FRACTURES OF THE CARPAL

BONES EXCLUDING THE

SCAPHOID
BY MUNIR A. SHAH, MD, AND STEVEN F. VIEGAS, MD

Carpal fractures excluding the scaphoid can cause morbidity that is dispropor-
tionate to their incidence because they are easily overlooked and are often
harbingers of a wider wrist injury. Failure to recognize a more global injury
pattern can result in undertreatment and permanent wrist dysfunction. Diagnosis
requires a high index of suspicion, familiarity with carpal topography to guide
the physical examination, and judicious use of specialized radiographic views and
ancillary imaging techniques.
Copyright © 2002 by the American Society for Surgery of the Hand

racture of the carpal bones, excluding the topography to guide the physical examination and

F scaphoid, account for approximately 40% of

all carpal fractures.1 Paradigms for evaluation
and treatment of the fractured scaphoid are well
delineated in the literature. The less common frac-
tures of other carpal bones have received consider-
ably less attention. However, these injuries can
produce morbidity that is disproportionate to their
incidence for several reasons. First, carpal fractures
excluding the scaphoid may have a subtle clinical
and radiographic presentation and are easily over-
looked. Diagnosis requires familiarity with carpal
judicious use of specialized radiographic views and
ancillary imaging techniques based on clinical sus-
picion. Second, such fractures are often harbingers
of significant ligamentous disruption or associated
carpal fractures. Failure to recognize a more global
injury pattern can result in undertreatment and
permanent wrist dysfunction.
We examine the incidence, mechanisms of injury,
associated osseous and ligamentous injuries, physical
examination findings, useful radiographic views, and
ancillary imaging techniques and management prin-
ciples of these often overlooked carpal fractures.

From the Division of Hand Surgery, Department of Orthopaedics and

Rehabilitation, University of Texas Medical Branch, Galveston,
TX.
Address reprint requests to Munir A. Shah, MD, Department of
Orthopaedics, Rebecca Sealy Hospital, Room 2.616, 301 University
Blvd, Galveston, TX 77555-0165. E-mail: mashah@utmb.edu
Copyright © 2002 by the American Society for Surgery of the Hand
1531-0914/02/0203-0003$35.00/0
doi:10.1053/jssh.2002.34795
TRIQUETRUM
riquetral fractures are probably the most com-
T mon carpal fracture excluding the scaphoid. In a
population-based study conducted in Bergen, Nor-
way, triquetral fractures comprised 31% of all carpal
fractures.1

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND 䡠 VOL. 2, NO. 3, AUGUST 2002 129
130 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS

Triquetral fractures can involve the dorsal rim or

body.2 Fractures of the dorsal rim can result from
avulsion of the dorsal intercarpal, dorsal radiocar-
pal, or lunotriquetral ligaments during a hyperflex-
ion/radial deviation injury to the wrist. Alterna-
tively, hyperextension/ulnar deviation injuries can
produce an impaction fracture when the ulnar
styloid or hamate chisel into the dorsal triquetral
rim (Fig 1).3,4
Triquetral body fractures most commonly involve
the medial tuberosity, typically caused by a direct
blow to the ulnar border of the wrist. Other fracture
patterns involving the body include comminuted,
transverse, or sagittal fractures and are commonly
associated with higher energy mechanisms of injury.
Triquetral body fractures may be the sole radiographic
manifestation of a more global wrist injury including
axial disruption of the carpus secondary to severe
dorsopalmar crush or a perilunate greater arc injury
(Fig 2).5,6
Physical examination reveals dorsoulnar wrist ten-
derness over the triquetrum. Standard wrist radio-
graphs are typically diagnostic. The oblique view is
the most useful for visualizing dorsal rim fractures.2
Occasionally, bone scan or computed tomography
(CT) may be necessary to corroborate clinical suspi-
cion.
Cast immobilization is sufficient for dorsal avul-
sion/chisel fractures and nondisplaced fractures of the
triquetral body if carpal instability has been excluded.
Patients should be counseled that dorsal rim fractures
may produce prolonged soreness.2 In addition, pro-
gression to symptomatic nonunion may occur and can
be treated with fragment excision and ligament repair.
Isolated, nondisplaced body fractures can be treated
with cast immobilization. Triquetral body fractures
that are displaced or are part of a broader ligamentous
insult require surgical treatment to reduce and stabi-
lize the fracture and, when necessary, address carpal
instability.6-8

