCUTANEOUS SCAPHOID FIXATION
THROUGH A VOLAR APPROACH.
With
longitudinal
traction and
ulnar deviation,
the guidewire is
inserted through
a 5-mm incision
directly over the
scaphoid
tubercle.
PERCUTANEOUS FIXATION OF SCAPHOID
FRACTURES

A, Central axis of scaphoid is located on posteroanterior

view.
B, Wrist is pronated until scaphoid poles are aligned.
C, Wrist is flexed until scaphoid has ring appearance on
fluoroscopy.

Guidewire in central axis of scaphoid for placement of

screw.
 COMPLICATIONS OF SCAPHOID
FRACTURES
Osteoarthritis
Delayed union
Malunion
Nonunion
Nonunion SNAC wrist
(scaphoid nonunion
advanced collapse)
Osteonecrosis (PREISER'S DISEASE )
Algorithm for treatment of scaphoid
nonunion developed by Knoll and
Trumble
SCAPHOID NONUNION AND SCAPHOID NONUNION
ADVANCED COLLAPSE (SNAC WRIST)
Radiographic findings of
arthritis usually seen with
scaphoid nonunion include
radioscaphoid narrowing,
capitolunate narrowing, cyst
formation, and pronounced
Dorsal Intercalated Segment
Instability.
This is the so-called
SCAPHOID NONUNION
ADVANCED COLLAPSE
PATTERN.
 The following operations can be useful for
nonunions of the scaphoid:
(1) Radial Styloidectomy.
(2) Excision of the proximal fragment, the distal
fragment, and, occasionally, the entire
scaphoid.
(3) Proximal row Carpectomy.
(4) Traditional Bone Grafting.
(5) Vascularized Bone Grafting.
(6) Partial or Total Arthrodesis of the wrist.
PROXIMAL ROW CARPECTOMY
 Arthroscopic proximal row carpectomy

Arthroscopic proximal row carpectomy .

A, Initial removal of distal ulnar pole of scaphoid.
B, Entire proximal row has been excised.
C, After release of traction.
BONE GRAFT TECHNIQUES
STARK ET AL. GRAFTING TECHNIQUE
VASCULAR BONE GRAFT FROM RADIUS

