Delayed diagnosis and surgical management of an isolated capitate fracture: A case report with two-year follow-up

Abstract

Introduction: Isolated capitate fractures are among the rarest carpal injuries and often remain undetected due to subtle radiographic findings and the bone's central location within the carpus. When diagnosis is delayed, complications such as nonunion and avascular necrosis (AVN) may develop, requiring advanced surgical management.

Case presentation: A 20-year-old male manual laborer presented with persistent wrist pain and restricted motion six months after a motorcycle accident. Initial radiographs failed to detect a fracture. Subsequent imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), revealed an isolated capitate fracture with nonunion and diffuse AVN. The patient underwent surgical treatment consisting of resection of the necrotic proximal capitate pole, dorsal capsular interposition, Kirschner wire (K-wire) fixation of the distal fragment, and core decompression to enhance vascularity. Early rehabilitation was implemented. At the two-year follow-up, the patient had regained pain-free wrist motion, and imaging showed no progression of AVN or development of osteoarthritis.

Discussion: The capitate's predominantly retrograde blood supply makes it particularly prone to AVN. In cases with delayed presentation, internal fixation may be unfeasible, and joint-sparing salvage procedures become necessary. Our approach preserved motion and avoided wrist arthrodesis. Early, structured rehabilitation was essential to achieving functional recovery.

Conclusion: This case illustrates the value of early recognition and customized management in isolated capitate fractures complicated by AVN. Non-arthrodesis surgical techniques, combined with early rehabilitation, can yield excellent long-term outcomes, particularly in young, active patients.

Keywords: Capitate avascular necrosis; Capitate fracture; Capitate nonunion; Case report; Wrist rehabilitation.

Fig. 1

A: Posteroanterior (PA) and B: lateral radiographs of the left wrist demonstrating an old capitate fracture with nonunion and sclerotic bone margins without degenerative changes.

Fig. 2

Computed tomography (CT). A: coronal, B: Axial, C: sagittal, D: 3-D scans of the left wrist demonstrating an old capitate fracture with nonunion, malrotation of the fracture fragments, and sclerotic margins around the fragments.

Fig. 3

The left wrist's magnetic resonance imaging (MRI) shows the capitate bone. A: hypointense signals on T1-weighted sequences and B: hyperintense signals on T2-weighted sequences, consistent with diffuse avascular necrosis involving the entire capitate.

Fig. 4

A, B: Intraoperative digital imaging demonstrating resection of the proximal segment of the capitate bone during surgery.C, D: Postoperative radiographs demonstrate resection of the proximal capitate fragment and fixation of the remaining fragments using K-wires.

Fig. 5

Follow-up images were obtained immediately after K-wire removal in the sixth postoperative week, demonstrating approximately 30 degrees of palmar flexion (A) and 40 degrees of dorsiflexion (B).

Fig. 6

Two-year follow-up of the patient. A: demonstrates 80 degrees of palmar flexion; B: 80 degrees of dorsiflexion. C and D: posteroanterior and lateral radiographs of the wrist show that the preserved distal capitate fragment remains stable. Although imaging features of avascular necrosis were noted, there was no radiographic progression of osteoarthritis or collapse severity two years after surgery.