HAMATE FIGURE 1. Mechanisms of triquetral avulsion fractures.

amate fractures constitute approximately 7% of
H carpal fractures and can involve the hamular
process (hook) or, more commonly, the body.1 Body
fractures are typically associated with a broader hand
and/or wrist injury, most commonly dorsal fracture
dislocation of the 4th and/or 5th carpometacarpal
(CMC) joints (Fig 3).9 The typical mechanism is axial
loading of the flexed CMC joints (eg, striking an
unyielding object with a clenched fist), that produces
a coronally oriented fracture of the dorsal, distal
hamate with variable degrees of comminution.10 Body
fractures also may be associated with greater arc peri-
 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS 131

FIGURE 2. (A) Anteroposterior wrist radiograph shows a seemingly isolated triquetral fracture (arrow). However, there is
disruptions of Gilula’s arcs, a minute fleck avulsion from the radial styloid and palmar flexion of the lunate as evidenced by its
triangular radiographic appearance. (B) Lateral wrist radiograph shows a dorsal perilunate dislocation. Triquetral fractures can
represent an osseous component of a wider ligamentous injury.

lunate injuries or axial carpal dislocations.8 The latter
injury is associated with dorsopalmar crush and flat-
tening of the carpal arch, which produces sagittal-
oblique hamate body fracture.5
Fractures of the hamular process are typically iso-
lated injuries. The mechanism of injury is classically
direct trauma to the patient’s nondominant hand by
the base of a golf club, bat, or racquet.10-13 Falls on an
outstretched hand can also produce hook fractures,
either by direct trauma or flattening of the carpal arch
with avulsion by the transverse carpal ligament. The
hook of the hamate may fracture at the tip, waist, or
base.
Physical examination of the typical body fracture
(CMC joint fracture dislocation) reveals dorsoulnar
wrist swelling. Tenderness is well localized to the
CMC joints. Loss of knuckle prominence from abnor-
mal flexion of the metacarpal(s) or abrasions over the
metacarpal heads may be present. Poorly localized
tenderness should alert suspicion for additional liga-
mentous disruptions, particularly in patients with
a history of high-energy injury (eg, dorsopalmar
crush).5
In contrast, patients with hook of the hamate frac-
tures may have a subtle initial presentation, and the
injury can be easily overlooked. Diagnosis requires a
high index of suspicion. Patients may complain of
poorly localized palmar wrist pain aggravated by
power grip.13 Examination reveals tenderness over the
hamular process (radial and distal to the pisiform) and,
often, over the dorsal aspect of the hamate.12-14 Pain
can be elicited with resisted ring and small finger
distal interphalangeal joint flexion when the wrist is
in ulnar deviation (Fig 4). Pain is relieved when the
test is performed with the wrist in radial deviation.15
Patients with delayed presentation may have flexor
tendon rupture that should be specifically excluded
during the initial examination. Patients with hamular
process and hamate body fractures require a thorough
evaluation of ulnar nerve function, particularly the
deep motor branch, because both injuries can be as-
sociated with ulnar neuropathy. Associated carpal tun-
nel syndrome has also been reported.12,13
Hamate body fractures are usually apparent on
standard wrist radiographs, particularly the oblique
and lateral views.16 When associated with a fracture
dislocation of the CMC joints, the metacarpals are
usually flexed, with their bases residing in an abnor-
mal dorsal position and relative to the intact carpus
and adjacent metacarpals. Hamular process fractures
are notoriously difficult to visualize with standard
radiographs. The carpal tunnel and 30° supinated
oblique views are valuable additional radiographic
projections that may visualize hook of hamate frac-
tures (Fig 5).13,17 Transverse CT images or bone scan
should be obtained if the diagnosis remains in ques-
tion.18
Nondisplaced, isolated hamate body fractures may
be treated with immobilization. More commonly,
these fractures are part of a larger injury, and surgical
132 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS

