This is a fracture of one or more of the eight carpal bones of the wrist located between the radius and the ulna bones of the forearm and the metacarpal bones of the hand. This chapter describes the fractures of all carpal bones with the exception of the scaphoid, which is elaborated in a separate chapter.
The fracture of each carpal bone is the result of different forms of trauma. In the proximal wrist they involve the scaphoid, the lunate, triquetrum and pisiform and in the distal wrist the hamate, capitate, trapezium and trapezoid. Together they comprise 18% of all wrist-hand fractures. The scaphoid fracture is the most common one reaching 70%. The mechanisms leading to these fractures are divided into: direct trauma, indirect trauma and high-energy injuries. The fracture of each carpal bone is described individually in the following sections.
The fracture of the lunate can occur as a crash fracture from a traumatic impact onto the heel of the hand or as a consequence of repetitive trauma causing micro-fractures that over time develop into a degenerative condition of the lunate. Due to the particular anatomical structure, the lunate is normally poorly vascularised. Therefore, damage to vessels caused by a fracture can compromise blood supply to the bone. This reduces the success of healing, potentially causing bone necrosis (death) or Kienböck’s disease and wrist osteoarthritis (see separate pathologies).
The triquetrum may be fractured by a direct blow to the dorsal hand or by a forced dorsiflexion of the wrist as it happens with a fall. The fractures of the triquetrum are differentiated into fragment or chip fractures and fractures across the entire carpal bone. Such fractures can be complicated by bone displacement requiring surgical treatment.
The fracture of the trapezium, located below the thumb, is usually the result of an impact to the dorsal side of the hand or the radial deviation of the wrist. These fractures often occur along the bone ridge.
The capitate is the central carpal bone situated below the middle finger. Its fracture is usually associated with wrist dislocation or a fracture to the scaphoid. When isolated the capitate fracture is the consequence of a force load to the third metacarpal bone of the hand. The fractures of this bone are less common compared to other carpal bones.
The fractures of the hamate are frequently located at the bone hook and occasionally throughout the carpal bone. They are caused by crushing injuries, direct trauma to the outstretched hand as well as stress fractures. Hamate fractures may be associated with the dislocation of the fourth and fifth metacarpal bones (little and ring finger) at the radial side of the wrist. Hook fractures are mostly treated conservatively.
Due to its location at the palmar side of the hand, the fracture of the pisiform occurs with a traumatic impact to the heal of the hand. It is generally treated conservatively.
Carpal fractures are classified as non-displaced, when the bone fragments maintain their anatomical position, or displaced when the bone fragments have moved from their original anatomy. These characteristics determine the therapeutic approach, with conservative versus operative treatment.
Intra-articular fracture extends to the wrist joint (or articulation)
Extra-articular fracture is located outside of the wrist joint
Open fracture when bone fragments perforate the skin
Comminuted fracture when the bone breaks into multiple fragments
Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.
Melone’s classification describes the characteristics of intra-articular fractures of the radius:
i Stable fracture
ii Unstable "die-punch"
iii "Spike" fracture
iv Split fracture
v Explosion injuries
These fractures are divided into:
Anterior pillar (not weight bearing part of joint)
Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)
Comminuted involving both column type
Sacral / coccygeal fractures
The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.
Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.
The causes leading to carpal fractures include:
Fall on the outstretched hand
Blow to the dorsal or the palmar side of the hand/wrist
Repetitive traumas causing stress fractures (hamate hook)
Dislocation caused by hyperflexion or hyperextension of the wrist
Possible risks factors leading to carpal bone fractures include:
Sports using racquets, clubs and bats (tennis, baseball, hockey) (hamate fractures)
High risk of falls in the elderly
Workers with frequent repetitive grabbing, gripping or lifting activities.
The symptoms arising from a carpal bone fracture are:
Sharp pain at the carpal region of the wrist affected
Pain at the ulnar aspect of the palm or dorso-ulnar aspect of the wrist
Central dorsal wrist pain
Tenderness at touch
Pain exacerbated with wrist movement
Reduced pinch grip strength
Diminished wrist movement
The medical specialist will review the medical history of the patient including the occurrence of previous wrist dislocations, injuries or predisposing activities. Clinical examination will determine:
Changes in the anatomy of the injured wrist against the healthy wrist
Tenderness when applying gentle pressure on the fractured carpal bone (acute fracture)
Pain when applying pressure to the wrist or when extending the wrist
Testing for grip strength
X-rays usually confirm the presence of a carpal bone fracture. Images are taken under different views: antero-posterior and lateral planes to visualise the complexity of the carpal bone arrangement in the wrist. This increases the chance to detecting a fracture that could be overseen. A CT scan or MRI allow for a superior characterisation of carpal fractures and thus provide a guide towards suitable treatment.
The management of the carpal fractures varies in relation to the fracture site and whether or not the fracture is displaced or comminuted. Uncomplicated fractures are usually managed conservatively. Rest and immobilisation with a short-arm cast for up to 6-8 weeks is the treatment of choice. Additional treatments include:
Administration of NSAIDs
Surgery is required in significantly displaced fractures of the carpal bones or following the diagnosis of a non-union from an older untreated fracture.
Internal fixation is done in displaced fractures using special screws and wires after an incision is made either on the back or the frontal side of the wrist. The size of the incision varies depending on the level of fracture. This fixation will accelerate the healing process and allow a faster return to sports and other daily activities. A graft may be used if the bone is comminuted in several parts.
In case of complications e.g. non-unions, following a carpal bone fracture, surgery will involve the removal of the necrotic bone followed by the replacement with a bone graft taken from the wrist or the pelvis region. This procedure also includes the vessels of the grafted bone to ensure optimal blood supply and healing. The recovery time after a bone graft can last several months of cast treatment. Ultrasound and electromagnetic waves can support the bone healing process. Other complications after carpal bone fracture include:
Non-union of the carpal bone if fracture was untreated immediately after injury
Non-union combined with an injury to the radial artery causing avascular necrosis of the bone. This is often detected with X-rays months after injury and requires surgical treatment
Lunate bone is at particular risk to develop avascular necrosis after a fracture
Nerve injury (ulnar nerve after hamate fracture)
Wrist arthritis involving chronic pain and restricted wrist movement
Regardless of the treatment type following a carpal bone fracture, a cast or splint is normally worn for 9-12 weeks or up to 6 months. Any physical activities that increase the risk of a fall or stress to the wrist should be avoided until the carpal fracture has completely healed. To prevent stiffness, it is critical to maintain finger movement and begin physical therapy soon after the fracture has repaired, approximately 6-8 weeks after surgery.
A physical or occupational therapist will recommend exercises to restore flexibility and strength of the wrist including fine movement of the fingers. Education will inform the patient how to modify activities to avoid future carpal injuries. Standard rehabilitative therapy includes:
Return to activity plan
Taping / bracing
The main preventative measures aim at reducing the risk of falls and protect the wrist during sport or working activities that are known to increase the risk of carpal bone fracture. Common preventive strategies are:
Devices to improve elderly patient stability
Modification of physical activities
Exercise to improve muscle strength, flexibility, balance and posture