312
Isolated Fractures of the Capitate: Use of Nuclear Medicine as an Aid to Diagnosis S. R. Hopkins and W. Ammann Faculty of Medicine, Division of Sports Medicine and Department of Radiology, University of British Columbia, Vancouver, Canada
POST
S. R. Hopkins and W. Anvnann, Isolated Fractures of the Capitate: Use of Nuclear Medicine as an Aid to Diagnosis. mt J Sports Med, Vol 11, No 4, pp 312—314, 1990.
Accepted: October 9, 1989
Fractures of the capitate are considered to be uncommon injuries of the wrist, however, delay in diagnosis
may result in prolonged disability and avascular necrosis. Two cases are reported in which an isolated fracture of the capitate was diagnosed with a 99mTc-MDP nuclear medicine bone scan and confirmed with CT scan or repeated conventional x-rays. These two cases illustrate that an isolated
L
fracture of the capitate should be considered in an individual presenting with persistant wrist pain of traumatic origin, even when conventional x-ray views are negative. The nuclear medicine bone scan can be a useful investigative tool and serve to guide further radiological investigations. Key words
99mTc-MDP bone scanning, carpal bone fracture, capitate
Infroduction
Fractures of the capitate are considered to be uncommon injuries whether in isolation (Adler and Shaftan, 1962; Harrigan, 1908; Lowry and Cord, 1981; Young, 1986) or in combination with other carpal bone injuries (Adler and Shaftan, 1962; Meyers et al., 1971; Vance et al., 1980). Two cases are reported in which the diagnosis was not evident on one or more radiological investigations. Material and Methods
The two cases presented to the first author, in practice as a primary care sports medicine physician.
Int,J.SportsMed. 11(1990)312—314 GeorgThieme Verlag StuttgartNew York
Fig. 1 Bone scan of both wrists revealing intense uptake in the region of the left capitate.
Case Reports
Case one: A 28 year old female injured her left wrist when she collided with a tree while riding a mountain bike. She landed on her out-stretched hand and suffered a fracture of the right clavicle and an interarticular fracture of the left olecranon in addition to the wrist injury. X-rays including scaphoid views of the wrist were obtained shortly after the injury and two weeks later showed no evidence of injury to the carpal bones. She presented to the authors, complaining of persistent
pain over the palmar aspect of the left wrist, which was associated with localized tenderness in the region of the capitate. Nuclear medicine bone scan with 99mTc-MDP (methylene diphosphonate) was obtained, which revealed increased uptake in the distal carpal row, most likely in the capitate (Fig. 1). A third set of X-ray films were obtained (now six weeks after the
initial injury) and demonstrated an indistinct lucency traversing the distal pole of the capitate (Fig. 2). The patient was immobilized in a short arm cast for eight weeks, and subsequently regained normal pain-free function.
Case two: A 27 year old female was thrown from her bicycle when she collided with a motor vehicle. She was thrown over the handle bars and landed on the dorsum of both hands forcing the wrist into palmar flexion. Initial x-rays were obtained and were negative. The patient sought advice
Downloaded by: National University of Singapore. Copyrighted material.
Abstract
Int.J.SportsMed. 11 (1990) 313
Fig. 2 Plain x-rays of left wrist six weeks after trauma showing radiolucency through distal capitate (arrow).
Fig. 3 Bone scan of right wrist demonstrating focal increase of uptake in the area of the third carpo-metacarpal junction.
only sporadically since then. We are aware of only 51 previ-
ously reported cases (Adler and Shaftan, 1962; Apple et al., 1986; Lowrey and Cord, 1981; Young, 1986). In perhaps the most complete review of the problem, Adler and Shaftan (1962) reported six cases of isolated fracture of the capitate
and reviewed 42 other cases. In most, a fall on the outstretched hand was the mechanism of injury, although a fall on
the dorsum of the hand or the metacarpals has also been reported. Rarely a blow to the hand has been listed as the cause of injury. Fig. 4 A CT scan of the right wrist confirms an undisplaced fracture of the capitate (arrow).
one month after the accident because of persistent pain and
swelling over the dorsum of the wrist. A second set of x-rays were also normal and the patient underwent a nuclear medicine bone scan with 99mTc-MDP, which demonstrated focal uptake in the region of the 3rd carpo-metacarpal junction (Fig. 3). A CT scan was performed revealing an undisplaced fracture of the distal one third of the capitate (Fig. 4). The patient was immobilized in a short arm cast for eight weeks with clinical union of the fracture. Her return to her sport of flat water kayaking has been hampered by limitation of range of motion of the wrist, which continues to improve. Discussion
Although a radiographically confirmed isolated fracture of the capitate was reported in the literature as early as 1908 (Harrigan, 1908), this injury has been reported
Associated injury with the scaphoid or other carpal bones is also uncommon (Meyers et al., 1971; Vance et al., 1980), usually resulting from severe trauma. This injury is
complex, with rotation of the proximal part of the capitate, often requiring open reduction and internal fixation (Vance et al., 1980; Yeager and Dalinka, 1985). In isolated fractures, immobilization in a plaster cast for six to eight weeks is the treatment of choice (Adler and Shaftan, 1962; Young, 1986).