FIGURE 3. Fracture-dislocations of the 4th and 5th CMC joints often have minimal findings on the (A) anteroposterior wrist
radiograph except increased overlap of the 5th metacarpal and hamate. The (B) oblique and (C) lateral views show a flexed
posture of the 5th metacarpal, abnormal dorsal prominence of the metacarpal bases and a coronally oriented fracture of the
dorsal, distal hamate (C, arrow). Postoperative (D) anteroposterior and (E) lateral wrist radiographs show reduction of the CMC
joints and restoration of hamate articular congruity. A dorsal, coronally oriented capitate fracture resulted from this injury
because the capitate has a facet for articulation with the 4th metacarpal. This patient had a complete, preoperative motor palsy
of the ulnar-innervated intrinsic hand muscles that resolved over 8 weeks.

treatment is usually required to reduce and stabilize
the hamate fracture and to address carpal or carpo-
metacarpal instability.8 Acute, nondisplaced hamular
process fractures may be treated with cast immobili-
zation.19 Symptomatic nonunion has been reported,
particularly in fractures adjacent to the hamular pro-
cess base. Excision of the ununited fragment pro-
vides reliable symptomatic and functional improve-
ment.13,17 Certain investigators recommend excision
of asymptomatic nonunions to minimize the risk for
flexor tendon rupture.11 Others recommend open re-
duction and internal fixation of nonunion based on the
possible functional importance of the hamular process
as a pulley for the digital flexors.20
TRAPEZIUM
rapezial fractures comprise approximately 3% of
T carpal fractures and can involve the body or
ridge.1,21 Ridge fractures are typically isolated injuries
 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS
FIGURE 4. Resisted flexor digitorum profundus flexion of the
ring and small fingers with the wrist in ulnar deviation will
commonly elicit pain at the hook of the hamate if a fracture
exists.
caused by direct trauma or avulsion by the transverse
carpal ligament during a fall on an outstretched
hand.22,23 Palmar classified ridge fractures based on
location and propensity for healing. Type I fractures
involve the base of the ridge and typically heal with
immobilization. Type II fractures involve the tip of
the ridge and can progress to symptomatic non-
union.23
Trapezial body fractures may occur during extreme
wrist dorsiflexion and radial deviation, effectively
crushing the trapezium between the base of the
thumb metacarpal and the radial styloid. Vertical
transarticular body fractures may be the most com-
mon type. This fracture pattern may be associated
with fracture dislocation of the 1st CMC joint and a
thumb metacarpal Bennett’s fracture secondary to a
direct blow to the adducted and flexed thumb.24-27
Physical examination of patients with trapezial
ridge fractures show tenderness localized just distal to
the scaphoid tuberosity.28 Pain can be elicited with
133
resisted wrist flexion by producing apposition of the
flexor carpi radialis against the trapezial ridge.23 Car-
pal tunnel syndrome is a common comorbid condition
and should be excluded specifically.22 Body fractures
may show abnormal dorsoradial prominence of the
thumb metacarpal base.25 Tenderness is localized to
the CMC joint and/or the distal aspect of the anatomic
snuffbox.27
Radiographic evaluation of suspected trapezial
ridge fractures should include a carpal tunnel view.22
Occasionally, CT may be required to delineate an
acute or chronic ridge fracture. Body fractures, espe-
cially if associated with concomitant thumb CMC
joint dislocation, are often distinguishable on standard
wrist radiographs, although CT is sometimes required
to visualize the fracture.28 An oblique lateral, with the
ulnar aspect of the hand down and the forearm in 20°
of pronation, may reveal more subtle body fractures by
decreasing the radiographic overlap between the trap-
ezoid and trapezium.26
Trapezial ridge fractures can be treated with cast
immobilization. Symptomatic nonunions may be
treated with fragment excision.22,23 Body fractures
with intra-articular displacement should be reduced
anatomically and rigidly fixed.29
PISIFORM
isiform fractures account for approximately 2% of