VASCULAR BONE GRAFT

FROM RADIUS
gaining popularity and a
good option for proximal
pole fractures with
osteonecrosis confirmed
by MRI
1-2 intercompartmental
supraretinacular
artery (branch of radial
artery) is harvested to
provide vascularized graft
from dorsal aspect of
distal radius
 PREISER'S DISEASE (SCAPHOID AVN)
Osteonecrosis of the scaphoid can occur as a late
complication of scaphoid fractures, especially
those involving the proximal pole.
Epidemiology
Rare condition
Mostly idiopathic
Average Age of onset is 45 years
Operative treatment options:
microfracture drilling, revascularization procedure, or
allograft replacement
proximal row carpectomy or scaphoid excision with four
corner fusion
TRIQUETRAL FRACTURES
 TRIQUETRUM FRACTURES
2 nd most common carpal bone fracture after scaphoid
Mode of injury:
wrist in extension and ulnar deviation
Clinical evaluation:
tenderness on palpation on the dorsolunar aspect of the wrist
directly dorsal to pisiform,painful wrist motion
Radiological evaluation:
1.tranverse fracture of body identified on PA view
2.Dorsal triquetrum visualized by oblique ,pronated lateral view
Treatment:
nondisplaced fractures of the body or dorsal chip fractures may
be treated in short arm cast or splint for 6 wks.
displaced with ORIF.
TRAPEZIAL FRACTURES
 TRAPEZIUM FRACTURES
3-5% of carpal bone fractures
60% unsatisfactory due to secondary
degenerative changes
Ridge avulsion or vertical fracture of body
 MODE OF INJURY OF TRAPEZIAL
FRACTURES
Axial loading of adducted thumb
Driving base of 1st metacarpal into articular
surface of trapezium
Avulsion fractures- forceful
deviation,traction,rotation of thumb
Direct trauma to palmar arch- avulsion of trapezial
ridge by transvers carpal ligament
 CLINICAL EVALUATION OF TRAPEZIAL
FRACTURES
Tenderness of radial wrist
Painful range of motion of 1st carpometacarpal
joint
 RADIOGRPHIC EVALUATION
Along with standard PA and Lateral
views
Robert view
True PA of 1st CMC joint and
trapezium with hand in maximum
pronation
Carpal tunnel view-dorsal ridge
visualization
 TREATMENT OF TRAPEZIUM
Non displaced:
Thumb spica splinting for 6 weeks
Displaced, Comminuted, Carpometacarpal
Articulation involvement
ORIF +\- Bone Grafting
LUNATE FRACTURES
 LUNATE FRACTURES
4TH most fractured
CARPAL KEYSTONE
lunate sits like a keystone in the proximal carpal row in the well-protected
concavity of the lunate fossa of the radius, anchored on either side by the
interosseous ligaments to the scaphoid and triquetrum with which it
articulates. Distally, the convex capitate head fits into the concavity of the
lunate
 BLOOD SUPPLY TO LUNATE
vascular supply of the lunate is primarily through the
proximal carpal arcade both dorsally and palmarly.
However, the literature suggests that 7% to 26% of
lunates may have a single volar or dorsal blood supply
and are therefore vulnerable to Osteonecrosis because
of disruption of extraosseous blood supply
 MECHANISM OF INJURY
Outstreched hand
Wrist in hyperextension
Strenous push with wrist in extension
 CLINICAL EVALUATION FOR LUNATE
FRACTURES
Tenderness on dorsal wrist overlying the distal
radius and lunate
Painful ROM
 RADIOGRAPHIC EVALUATION OF
LUNATE
PA & Lateral views inadequate
Oblique views may be helpful
CT best demonstrates fractures
MRI increasingly used for vascular changes
associated with injury and healing.
test of choice for evaluation of Kienbock Disease.
 ACUTE LUNATE FRACTURE
CLASSIFICATION
acute fractures of the lunate are classified into
five groups:
1. Frontal fractures of the palmar pole with
involvement of the palmar nutrient arteries.
2. Osteochondral fractures of the proximal articular
surface without substantial damage to the nutrient
vessels.
3. Frontal fractures of the dorsal pole.
4. Transverse fractures of the body.
5. Transarticular frontal fractures of the body of the
lunate.
 TREATMENT OF LUNATE FRACTURES
Non displaced:
Most fractures of the lunate can be treated by cast
immobilization for 4 weeks.
Displaced :
displaced or angulated fractures treated surgically for
adequate apposition for vascular anastomosis.
Fractures with more than 1 mm offset and avulsion
fractures usually require open reduction.
Internal fixation techniques vary depending on the
requirements of the individual situation and may
include Kirschner wires,small cannulated screws, and
suture anchors
 COMPLICATIONS OF LUNATE
FRACTURES
The lunates believed to be most at risk for
osteonecrosis are those with a single vessel or
one surface exposed to the blood supply,
representing about 20% of lunates.
Kienbck disease is a painful disorder of the
wrist of IDIOPATHIC cause in which
radiographs eventually show osteonecrosis of
the carpal lunate.
 KIENBOCK'S DISEASE

Avascular necrosis of the luntate leading to

abnormal carpal motion
Epidemiology
incidence
most common in males between 20-40 years old
risk factors
history of trauma
 CLINICAL PRESENTATION of
KIENBOCKS DIESEASE
Symptoms
dorsal wrist pain
usually activity related
more often in dominant hand
Physical exam
inspection and palpation
+/- wrist swelling
often tender over radiocarpal joint
range of motion
decreased flexion/extension arc
decreased grip strength
 Prognosis
potentially debilitating condition if unrecognized
and untreated
Blood supply to lunate
3 variations

