Carpal coalitions Intercarpal coalitions are well-known cavitation
of a common
intrauterine
but poorly documented entities, resulting from incomplete
embryologic
life. At our institution
carpal presursor
during the fourth to eighth weeks of
we have collected a series of 36 cases of carpal coalition in
24 persons. We found the condition to be much more common in American blacks than whites. The patients reported no symptoms or wrist dysfunction relative to the condition. The coalitions were incidental
findings on radiographs
largest series in the English-language
Terence
J. Delaney,
MD,
taken for other reasons (usually trauma).
literature.
and Sounder
I
ndividual carpal bones arise from the cavitation of a common cartilaginous precursor during the fourth to eighth weeks of intrauterine life. ’ Incomplete
From the Department of Orthopaedic Surgery, The Catholic Medical Center of Brooklyn and Queens, Inc.. Jamaica, N.Y. Received for publication March 4, 1991.
Nov. 26, 1990; accepted
in revised form
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:
Terence J. Delaney,
Department
of Orthopaedic
Surgery, The Catholic Medical Center of Brooklyn and Queens, Inc., 88-25,
153rd St., Jamaica,
NY 11432.
3/l/30256
This is the
(J HAND SURC 1992;17A:28-31.)
Eswar,
MD, Jamaica,
N.Y.
cavitation leads to carpal coalition, which becomes radiographically apparent as the carpus ossifies. Coalitions occurring as part of a syndrome are often seen with other anomalies in the involved extremity as well as anomalies of other organ systems (Table I).‘. 3 In general, postinfectious coalitions involve carpal bones in adjacent rows. Isolated coalitions, such as those presented in this series, tend to involve bones in the same carpal row. The most common variant occurs between the lunate and the triquetral bones, although coalitions may occur anywhere in the carpus. Carpal coalition was first described by Sandifort in 1779. This was followed in 1908 by a case report from Corson.4 In 1952 Minaar,S in a series of twelve cases, published his classification of lunate-tiquetral coali-
Minaar Classification
IV. With Associated Anomalies
Fig. 1. Minaar’s classification of lunate-triquetral coalition. Type I-Proximal pseudartbrosis. Type II-Proximal osseous bridge with distal notch. Type III-Complete fusion. Type IV-Fusion with other carpal anomalies.
28
THE JOURNAL OF HAND SURGERY
Vol. 17A, No. 1 January 1997
Carpal coalitions
Fig. 2. Minaar type II coalition.
Table I. Syndromes carpal coalitions
associated
with
Acre-pector-vertebraldysplasia Arthrogryposismultiplex congenita Nievergeltsyndrome Otopalatodigital syndrome Bird-headed dwarfism Hand-foot-uterus syndrome Feral alcohol syndrome Diastrophic dwarfism Turner’s syndrome
Fig. 3. Minaar type III coalition
Table II. The CMC experience Time of study Total wrists Total patients Age range Race Sex Unilateral
cases
Type of coalition
tion. Minaar noted, as had others before him, that this condition usually appears as an incidental radiologic finding, is asymptomatic, and occurs more commonly in blacks than in whites. Blacks of western African origin had an especially high incidence. There is often a familial predisposition, and bilaterality is common. Isolated cases of carpal coalition are rarely associated with wrist dysfunction.
Prior symptoms Prior trauma Prior disease i infection Ulnar variance Minaar class
24 mo 36 24 10 to 80 22 black 2 white 20 male 4 female I2 4 left 8 right 32 lunate-triquetral 2 capitohamate I lunate-navicular 1 trapeziocapitate None None None Not relative I-I case II-20 cases III- I 1 cases IV-No cases
29
30
The Journal of HAND SURGERY
Delaney and Eswar
Fig. 4. Bilateral Minaar type II.