P all carpal fractures.1,21 The pisiform is a sesamoid
attached to the flexor carpi ulnaris tendon proximally,
and to the pisohamate, pisometacarpal, and pisotrique-
tral ligaments distally. Additional soft-tissue attach-
ments include the abductor digiti minimi and the trans-
FIGURE 5. This carpal tunnel view shows a hamular process
fracture that was missed on standard wrist radiographs.
134 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS
FIGURE 6. (A) Anteroposterior wrist radiograph of a patient with ulnar-sided wrist pain shows a possible fracture of the pisiform.
(B) Carpal tunnel view clearly shows a displaced parasagittal pisiform fracture.
verse carpal ligament.30 The ulnar nerve and artery are
immediately radial to the pisiform in Guyon’s canal.
The typical history is a fall on an outstretched hand
that most often produces a transverse pisiform fracture
by a combination of both direct and indirect mecha-
nisms. The pisiform becomes fixed at the pisotriquetral
joint when the outstretched hand strikes the ground;
forceful contraction of the flexor carpi ulnaris then pro-
duces a transversely oriented avulsion fracture. Other
injury patterns include comminuted, parasagittal, and
osteochondral impaction fractures (Fig 6).5,31
Physical examination reveals tenderness over the
pisiform. Examination should exclude other wrist in-
juries (eg, perilunate dislocation, distal radius or ad-
ditional carpal fracture) that can occur in up to 50%
of pisiform fractures.32 The ulnar nerve requires eval-
uation, particularly in patients with comminuted frac-
tures that result from a direct blow and those with
established posttraumatic pisotriquetral osteoarthri-
tis.33,34 Pisiform fractures are poorly visualized on
anteroposterior and oblique wrist radiographs but
may be visualized on the lateral view. Additional
projections that bring the pisiform and pisotriquetral
joint into profile are the carpal tunnel view and the
30° supinated lateral radiograph.32,33 Occasionally,
CT or bone scan may be required to corroborate
clinical suspicion.
Most pisiform fractures can be treated with splint
immobilization. Symptomatic posttraumatic osteoar-
thritis or nonunion can be treated with pisiform enu-
cleation and reconstruction of the flexor carpi ulnaris
with minimal adverse sequellae.33-35 Fractures that
have a transverse, as opposed to longitudinal, orien-
tation functionally disrupt the flexor carpi ulnaris
function and have a more guarded prognosis.5
LUNATE
unate fractures comprise approximately 1% of all
L carpal fractures.1,21 Their incidence may have
been previously overestimated because some investi-
gators included fractures that occurred in the setting
of Kienbock’s disease, and others have probably as-
cribed dorsal triquetral fractures to the lunate.5 In 1
series, only 17 cases of lunate fracture were collected
over a 31-year period.21
Lunate fractures can involve the dorsal or palmar
poles or the lunate body.21 Dorsal pole fractures may
result from scapholunate or lunotriquetral interosse-
ous or dorsal radiocarpal ligament avulsion. Alterna-
tively, impingement of the dorsal pole between the
radius and capitate during extreme wrist dorsiflexion
can produce an impaction fracture. Palmar pole frac-
tures may result from avulsion by the long and short
radiolunate ligaments.15 Body fractures occur second-
ary to axial loading of the lunate between the capitate
head and lunate fossa.
Examination reveals painful wrist motion and lo-
calized tenderness when the fracture is dorsal. Frac-
tures of the lunate may be the radiographic harbinger
of a more global carpal injury (eg, perilunate disloca-
tion) and demand rigorous evaluation of the wrist.
 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS 135

FIGURE 7. A minimally displaced fracture of the (A) lunate volar pole was treated with cast immobilization. The patient
developed significant displacement of the (B) volar lunate fragment (arrow) and midcarpal collapse with severe lunate flexion
and palmar subluxation of the capitate. (C, D) Open reduction of the volar pole, with its attached long and short radiolunate
ligaments, and the midcarpal joint restored carpal alignment.