This injury is often overlooked (Adler and Shaftan, 1962; Lowry and Cord, 1981); early diagnosis is es-
sential as avascular necrosis has been reported as a consequence in delay of diagnosis (Lowry and Cord, 1981). In patients where a fracture is suspected clinically, but radiography fails to confirm the diagnosis the bone scan can be very useful. The minimum time required for the bone scan to become abnormal following a fracture from acute trauma is dependent on the age of the patient. In a young adult, the bone scan usually becomes abnormal by 24 hours, in an older individual with osteoporotic bones it may take three days before changes are visible (Matin, 1979). In the first few days after a
Downloaded by: National University of Singapore. Copyrighted material.
Isolated Fractures of the Capitate: Use of Nuclear Medicine as an Aid to Diagnosis
S. R. Hopkins and W. Ammann
314 mt. J. Sports Med. 11(1990) fracture, the area of increased activity is diffuse and of relative
Dr. Susan Hopkins
mild intensity. As the callus begins to form, the uptake becomes more intense and better defined. The increased uptake
Faculty of Medicine Division of Sports Medicine University of British Columbia 3055 Wesbrook Mall Vancouver B.C.
in the first few weeks and months following the trauma reflects continued augmented blood flow and osteoblastic activity. In
the healing phase, the uptake gradually returns to normal, in some cases as early as 5 months after the injury; by two years 90% of fractures will demonstrate normal uptake. Although no series has been published concerning the bone scan findings in capitate fractures, Young et al.. (1988) have recently
V6T I W5
acute wrist injury in whom a scaphoid fracture was clinically suspected because of localized tenderness. Bone scanning was performed 10 to 14 days after the injury. Bone scintigraphy was positive in all three scaphoid fractures which were subsequently confirmed radiologically. Three other patients who also had strongly positive scans had no fracture on follow-up investigations, and contusion or traumatic tenosynovitis was suggested as the possible cause of the findings. There were no
false negative bone scans in the remainder of the patients. Other studies (Stordahl eta!., 1984) have also confirmed that a
normal bone scan two weeks after a wrist injury rules out a fracture.
These case reports illustrate the need for further investigations in an individual who has persistent pain, and negative radiographs following wrist trauma. The 99mTcMDP bone scan is a sensitive means of confirming and localizing bone injury. An abnormal bone scan in these patients warrants further investigation preferably with CT scanning. Isolated fractures of the capitate may be under-diagnosed as they are rare and may be radiologically occult. References
-.
Adler J. B., Shaftan G. W.: Fractures of the capitate. JBone Joint Surg44-A: 1537—1547,1962. Apple J. S., Martinez S., Khoury M. B., Nunley J. A.: Occult carpal pathology: tomographic evaluation. Skeletal Radiol 15: 228—232, 1986.
Harrigan A. H.: Fractures of the Os Magnum. Ann Surg 48: 917— 922, 1908.
S. A.: Traumatic avascular necrosis of the capitate bone — Case report. J Hand Surg 6(3): 245—248, Lowrey W. E., Cord
-
1981.
Matin P.: The appearance of bone scans following fractures, including immediate and long-term studies: J NucI Med 20: 1227— 6
1231, 1979. Meyers M. H., Wells R., Harvey J. P.: Naviculo-capitate fracture
syndrome.JBoneJointSurg53A: 1383—1386,1971. Stordahl A., Schjøth, Woxholf B.: Bone scanning of fractures of the
8
scaphoid. JHandSurg 9B: 189, 1984.
Vance R. M., Gelberman R. H., Evans E. F.: Scaphocapitate frac-
tures. JBoneJointSurg 62-A(2): 271—276, 1980. Yeager B. A., Dalinka M. K.: Radiology of trauma to the wrist: dislocations, fracture dislocations, and instability patterns. Skeletal 120—130,1985. ° Radioll3: Young M. R. A., Lowrey J. H., Laird J. D., Ferguson W. R.: 99Tcm. MDP scanning of the carpal scaphoid. Injury 19: 14—17, 1988.