Y-pattern
X-pattern
I-pattern
31% of patients
postulated to be at the highest risk for avascular necrosis
 PATHOPHYSIOLOGY OF KIENBOCKS
DIESEASE
thought to be caused
by multiple factors
biomechanical factors
ulnar negative variance
leads to increased radial-lunate
contact stress
repetitive trauma
anatomic factors
geometry of lunate
vascular supply to lunate
patterns of arterial blood supply
have differential incidences of AVN
disruption of venous outflow
 IMAGING OF KIENBOCKS
Radiographs
recommended views
AP, lateral, oblique views of wrist
CT
most useful once lunate collapse has already occurred
best for showing
extent of necrosis
trabecular destruction
lunate geometry
MRI
best for diagnosing early disease
findings
decreased T1 signal intensity
reduced vascularity of lunate
 LICHTMAN CLASSIFICATION AND
TREATMENT RECOMMENDATIONS
CAPITATE FRACTURES
 CAPITATE FRACTURES
Isolated capitate fractures
uncommon
Associated with Greater Arc
Injury Pattern (Transscaphoid
Transcapitate Perilunate
Fracture-Dislocation )
Naviculocapitate syndrome
variation in which capitate
and scaphoid fractured
without associated
dislocation
Mechanism
Direct trauma or crushing
injuries associated with
carpal or metacarpals
 CAPITATE FRACTURES
CLINICAL EVALUATION:
Point tenderness
Painful dorsiflexion of wrist as capitate impinges
on dorsal rim of radius
RADIOGRAPHIC EVALUATION
Standard scaphoid views
CT scan
 CAPITATE FRACTURES
Treatment
CRIF or ORIF with Kirschner wires or Lag screws to
restore normal anatomy to reduce risk of
Osteonecrosis
Complications
Midcarpal arthritis
osteonecrosis
HAMATE FRACTURES
 HAMATE FRACTURES
May be fractured through
Through Hook(most common)
Through Hamulus
Through Distal articular surface
Through Other articular surface
Present with history of blunt trauma to palm of hand
often seen in racquet sports
hockey
golf (miss ball and hit ground)
tennis
Must distinguish from bipartite hamate (will have
smooth cortical surfaces)
 CLINICAL EVALUATION OF HAMATE
FRACTURES
Symptoms
hypothenar pain
decreased grip strength
paresthesias in ring and small finger
Ulnar & Median Neuropathy
ulnar nerve compression in Guyon's canal
occasionally in thumb, index, middle and ring finger due to
median nerve compression in carpal tunnel
motor weakness of intrinsics (ulnar nerve
compression in Guyon's canal)
 RADIOGRAPHIC EVALUATION OF
HAMATE FRACTURES
Radiographs
recommended views
difficult to visualize fracture on AP
best seen on a carpal tunnel view
CT
best study to make diagnosis
 TREATMENT OF HAMATE FRACTURES
Nonoperative
immobilization in a short arm splint/cast for 6 weeks
Operative
excision of hamate fracture fragment
indications
chronic hook of hamate fractures
ORIF
With k-wires or screws
Complications
Symptomatic non union
Ulnar and median neuropathy
Rupture of the flexor tendons to the small finger
PISIFORM FRACTURES
 PISIFORM FRACTURES
The Pisiform is a sesamoid bone located within the Flexor Carpi
Ulnaris tendon
origin for Abductor Digiti Minimi

Epidemiology
incidence
1%-3% of carpal fractures
Mechanism
Fall on outstretched hand
Fall on Dorsiflexed hand
Direct blow to volar aspect of wrist
Associated conditions
50% of pisiform fractures occur with distal radius, hamate, or
triquetral fractures
 PISIFORM FRACTURES
CLINICAL EVALUATION
Tenderness on volar aspect,ulnar side of wrist. With
painful passive extension of wrist as flexor carpi
ulnaris is tensed.
RADIOGRAPHIC EVALUATION
Radiographs
recommended views
lateral view of wrist with forearm supination of 20-45 degrees
utilizing the carpal tunnel view of 20 degree supination oblique
view demonstrating an oblique projection of the wrist in radial
deviation and semisupination.
CT
TREATMENT OF PISIFORM FRACTURES
NONOPERATIVE
IMMOBILIZATION
indications
first line of treatment
short arm cast with 30 degrees of wrist flexion and ulnar deviation
for 6 weeks
outcomes
patients that sustain fracture of pisiform most often go on to heal
without posttraumatic osteoarthritis
OPERATIVE
PISIFORMECTOMY
indications
painful nonunion
outcomes
studies show a pisiformectomy is a reliable way to relieve this pain
and does not impair wrist function
TRAPEZOIDAL FRACTURES
 TRAPEZOID FRACTURES
Rare
Axial load and crush injuries associated with
other carpal fractures
Clinical evaluation
Tenderness and painful range of motion proximal
to base of 2nd metacarpal
 TRAPEZOID FRACTURES
Radiographic evaluation
Radiographs
PA views compared with contralteral, uninjured wrist
Oblique views
CT scan
Treatment
Short arm Splint/cast for 6 weeks in undisplaced fractures
ORIF with K-wires with restoration of articular congruity
Complication
2nd CMC articulation joint congruity of not restores leads to
post traumatic osteoarthritis
PUTMAN AND MEYER TABULATED THE TYPES OF FRACTURES OF CARPAL BONES OTHER THAN
THE SCAPHIOD
 REFERENCES
CAMPBELLS OPERATIVE ORTHOPAEDICS,
TWELFTH EDITION.
Rockwood & Green's Fractures in Adults, 6th
Edition.
GRAYS Anatomy for Students.
World Wide Net
THANK YOU