Radiographs frequently fail to visualize or underesti-
mate the size or displacement of fracture fragments.
Therefore, CT is invaluable to evaluate lunate injuries,
particularly body fractures.
Lunate fractures should be approached with caution
because even seemingly innocuous, isolated fractures
may functionally detach critical wrist ligaments and
lead to profound malalignment of the carpus.36 Alter-
natively, lunate fractures may be part of a larger
ligamentous insult.37,38 Patients whose fractures do
not appear to warrant surgical intervention require
meticulous follow-up care to ensure that wrist mal-
alignment does not develop.
Palmar pole fractures require reduction and fixation
because they produce functional loss of the long and
short radiolunate ligaments. Untreated, this fracture may
produce profound volar flexion and dorsal translation of
the lunate. Failure to recognize and treat this injury can
produce chronic palmar subluxation of the capitate and
midcarpal arthritis (Fig 7).15,36 Conversely, large dorsal
pole fractures require fixation because they can produce
functional loss of the dorsal component of the scapholu-
nate interosseous, the dorsal radiocarpal and lunotrique-
tral ligaments. Loss of dorsal constraints can lead to
dorsiflexion and volar translation of the lunate and
secondary arthritis. Occasionally, dorsal lunate avul-
sion fractures are limited to the attachment of the
scapholunate interosseous ligament (Fig 8). This fracture
pattern requires reduction and fixation to prevent dorsal
intercalated collapse instability of the wrist. Axial com-
pression injuries with displacement and/or articular im-
paction require reduction and fixation (Fig 9). Neutral-
ization of axial loads with an external fixator may assist in
maintaining the reduction. Patients should be counseled
that lunate fractures can be complicated by avascular
necrosis, nonunion, and carpal malalignment.39
CAPITATE
he capitate is central and well protected within the
T carpus and infrequently injured. Capitate fractures
comprise approximately 1% of all carpal fractures.1,21
136 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS

