Clinicians › Wrist

Carpal Fractures Other Than the Scaphoid

65 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Carpal fractures other than the scaphoid account for 15% to 41% of carpal fractures [1] and represent 30% to 40% of all osseous injuries to the wrist [2]. These injuries comprise approximately 1.1% of all fractures [4]. The triquetrum is the most commonly affected bone in this group [1]. Because these fractures are frequently missed on initial presentation, diagnosis requires a high index of suspicion and tailored imaging [3]. Accurate diagnosis and management are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [14].

Management depends on the specific fracture pattern, displacement, and associated ligamentous injuries [4]. Outcomes for isolated carpal fractures other than the scaphoid are generally good [4], though complications such as nonunion and instability arise in cases with concomitant injuries [4]. Prompt diagnosis and early treatment are crucial to prevent nonunion, avascular necrosis, and carpal instability [5]. One year after injury, carpal fractures have a small negative effect on Short Musculoskeletal Function Assessment Hand/Arm Index scores [6] and EQ-5D scores [6].

Physicians must discriminate between injuries manageable with early return to sport and those requiring aggressive treatment to prevent late disability [7]. Timely recognition and thoughtful management may reduce the risk of long-term complications and support favorable outcomes in select cases [8]. Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes [9]. When a trapezium fracture is identified, additional evaluation for ulnar-sided injuries of the carpus is recommended [10]. Isolated scaphoid and other carpal fractures exhibit different demographics in terms of age and gender [12], and a high-energy mechanism of injury was associated with multiple carpal fractures [12].

Anatomy & Pathophysiology

Epidemiology

Carpal fractures other than the scaphoid account for 15% to 41% of carpal fractures, with triquetral fractures being the most common [1]. Overall, carpal fractures are relatively frequent, accounting for 2.8% of all fractures with an annual incidence of 37.5/10⁵ population per year [58]. The relative incidence of carpal fractures excluding the scaphoid is estimated at 36 fractures per 100,000 people annually [81]. In a review of 1000 consecutive hand injuries, only 18% involved fractures of the carpus, with the scaphoid being the most commonly injured carpal bone at 58% [81]. Scaphoid fractures and fractures of the triquetrum account for over 90% of all carpal fractures [58].

The mean age at the time of injury for all carpal fractures ranges from 35 to 40 years with a male predominance [58]. Fractures of the carpus have a type A fracture curve with a bimodal distribution involving younger males and older females [58]. Isolated scaphoid and other carpal fractures exhibit different demographics in terms of age and gender, which may be related to differences in the mechanism of injury [12]. Fractures of the scaphoid, hamate, pisiform, and trapezium occur predominantly in younger males with a mean age ranging from 29 to 43 years and a male predominance ranging from 66% to 100% [58]. Triquetral fractures occur at a mean age of 51 years with an approximately equal gender distribution [58]. A fall from standing height accounts for almost two-thirds of all carpal injuries [58].

Specific carpal bones present distinct epidemiological profiles. Trapezoid fractures are the least common carpal fracture, occurring in less than 1% of cases [29], with a reported incidence of 0.4% of all carpal fractures [31]. Capitate fractures are rare, occurring in less than 5% of all carpal fractures, and are the third most common [29]. Trapezium fractures are rare, occurring in less than 5% of all carpal fractures [29]. Pisiform fractures are rare, occurring in less than 5% of all carpal fractures [29]. Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury [6]. Triquetro-lunate fusions are the commonest type of fusions in the carpal region [65].

Bony Anatomy

The carpus encompasses two rows of eight bones that serve as a bridge between the forearm and the hand [48]. The proximal carpal row from radial to ulnar includes the scaphoid, lunate, and the triquetrum [48]. The distal carpal row from radial to ulnar includes the trapezium, trapezoid, capitate, and the hamate [48]. The pisiform bone is a sesamoid bone enclosed within the sheath of the flexor carpi ulnaris tendon and should not theoretically be considered to be within the proximal carpal row [48]. The trapezium articulates with the first metacarpal, the trapezoid with the second, the capitate with the third, and the hamate articulates with the fourth and fifth [48].