Downloaded by: National University of Singapore. Copyrighted material.
studied 23 patients with normal radiographs following an
Isolated Fractures of the Capitate: Use of Nuclear Medicine as an Aid to Diagnosis S. R. Hopkins and W. Ammann Faculty of Medicine, Division of Sports Medicine and Department of Radiology, University of British Columbia, Vancouver, Canada
POST
S. R. Hopkins and W. Anvnann, Isolated Fractures of the Capitate: Use of Nuclear Medicine as an Aid to Diagnosis. mt J Sports Med, Vol 11, No 4, pp 312—314, 1990.
Accepted: October 9, 1989
Fractures of the capitate are considered to be uncommon injuries of the wrist, however, delay in diagnosis
may result in prolonged disability and avascular necrosis. Two cases are reported in which an isolated fracture of the capitate was diagnosed with a 99mTc-MDP nuclear medicine bone scan and confirmed with CT scan or repeated conventional x-rays. These two cases illustrate that an isolated
L
fracture of the capitate should be considered in an individual presenting with persistant wrist pain of traumatic origin, even when conventional x-ray views are negative. The nuclear medicine bone scan can be a useful investigative tool and serve to guide further radiological investigations. Key words
99mTc-MDP bone scanning, carpal bone fracture, capitate
Infroduction
Fractures of the capitate are considered to be uncommon injuries whether in isolation (Adler and Shaftan, 1962; Harrigan, 1908; Lowry and Cord, 1981; Young, 1986) or in combination with other carpal bone injuries (Adler and Shaftan, 1962; Meyers et al., 1971; Vance et al., 1980). Two cases are reported in which the diagnosis was not evident on one or more radiological investigations. Material and Methods
The two cases presented to the first author, in practice as a primary care sports medicine physician.
Int,J.SportsMed. 11(1990)312—314 GeorgThieme Verlag StuttgartNew York
Fig. 1 Bone scan of both wrists revealing intense uptake in the region of the left capitate.
Case Reports
Case one: A 28 year old female injured her left wrist when she collided with a tree while riding a mountain bike. She landed on her out-stretched hand and suffered a fracture of the right clavicle and an interarticular fracture of the left olecranon in addition to the wrist injury. X-rays including scaphoid views of the wrist were obtained shortly after the injury and two weeks later showed no evidence of injury to the carpal bones. She presented to the authors, complaining of persistent
pain over the palmar aspect of the left wrist, which was associated with localized tenderness in the region of the capitate. Nuclear medicine bone scan with 99mTc-MDP (methylene diphosphonate) was obtained, which revealed increased uptake in the distal carpal row, most likely in the capitate (Fig. 1). A third set of X-ray films were obtained (now six weeks after the
initial injury) and demonstrated an indistinct lucency traversing the distal pole of the capitate (Fig. 2). The patient was immobilized in a short arm cast for eight weeks, and subsequently regained normal pain-free function.
Case two: A 27 year old female was thrown from her bicycle when she collided with a motor vehicle. She was thrown over the handle bars and landed on the dorsum of both hands forcing the wrist into palmar flexion. Initial x-rays were obtained and were negative. The patient sought advice
Downloaded by: National University of Singapore. Copyrighted material.
Abstract
Int.J.SportsMed. 11 (1990) 313
Fig. 2 Plain x-rays of left wrist six weeks after trauma showing radiolucency through distal capitate (arrow).
Fig. 3 Bone scan of right wrist demonstrating focal increase of uptake in the area of the third carpo-metacarpal junction.
only sporadically since then. We are aware of only 51 previ-
ously reported cases (Adler and Shaftan, 1962; Apple et al., 1986; Lowrey and Cord, 1981; Young, 1986). In perhaps the most complete review of the problem, Adler and Shaftan (1962) reported six cases of isolated fracture of the capitate
and reviewed 42 other cases. In most, a fall on the outstretched hand was the mechanism of injury, although a fall on
the dorsum of the hand or the metacarpals has also been reported. Rarely a blow to the hand has been listed as the cause of injury. Fig. 4 A CT scan of the right wrist confirms an undisplaced fracture of the capitate (arrow).
one month after the accident because of persistent pain and
swelling over the dorsum of the wrist. A second set of x-rays were also normal and the patient underwent a nuclear medicine bone scan with 99mTc-MDP, which demonstrated focal uptake in the region of the 3rd carpo-metacarpal junction (Fig. 3). A CT scan was performed revealing an undisplaced fracture of the distal one third of the capitate (Fig. 4). The patient was immobilized in a short arm cast for eight weeks with clinical union of the fracture. Her return to her sport of flat water kayaking has been hampered by limitation of range of motion of the wrist, which continues to improve. Discussion
Although a radiographically confirmed isolated fracture of the capitate was reported in the literature as early as 1908 (Harrigan, 1908), this injury has been reported
Associated injury with the scaphoid or other carpal bones is also uncommon (Meyers et al., 1971; Vance et al., 1980), usually resulting from severe trauma. This injury is
complex, with rotation of the proximal part of the capitate, often requiring open reduction and internal fixation (Vance et al., 1980; Yeager and Dalinka, 1985). In isolated fractures, immobilization in a plaster cast for six to eight weeks is the treatment of choice (Adler and Shaftan, 1962; Young, 1986).
