Delayed Union of Fracture Capitate in A
Two Years Old Child
Mohamed Abou Elatta1*, Hussam M Basheer2 and Ahmed F El Morshidy3
1Specialist of hand and microsurgery, Alrazi hospital, Kuwait
2Consultant and head of hand and microsurgery unit, Alrazi hospital, Kuwait
3Consultant of hand and microsurgery, Hand unit, Al-Razi hospital, Kuwait
Submission: June 06, 2018; Published: September 28, 2018
*Corresponding author: Mohamed Abou Elatta, Specialist of hand and microsurgery, Alrazi hospital, Kuwait, Email: [email protected]
How to cite this article: Md Abou Elatta, Hussam M B, Ahmed F E Morshidy. Delayed Union of Fracture Capitate in A Two Years Old Child. JOJ Orthoped
Ortho Surg. 2018; 2(1): 555580. DOI: 10.19080/JOJOOS.2018.02.555580
Two years old child presented with severe hand swelling after a heavy object was fall on him. Entail X rays was unclear but the following x rays and magnetic resonance image was diagnostic. Open reduction and fixation by Kirschner wire was used for treatment. Whether the union was achieved after 2 years post-operative, but the range of motion and the hand grip was about 95% of the contralateral healthy side.
Keywords: Capitate fracture carpal; Fractures children fractures; Delayed union; Open reduction; Fixation
Fractures of the carpal bones are quite rare in skeletally immature patients. Fracture Capitate is less common than fracture scaphoid . Fracture Capitate may occur alone or associated with other carpal fractures. Capitate fracture may associate with Scaphoid fracture as a part of Scapho-Capitate syndrome (Fenton syndrome) [2,3] or fracture hamate . Computed tomography (CT) and magnetic resonance imaging (MRI) are quite important in establishing the diagnosis because conventional radiography may be inadequate [4,5,11]. Conservative treatment is indicated for non-displaced or minimally displaced Capitate fracture, while open reduction and kircshner wire fixation is indicated for displaced fracture .
Two years old male child was admitted in our hospital 3 days after a cupboard was fall on him. He had fracture both right bones leg with sever ipsilateral hand and wrist swelling. Initial wrist radiographs were inconclusive. (Figure 1) MRI was requested but was done on the 10th day post-trauma (Figure 2). It showed a displaced fracture of the Capitate. On the 15th day
post-traumatic open reduction and internal fixation was carried out. Through a transverse skin incision, retracted the long extensors, then the wrist capsule was incised longitudinally. A displaced fracture of the Capitate and un-displaced fracture Hamate was found. Capitate fracture reduced and fixed with 2 smooth K. wires (Figure 3). The capsule is repaired. A slab was applied for 30 days (Figure 4). K wires were removed on the 35 days post-operative. Regular follow up visits were scheduled,
and physiotherapy was started. As most of the Capitate is cartilaginous, repeated radiographs were difficult to assess, signs of non-union appeared at 6 months. Conservative approach was agreed on with family. After 24 months after operation radiographic union was achieved (Figures 5-7).
Carpal injuries in children are relatively rare. The Scaphoid is
most susceptible to injury incidence is about 0.39%. The fracture
Capitate is the 2nd common carpal bone fracture which often
presents in association with other carpal bone injuries. Other
carpal bone fractures are very unusual [1,3,4,7,8,10,11]. Most of
the cases described were fractures the Capitate in association
with fracture Scaphoid as a part of Scapho-Capitate syndrome
which was first described by Fenton [2, 3,11]. Fracture Capitate
in association with hamate was also reported .
Carpal bones are largely cartilaginous at birth and remain
largely cartilaginous until late childhood. Such a cartilaginous
structure acts as a cushion to protect the carpal bones from
fracture in small children. At the end of second year, only the
Capitate and the Hamate are ossified . Diagnosis is likely to be
missed, or the severity of the injury might not fully be appreciated
at the time of presentation . Conventional radiography may be
inadequate for the diagnosis or may lead to misdiagnosis .
The cartilaginous components of the carpal bones or fractures
of the carpal bones can be visualized by ultrasonography,
CT, scintigraphy, and MRI. However, ultrasonography is not
commonly used for the diagnosis of fractures, except for
displacement of un-ossified epiphyseal cartilage [1,9]. MRI scan
is a sensitive, reliable and quite important technique for detecting
carpal bone injuries in children, in whom osseous development
is progressing and the cartilaginous structure is predominant,
particularly when there is a clinical suspicion. MRI may
demonstrate bone marrow changes and cortical disruption and
can clearly delineate fracture lines, particularly if the imaging is
performed in more than one plane [9,11]. MRI has the advantage
of detecting associated soft-tissue changes around the wrist
joint and joint effusions between the carpal bones and may be
beneficial in evaluating the vascularity of the fracture fragments.
MR sensitivity was 100% with a specificity of 92% [4,7]. CT may
play a role in case of complex fractures, Osteochondral lesions
and can assist surgical planning by providing detailed depiction
of the position and alignment of fracture lines and fracture
fragments . Generally, most of pediatric carpal injuries heal
uneventfully with simple cast immobilization, which is indicated
for non-displaced or minimally displaced Capitate fracture in
children  Kuniyoshi et al.  reported a case of oblique fracture
of the Capitate with a displacement of 5 mm on the lateral view,
which was successfully treated with immobilization. During
follow-up, the Capitate showed marked remodeling and at four
and a half years after injury it had regained an almost normal
shape. Eleven years after injury, there were no radiographic
changes such as malalignment or arthrosis in the carpal bones.
Displaced Capitate fractures require open reduction and
percutaneous K-wire fixation . Obdeijn et al.  published
case of fracture Capitates and Hamite, the Capitate was treated
by dorsal approach and reduced the Capitate anatomically and
fixed with 2 K-wires leaving the skin outside and removed in 6
weeks while the Hamite was treated conservatively. Kai et al.
 reported an eleven years old girl had fracture Capitate in
association with Scaphoid fracture (Scapho-Capitate syndrome)
and fracture distal radius and ulna but the proximal part of
Capitate was rotated 180 degrees. The injury was treated by open reduction and internal fixation. The patient had a full range
of motion of the wrist, as well as full pronation and supination
of the forearm with no signs of avascular necrosis after 1-year
post-operative.) Fractures of the scaphoid, the Capitate, and the
Hamite were treated with wire fixation, leading to good clinical
results twenty-nine months after surgery .
Fujioka et al.  reported a nine-year-old boy had fracture
scaphoid and Capitate. The patient was treated conservatively
with a cast for two months. Fracture of the Capitate healed;
however, fracture of the scaphoid resulted in non-union. They
treated scaphoid non-union with an iliac bone graft and internal
fixation. Three years after surgery, the patient had neither
complaints nor complications and union of the scaphoid was
confirmed on the radiographs. We treated a 2 years old child
who had a displaced fracture Capitate in association with
fracture Hamite in place by open reduction and k. wire fixation.
The union of Capitate was achieved 2 years post-operative.
Although the fracture did not unite initially but it remained
un-displaced, probably by fibrous union the united fully at 2
years. We recommend to treat such cases by open reduction and
fixation but keep wires for longer period more than one and half
months and do not hurry to re-operate the such cases of delayed
union in such age.
All procedures followed were in accordance with the
ethical standards of the responsible committee on human
experimentation (institutional and national) and with the
Helsinki Declaration of 1975, as revised in 2008. Informed
consent was obtained from all patients for being included in the