The capitate and trapezoid are tightly connected to the metacarpals, whereas there is 30 to 40 degrees of flexion–extension and rotation at the metacarpotrapezial joint [48]. The proximal carpal row has no direct tendinous attachments, and its movement results from the shape of the bones, their interaction with other bones, and ligament attachments [48]. The distal carpal row is rigid with little motion between its bones due to stout intercarpal ligaments, acting as a functional unit [46]. The scaphoid bridges both the proximal and distal carpal rows [46]. The capitate and hamate have only 2 degrees of intercarpal rotation and less than 2 mm of proximal-distal translation [70]. The trapezoid is closely involved in the forming of an arch-shaped hand [21]. The trapezoid is held in a rigid position owing to its surrounding attachments [31].

Ligamentous Anatomy

Extrinsic carpal ligaments connect the radius or the ulna to the carpus, with volar ligaments generally being stronger than dorsal ligaments [46]. Intrinsic carpal ligaments originate and insert within the carpus [46]. The scapholunate interosseous ligament (SLIL) is C-shaped, consisting of dorsal, palmar, and interosseous portions, with the dorsal portion being the strongest and thickest [46]. The lunotriquetral interosseous ligament (LTIL) is C-shaped, with the volar portion being the thickest and strongest [46]. The capitohamate ligament is a thick ligament, 5 × 5 mm in cross section, with extensions to the third or fourth metacarpals [46]. The dorsal intercarpal ligament (DIC) passes from the dorsal tubercle of the triquetrum to the distal pole of the scaphoid [46].

The Space of Poirier is an area adjacent to the proximal capitate without ligamentous attachment, situated ulnar to the radioscaphocapitate ligament and radial to the long radiolunate ligament in the floor of the carpal tunnel [46]. The distal carpal row separates from the lunate through the Space of Poirier during a perilunate dislocation [46]. The dorsal scaphotriquetral (DST) ligament spans the dorsal-distal rims of the scaphoid, lunate, and triquetrum [70]. The palmar scaphotriquetral ligament spans transversely from the waist of the scaphoid to insert just palmar and distal to the LT ligament on the triquetrum [70]. The dorsal and palmar scaphotriquetral ligaments complete a near-acetabular shaped articulation for the capitate [70]. There are no ligaments, palmar or dorsal, between the lunate and capitate [70].

The midcarpal joint is crossed by four additional palmar intercarpal ligaments: palmar triquetrohamate, triquetrocapitate, scaphocapitate, and the radiopalmar scaphotrapeziotrapezoid ligament [70]. The palmar triquetrohamate and triquetrocapitate ligaments are thick structures that play an important role in the stabilization of the midcarpal joint [70]. The strong ligamentous attachments of the scaphoid to the distal carpal row are considered important stabilizers of the proximal carpal row [70]. Disruption of the scaphoid's ligaments to the distal carpal row has been associated with both dissociative and nondissociative instability patterns of the proximal carpal row [70]. The deep and superficial fibers of the triangular fibrocartilage complex (TFCC) begin on the ulnar side of the lunate fossa of the radius [68]. The deep fibers of the TFCC attach ulnarly at the head of the ulna called the “fovea,” and the superficial fibers attach to the ulnar styloid tip [68]. Most of the distal radioulnar ligaments and the ulnocapitate ligament attach to the fovea at the base of the ulnar styloid [68].

Vascular Anatomy

Circulation to the carpus is comprised of an extraosseous and intraosseous vasculature via both dorsal and palmar vascular systems, which are branches of the radial, ulnar, anterior interosseous and deep palmar arch arteries [71]. The extraosseous arterial supply is formed by an anastomotic network of dorsal and palmar transverse arches connected longitudinally by the radial, ulnar, and anterior interosseous arteries [71]. The three dorsal transverse arches of the carpus include the radiocarpal, the intercarpal, and the basal metacarpal arches [71]. The three palmar transverse arches of the carpus include the radiocarpal, the intercarpal, and the deep palmar arches [71].

The vascular supply of most carpal bones enters the distal half, leaving the proximal half at risk of avascular necrosis [71]. The scaphoid, capitate, and about 20% of all lunates are supplied by a single vessel, increasing their risk of avascular necrosis [71]. The trapezium, triquetrum, pisiform, and 80% of lunates receive nutrient arteries through two nonarticular surfaces and have consistent intraosseous anastomoses, reducing the risk of avascular necrosis [71]. The trapezoid and 50% of hamates lack an intraosseous anastomosis and are at risk of avascular fragments [71].