This injury is often overlooked (Adler and Shaftan, 1962; Lowry and Cord, 1981); early diagnosis is es-
sential as avascular necrosis has been reported as a consequence in delay of diagnosis (Lowry and Cord, 1981). In patients where a fracture is suspected clinically, but radiography fails to confirm the diagnosis the bone scan can be very useful. The minimum time required for the bone scan to become abnormal following a fracture from acute trauma is dependent on the age of the patient. In a young adult, the bone scan usually becomes abnormal by 24 hours, in an older individual with osteoporotic bones it may take three days before changes are visible (Matin, 1979). In the first few days after a
Downloaded by: National University of Singapore. Copyrighted material.
Isolated Fractures of the Capitate: Use of Nuclear Medicine as an Aid to Diagnosis
S. R. Hopkins and W. Ammann
314 mt. J. Sports Med. 11(1990) fracture, the area of increased activity is diffuse and of relative
Dr. Susan Hopkins
mild intensity. As the callus begins to form, the uptake becomes more intense and better defined. The increased uptake
Faculty of Medicine Division of Sports Medicine University of British Columbia 3055 Wesbrook Mall Vancouver B.C.
in the first few weeks and months following the trauma reflects continued augmented blood flow and osteoblastic activity. In
the healing phase, the uptake gradually returns to normal, in some cases as early as 5 months after the injury; by two years 90% of fractures will demonstrate normal uptake. Although no series has been published concerning the bone scan findings in capitate fractures, Young et al.. (1988) have recently
V6T I W5
acute wrist injury in whom a scaphoid fracture was clinically suspected because of localized tenderness. Bone scanning was performed 10 to 14 days after the injury. Bone scintigraphy was positive in all three scaphoid fractures which were subsequently confirmed radiologically. Three other patients who also had strongly positive scans had no fracture on follow-up investigations, and contusion or traumatic tenosynovitis was suggested as the possible cause of the findings. There were no
false negative bone scans in the remainder of the patients. Other studies (Stordahl eta!., 1984) have also confirmed that a
normal bone scan two weeks after a wrist injury rules out a fracture.
These case reports illustrate the need for further investigations in an individual who has persistent pain, and negative radiographs following wrist trauma. The 99mTcMDP bone scan is a sensitive means of confirming and localizing bone injury. An abnormal bone scan in these patients warrants further investigation preferably with CT scanning. Isolated fractures of the capitate may be under-diagnosed as they are rare and may be radiologically occult. References
-.
Adler J. B., Shaftan G. W.: Fractures of the capitate. JBone Joint Surg44-A: 1537—1547,1962. Apple J. S., Martinez S., Khoury M. B., Nunley J. A.: Occult carpal pathology: tomographic evaluation. Skeletal Radiol 15: 228—232, 1986.
Harrigan A. H.: Fractures of the Os Magnum. Ann Surg 48: 917— 922, 1908.
S. A.: Traumatic avascular necrosis of the capitate bone — Case report. J Hand Surg 6(3): 245—248, Lowrey W. E., Cord
-
1981.
Matin P.: The appearance of bone scans following fractures, including immediate and long-term studies: J NucI Med 20: 1227— 6
1231, 1979. Meyers M. H., Wells R., Harvey J. P.: Naviculo-capitate fracture
syndrome.JBoneJointSurg53A: 1383—1386,1971. Stordahl A., Schjøth, Woxholf B.: Bone scanning of fractures of the
8
scaphoid. JHandSurg 9B: 189, 1984.
Vance R. M., Gelberman R. H., Evans E. F.: Scaphocapitate frac-
tures. JBoneJointSurg 62-A(2): 271—276, 1980. Yeager B. A., Dalinka M. K.: Radiology of trauma to the wrist: dislocations, fracture dislocations, and instability patterns. Skeletal 120—130,1985. ° Radioll3: Young M. R. A., Lowrey J. H., Laird J. D., Ferguson W. R.: 99Tcm. MDP scanning of the carpal scaphoid. Injury 19: 14—17, 1988.
Downloaded by: National University of Singapore. Copyrighted material.
studied 23 patients with normal radiographs following an
![[Isolated capitate fractures in the frontal plane].](/assets/img/hold.png)