FIGURE 8. (A) Anteroposterior radiograph of a patient who sustained a fall on an outstretched hand shows a radial styloid
(arrow) and 5th metacarpal fracture. A subtle abnormality is evident at the radial aspect of the lunate. Examination revealed
tenderness over the scapholunate ligament and a positive Watson’s maneuver during examination under anesthetic. (B) A
dorsal wrist approach confirmed lunate avulsion fracture of the scapholunate ligament. (D) The scapholunate joint and lunate
avulsion fracture (arrow) were reduced and secured with (C, D) K-wires.
 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS
FIGURE 9. Lunate body fracture (arrow) produced by an axial
loading injury. A CT scan should be obtained because dis-
placement and articular impaction are difficult to discern on
plain radiographs.
Capitate fractures can involve the body or the distal
dorsal articular margin. Body fractures are usually
transverse and may result from a direct blow that
causes multiple carpal bone fractures or as part of an
incomplete or self-reduced perilunate injury.15,40 The
scaphocapitate syndrome is a manifestation of the
perilunate injury pattern.41-43 Wrist extension results
in scaphoid fracture and, with further extension, the
capitate impacts on the dorsal lip of the radius. A
transverse fracture of the capitate body occurs, and its
proximal fragment can rotate 180° in the sagittal
plane as the hand returns to a neutral position. The
articular cartilage of the capitate head then faces dis-
tally in opposition to the fracture surface of the distal
capitate fragment (Fig 10). Transscaphoid, transcapi-
tate, perilunate injuries can also occur without mal-
rotation of the capitate head. Avascular necrosis of the
proximal fragment is possible because the head has no
soft-tissue attachments.40,42
137
Dorsal distal articular margin fractures of the cap-
itate occur as part of the 3rd CMC joint fracture
dislocation.9 The mechanism of injury is axial loading
combined with a flexion moment applied to the long
finger metacarpal. Occasionally, such fractures are
produced during fracture dislocations of the 4th CMC
joint because the capitate typically has a facet for
articulation with and ligamentous attachment to the
4th metacarpal (Fig 2).44 Fractures of the 3rd meta-
carpal base should be distinguished from an os styloi-
deum, a common accessory bone that resides within
the extensor carpi radialis brevis at the level of the
CMC joint. Roughly one half of capitate fractures are
associated with additional osseous and/or ligamentous
injuries (eg, dorsal fracture dislocation of the CMC joint
or transscaphoid perilunate injury), and the other one-
half are isolated.40
Physical examination may reveal localized tender-
ness for isolated capitate fractures or more diffuse
swelling and tenderness if the fracture is part of a
wider wrist injury. Standard wrist radiographs may
not reveal isolated body or dorsal articular margin
fractures. CT in the coronal plane for transverse frac-
tures and in the parasagittal plane for articular margin
fractures can show fractures that do not manifest on
plain radiographs. Magnetic resonance imaging is use-
ful to predict healing potential of transverse body
fractures by visualizing the vascular status of the
capitate head.5
Nondisplaced, isolated, capitate fractures can be
treated with cast immobilization.15 Capitate fractures
that are part of a larger wrist injury should be fixed
along with associated osseous/ligamentous inju-
ries.42,43 The seemingly isolated but displaced capitate
fracture requires meticulous evaluation because dis-
placement occurs with concomitant osseous or liga-
mentous injuries (Fig 11). Patients with capitate frac-
tures should be counseled that functional limitation is
common secondary to nonunion, avascular necrosis of
the proximal pole, capitate collapse, symptomatic
midcarpal arthrosis, or associated injuries.45 Painful
midcarpal arthrosis can be treated with midcarpal
arthrodesis.
TRAPEZOID
he trapezoid is well protected by the osseous
T architecture of the 2nd CMC joint. The base of
the 2nd metacarpal is fish tailed and interlocks with
138 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS
FIGURE 10. Mechanism of proximal capitate fragment rotation in the scaphocapitate syndrome. Note the 180° rotation of the
proximal fragment.
the trapezium, capitate, 3rd metacarpal, and trape-
zoid. The inherently stable joint geometry is rein-
forced by strong ligaments and explains why the
trapezoid is the least common carpal fracture.46 Hove1
reported no cases of trapezoid fracture in an analysis of
183 consecutive carpal fractures collected over a 10-
FIGURE 11. A displaced capitate fracture (solid arrow)
should prompt a meticulous search for a wider wrist injury.
This patient sustained a transcapitate, transtriquetral (hollow
arrow) greater arc injury.
month period. Most reports are limited to individual
cases.47
Most trapezoid fractures occur during CMC joint
dislocation, either isolated or in association with frac-
ture dislocations of multiple CMC joints.9,48 The
usual mechanism is high-energy axial loading of the
index or adjacent metacarpals.
Physical examination reveals tenderness and swell-
ing localized to the involved CMC joints. The 2nd
CMC joint is notoriously difficult to visualize on
routine radiographs. Mehara and Bhan49 described a
radiographic view that brings the 2nd CMC joint into
profile. The thumb is positioned in maximal palmar
abduction, and the radial border of the hand and
thumb are placed flat against the cassette by hyper-
pronating the forearm. The radiograph beam is di-
rected 30° off of the vertical line, toward the palm. CT
in the parasagittal plane is often necessary to visualize
fracture dislocations of the 2nd CMC joint.
Nondisplaced fractures can be treated with cast
immobilization. Displaced fractures require reduction
and fixation of the trapezoid and metacarpal. Adjacent
CMC joint injuries should be addressed at the same
setting. Symptomatic chronic injuries can be treated
with CMC joint arthrodesis.
 CARPAL FRACTURES (EXCLUDING SCAPHOID) 䡠 SHAH & VIEGAS
SUMMARY
arpal fractures can cause disproportionate morbidity
C relative to their incidence. Timely diagnosis and
effective treatment of these injuries requires a high index
of suspicion, judicious use of specialized radiographic
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