Clinical material This study involves 36 cases of carpal coalition occurring in 24 persons. The material was collected from two of our institution’s emergency rooms. One serves a black population and the other a white population. An equal number of patients with similar problems are seen in each emergency room. Therefore the racial distribution of the population from which we studied this condition was equal. All of the coalitions were discovered as incidental findings during radiographic examination of the forearm, wrist, or hand after an injury. Comparison views of the contralateral wrist were then obtained. All patients were questioned about the presence of wrist pain or associated symptoms before injury. When possible, any uninjured wrist containing a coalition was examined for range of motion. None of these wrists had pain or evidence of functional limitation. All
had a normal range of motion. Our results are summarized in Table II. The cases were collected over a 24-month period. Twelve cases were unilateral and 12 were bilateral. All of the bilateral cases had similar coalitions on each side. Four of the unilateral cases involved the left wrist and eight involved the right wrist. There were 32 lunatetriquetral f Figs. 2 to 4)) two capitohamate ( Fig. 5)) one lunate-navicular, and one capitotrapezoid (Fig. 6) coalitions. One of the lunate-triquetral coalitions was a Minaar type 1, 20 were Minaar type II, and 11 were Minaar type III. The age range was 10 to 80 years. There were 20 male and 4 female patients. Twenty-two patients were black and two were white. No patient gave a history of previous injury, infection, or wrist dysfunction. Ulnar variance and handedness were recorded and found to have no relevance to the condition. Grip and
Vol. 17A. No. I January 1992
Carpal coalitions
31
Fig. 6. Trapeziocapitate coalition.
REFERENCES
Fig. 5. Capitohamate coalition.
pinch strength were not measured in the emergency room because of the patients’ injuries.
Discussion Our series agrees with previously published accounts, which found that carpal coalitions are asymptomatic, often bilateral, and result in no wrist dysfunction. Carpal bone coalitions appear to be more common among American blacks than whites. A lunate-triquetral coalition was the most common variant in our series.
1. Moore KL. The developing human. 3rd ed. Philadelphia: WB Saunders, 1982:356-g. 2. Kelikan. Congenital deformities of the hand and forearm. 2nd ed. Philadelphia: WB Saunders, 1982:433-5. 3. Simons BP, McKenzie WD. Symptomatic carpal coalition. J HANDSURG 1985;10A:190-3. 4. Szaboky GT. Anomalous fusion between the lunate and triquetrium. J Bone Joint Surg 1969;5 1A: 1001-3. 5. Minaar ABdeV. Congenital fusion between the lunate and triquetral bones in the South African bantu. J Bone Joint Surg 1952;34B:45-58.
of a common
intrauterine
but poorly documented entities, resulting from incomplete
embryologic
life. At our institution
carpal presursor
during the fourth to eighth weeks of
we have collected a series of 36 cases of carpal coalition in
24 persons. We found the condition to be much more common in American blacks than whites. The patients reported no symptoms or wrist dysfunction relative to the condition. The coalitions were incidental
findings on radiographs
largest series in the English-language
Terence
J. Delaney,
MD,
taken for other reasons (usually trauma).
literature.
and Sounder
I
ndividual carpal bones arise from the cavitation of a common cartilaginous precursor during the fourth to eighth weeks of intrauterine life. ’ Incomplete
From the Department of Orthopaedic Surgery, The Catholic Medical Center of Brooklyn and Queens, Inc.. Jamaica, N.Y. Received for publication March 4, 1991.
Nov. 26, 1990; accepted
in revised form
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:
Terence J. Delaney,
Department
of Orthopaedic
Surgery, The Catholic Medical Center of Brooklyn and Queens, Inc., 88-25,
153rd St., Jamaica,
NY 11432.
3/l/30256
This is the
(J HAND SURC 1992;17A:28-31.)
Eswar,
MD, Jamaica,
N.Y.
cavitation leads to carpal coalition, which becomes radiographically apparent as the carpus ossifies. Coalitions occurring as part of a syndrome are often seen with other anomalies in the involved extremity as well as anomalies of other organ systems (Table I).‘. 3 In general, postinfectious coalitions involve carpal bones in adjacent rows. Isolated coalitions, such as those presented in this series, tend to involve bones in the same carpal row. The most common variant occurs between the lunate and the triquetral bones, although coalitions may occur anywhere in the carpus. Carpal coalition was first described by Sandifort in 1779. This was followed in 1908 by a case report from Corson.4 In 1952 Minaar,S in a series of twelve cases, published his classification of lunate-tiquetral coali-
Minaar Classification
IV. With Associated Anomalies
Fig. 1. Minaar’s classification of lunate-triquetral coalition. Type I-Proximal pseudartbrosis. Type II-Proximal osseous bridge with distal notch. Type III-Complete fusion. Type IV-Fusion with other carpal anomalies.
