CASE REPORT: Conservative management of wrist pain originating from capitate bone fracture

By Dallas Humble DC

Wrist pain can result from several conditions, however, in this case the symptoms are arising from a capitate bone fracture related to a recent automobile injury. The patient reported she was holding the steering wheel tightly when struck from behind. She presented herself to our office with this condition and spinal complaints on 5.24.2022. INTRODUCTION The patient was a 20-year-old female who presented to the practice with acute onset of right wrist pain and restricted range of motion. The patient entered this office seeking treatment for injuries sustained in a motor vehicle accident that occurred on 05/16/2022. She stated the pain was elicited immediately following the accident and worsened over the next few days.

CLINICAL FINDINGS

Ms. Rhoten reports she was the seatbelt restrained driver of a vehicle traveling South when a truck ran a stop sign pulling out of a neighborhood, causing a collision, with impact from the right bumper, headlight and rear panel. She reports her vehicle was shoved sideways and she was shoved forward upon impact, causing her right hand to strike the steering wheel. The patient recalls she experienced pain in her right wrist and left leg immediately following the collision. She states she went to local hospital that night where x-rays were taken. Ms. Rhoten further states she has lost days of work from this injury.

SUBJECTIVE COMPLAINTS

Ms. Patient reported a complex of symptoms. For the sake of this paper, we will be focusing on the symptoms associated with the right wrist subject matter at hand. The patient reported constant pain experienced in the area of the right hand, pain in her right wrist and coldness in her right hand since the accident.

Based on a pain scale from 0 to 10, the patient was asked to rate her current condition. She rated her wrist pain at VAS 6/10.

PHYSICAL EXAMINATION
Vitals:
Ht: 5'8"
Wt: 283 lbs
Blood Pressure: 118/84
Pulse: 76 BPM

Handedness: Right

Range of Motion
The patient’s right wrist was restricted and painful in all ranges. Orthopedic tests were difficult to perform due to pain levels and inability to move her wrist. Palpation elicited tenderness along the posterior and anterior aspect of the mid wrist.

Grip Strength
Left: 75, 70, 70
Right: could not perform right hand grip test due to pain and weakness

IMAGING Initial radiographs of the spine and wrist were taken in the emergency department following the accident at hand. No mention was made of the wrist injury from these imaging studies. Upon entering our office X-Rays of the entire spine related to her complaints were ordered along with an MRI of her right wrist due to the severity of pain and lack of findings from previous radiographs. Below are A-P and LAT MRI images taken of the right wrist.

Image 1. Capitate Bone (Right hand) AP view Image 2. Capitate Bone (Right hand) LAT view

The radiology report is listed below. After reviewing the studies and report I agree with the radiologist’s findings. 

STUDY
MRI, Right Wrist s/ Contrast

CLINICAL INDICATION
Hand pain and swelling following MVA 05/16/2022

COMPARISON

No relevant imaging examinations are available for review.

PROCEDURE DETAILS
Multiplanar multisequence MRI right wrist without contrast. Imaging was performed on a 1.5 Tesla GE magnet.

FINDINGS
Triangular fibrocartilage complex is normal with no radial, central or ulnar-sided triangular
fibrocartilage perforation. Scapholunate interval is normal with intact scapholunate ligament.
Lunotriquetral interval is normal with intact lunotriquetral ligament.
Acute linear nondisplaced fracture of the capitate bone with bone marrow edema, contusion and bone bruise
Joint effusion with synovial thickening about the dorsum of the mid carpal joint of the wrists dorsal to the capitate fracture consistent with synovitis.
Flexor tendons are normal. No tear or tendon sheath effusion.
Extensor tendons are normal. No tear or tendon sheath effusion.
Extensor carpi ulnaris tendon is intact and normally situated in the ulnar groove.
Structures of carpal tunnel are normal. The median nerve is normal in signal intensity and
morphology. The ulnar nerve within Guyon's canal is normal in signal intensity and morphology.
No dorsal or volar ganglion cysts.
Neurovascular structures are normal.
The muscles are normal in signal intensity.

IMPRESSION
1. Acute linear nondisplaced fracture of the capitate with bone marrow edema and contusion.
2. Dorsal mid carpal wrist joint effusion and synovitis.

As a practitioner in practice for over 3 decades, I have seen a battery of joint conditions throughout my career. The main issue involving the wrist pain, however, usually surround a sprain injury or carpal tunnel syndrome. Isolated fractures of the carpal bones, except for the scaphoid, are rare. Adlar and Shaftan (1) reviewed isolated fractures of the capitate and added 6 cases of their own. Since then, only 20 cases of isolated fracture of the capitate have been reported over the past 30 years. Most papers report isolated cases or limited series (1, 2, 3, 4, 5, 7, 8, 9).

This patient was referred to an orthopedic specialist for evaluation of the right wrist. Surgery was not recommended. He did, however, recommended a wrist brace and told her to continue seeing me. She was also advised to return for periodic follow up appointments to be sure the bone was healing properly. Cold laser therapy was performed on her right wrist at our office along with various other therapeutic procedures related to her spinal complaints.

Chiropractic adjustments were delivered to her entire spine and, after 6 weeks, eventually her right wrist extremity joint was adjusted with an instrument technique as well. During the following 5 months of the indicated therapy and chiropractic care the patient underwent care at 3x per week in the beginning eventually tapering off to 1-2x per month to actively monitor her condition. She presently complains only of mild stiffness in her right wrist and tingling in her right hand with a VAS of only 2/10. Fractures of the capitate are usually associated with additional carpal bone fractures such as the scaphoid or hamate. (2, 8) Identification of this patient’s origin of wrist pain was crucial to arrive at the appropriate options for proper co-management and treatment of her condition.

REFERENCES:

1. Adler J. B., Shaftan G. W. Fractures of the capitate. J. Bone Joint Surg., 1962, 44-A, 1537-1547.

2. Albertsen J., Mencke S., Christensen L., Teisen H., Hjarbäk J. Isolated capitate fracture diagnosed by computed tomography. Case Report. Handchir. Mikrochir. Plast. Chir., 1999, 31, 79-81. 3. Allen H., Gibbon W. W., Evans R.J. Stress fracture of the capitate. J. Accid. Emerg. Med., 1994, 11, 59-60.

3. Calandruccio S., Duncan S. Isolated non-displaced capitate wrist fracture diagnosed by magnetic resonance imaging. J. Hand Surg., 1999, 24-A, 856-859.

4. Dee W., Winckler S., Bing E. Die Faktur und die Luxationsfraktur des Os Capitatum. Unfallchirurg, 1994, 97, 478-484.
5. Gibbon W., Jackson A. An isolated capitate fracture in a 9-year-old boy. Br. J. Radiol., 1989, 62, 487-488.
6. Guiral J., Gracia A., Diaz-Oter J. M. Isolated fracture of the capitate with a volar dislocated fragment. Acta Orthop. Belg., 1993, 59, 406-408.
7. Moller J., Lybecker. Simultaneous fracture of the hamate and the capitate bones. Arch. Orthop. Trauma Surg., 1987, 106, 331-332.
8. Richards R. R., Paitichh C. B., Bell R. S. Internal fixation of a capitate fracture with Herbert screws. J. Hand Surg., 1990, 15A, 885-887.
9. Volk A., Schnall S., Merkle P., Stevanovic M. Unusual capitate fracture : a case report. J. Hand Surg., 1995, 20A, 681-682. 21. Young T. Isolated fracture of the capitate in a 10-year-old boy. Injury, 1986, 17, 133-134.