28
THE JOURNAL OF HAND SURGERY
Vol. 17A, No. 1 January 1997
Carpal coalitions
Fig. 2. Minaar type II coalition.
Table I. Syndromes carpal coalitions
associated
with
Acre-pector-vertebraldysplasia Arthrogryposismultiplex congenita Nievergeltsyndrome Otopalatodigital syndrome Bird-headed dwarfism Hand-foot-uterus syndrome Feral alcohol syndrome Diastrophic dwarfism Turner’s syndrome
Fig. 3. Minaar type III coalition
Table II. The CMC experience Time of study Total wrists Total patients Age range Race Sex Unilateral
cases
Type of coalition
tion. Minaar noted, as had others before him, that this condition usually appears as an incidental radiologic finding, is asymptomatic, and occurs more commonly in blacks than in whites. Blacks of western African origin had an especially high incidence. There is often a familial predisposition, and bilaterality is common. Isolated cases of carpal coalition are rarely associated with wrist dysfunction.
Prior symptoms Prior trauma Prior disease i infection Ulnar variance Minaar class
24 mo 36 24 10 to 80 22 black 2 white 20 male 4 female I2 4 left 8 right 32 lunate-triquetral 2 capitohamate I lunate-navicular 1 trapeziocapitate None None None Not relative I-I case II-20 cases III- I 1 cases IV-No cases
29
30
The Journal of HAND SURGERY
Delaney and Eswar
Fig. 4. Bilateral Minaar type II.
Clinical material This study involves 36 cases of carpal coalition occurring in 24 persons. The material was collected from two of our institution’s emergency rooms. One serves a black population and the other a white population. An equal number of patients with similar problems are seen in each emergency room. Therefore the racial distribution of the population from which we studied this condition was equal. All of the coalitions were discovered as incidental findings during radiographic examination of the forearm, wrist, or hand after an injury. Comparison views of the contralateral wrist were then obtained. All patients were questioned about the presence of wrist pain or associated symptoms before injury. When possible, any uninjured wrist containing a coalition was examined for range of motion. None of these wrists had pain or evidence of functional limitation. All
had a normal range of motion. Our results are summarized in Table II. The cases were collected over a 24-month period. Twelve cases were unilateral and 12 were bilateral. All of the bilateral cases had similar coalitions on each side. Four of the unilateral cases involved the left wrist and eight involved the right wrist. There were 32 lunatetriquetral f Figs. 2 to 4)) two capitohamate ( Fig. 5)) one lunate-navicular, and one capitotrapezoid (Fig. 6) coalitions. One of the lunate-triquetral coalitions was a Minaar type 1, 20 were Minaar type II, and 11 were Minaar type III. The age range was 10 to 80 years. There were 20 male and 4 female patients. Twenty-two patients were black and two were white. No patient gave a history of previous injury, infection, or wrist dysfunction. Ulnar variance and handedness were recorded and found to have no relevance to the condition. Grip and
Vol. 17A. No. I January 1992
Carpal coalitions
31
Fig. 6. Trapeziocapitate coalition.
REFERENCES
Fig. 5. Capitohamate coalition.
pinch strength were not measured in the emergency room because of the patients’ injuries.
Discussion Our series agrees with previously published accounts, which found that carpal coalitions are asymptomatic, often bilateral, and result in no wrist dysfunction. Carpal bone coalitions appear to be more common among American blacks than whites. A lunate-triquetral coalition was the most common variant in our series.
1. Moore KL. The developing human. 3rd ed. Philadelphia: WB Saunders, 1982:356-g. 2. Kelikan. Congenital deformities of the hand and forearm. 2nd ed. Philadelphia: WB Saunders, 1982:433-5. 3. Simons BP, McKenzie WD. Symptomatic carpal coalition. J HANDSURG 1985;10A:190-3. 4. Szaboky GT. Anomalous fusion between the lunate and triquetrium. J Bone Joint Surg 1969;5 1A: 1001-3. 5. Minaar ABdeV. Congenital fusion between the lunate and triquetral bones in the South African bantu. J Bone Joint Surg 1952;34B:45-58.