The scaphoid is supplied by branches of the radial artery, with the dorsal branch supplying 70–80% proximally [71]. The lunate receives vessels from palmar and dorsal surfaces in approximately 80% of cases, with palmar vessels originating from the radiocarpal arch, intercarpal arch, branches of the anterior interosseous and ulnar recurrent arteries [71]. The triquetrum is supplied by branches of the ulnar artery, dorsal intercarpal arch, and palmar intercarpal arch, with dorsal vessels supplying 60% and palmar vessels supplying 40% [71]. The pisiform is supplied by branches of the ulnar artery, with vessels entering through three nonarticular surfaces [71]. The trapezium is supplied by branches of the radial artery, with dorsal supply predominating [71]. The trapezoid is supplied by dorsal vessels (70%) and palmar vessels (30%), entering through two nonarticular surfaces [71]. The capitate is supplied by branches of the dorsal intercarpal arch, dorsal basal metacarpal arch, palmar intercarpal arch, and ulnar recurrent artery [71]. In one-third of cases, the supply to the capitate head is solely from the palmar side [71]. The hamate is supplied by branches of the dorsal intercarpal arch, the ulnar recurrent artery, and the ulnar artery [71]. Dorsal–palmar anastomoses are found in 50% of hamates, but no anastomoses exist with medial vessels [71].

Biomechanics and Kinematics

The wrist joint’s motion planes include flexion, extension, radial deviation, ulnar deviation, and circumduction, with minimal carpal motion during pronosupination [46]. Approximately 62° of wrist extension occurs through the radiocarpal joint and 62% of wrist flexion occurs through the midcarpal joint [46]. The midcarpal joint is mostly responsible for 20° and 40° of radial and ulnar deviation, respectively [46]. The midcarpal joint is responsible for the “dart thrower’s motion,” which involves moving from radial extension into ulnar flexion positioning of the wrist [46]. The radius bears 80% of the axial load transmitted through the radiocarpal joint, while the ulna bears 20% in neutral ulnar variance [46].

During wrist flexion from neutral, the distal row flexes and ulnarly deviates slightly while the scaphoid pronates [46]. During wrist flexion, the proximal row flexes differentially, with more rotation through the scaphoid, followed by the triquetrum and the lunate [46]. The proximal row translates dorsally during wrist flexion [46]. During wrist extension from neutral, the distal row extends and radially deviates slightly while the scaphoid supinates [46]. During wrist extension, the proximal row extends differentially, with more motion in the scaphoid, followed by the triquetrum and then the lunate [46]. The proximal row translates palmarly during wrist extension [46].

The dart-thrower’s path of radial extension to ulnar flexion defines the transition between flexion and extension of the scaphoid and lunate [66]. The dart-thrower’s motion occurs almost exclusively through the midcarpal joint [66]. The lunate, capitate, hamate, trapezium, and trapezoid function collectively as the “stable central column,” controlled by the scaphoid in a two-gear, four-bar linkage system [66]. The triquetrum buffers lunate rotation and prevents ulnar translation [66]. Carpal malalignment is related to dorsal tilt following a distal radial fracture, and reducing the fracture and improving dorsal tilt will reduce carpal malalignment [42].

Pathomechanics

Carpal injuries most frequently occur in young active patients [41]. Fractures of the carpus occur in three general groups: perilunate pattern injuries, axial pattern injuries, and local avulsion/impaction injuries [81]. Most carpal fractures are the consequence of a fall onto an outstretched hand [81]. The energy from a fall may be focused on the distal carpal row, producing an extension moment across the proximal carpal row transmitted through the volar carpal ligaments [81].

Perilunate-pattern or “lesser arc” injuries occur when only ligaments are injured without fracture [81]. Carpal fractures or ligamentous injuries may occur in an arc around the lunate [81]. Fractures of the scaphoid, capitate, triquetrum, or radial styloid, or all four, in conjunction with perilunate instability, are known as “greater arc” injuries [81]. Strong anterior to posterior compression injuries may result in axial-pattern disruption of the carpus [81]. Axial-pattern injuries propagate both radially and ulnarly, separating the carpus on both sides of the capitate [81]. Avulsions may occur owing to localized forced concentration, commonly causing avulsion injuries at the volar/dorsal aspect of the triquetrum secondary to ligament insertions [81]. Trapezial, hamate, and pisiform fractures may also occur from avulsion forces [81].

An injury to the carpus commonly occurs following a mechanism in which an axial compression force is applied to the wrist, commonly leading to hyperextension [92]. In hyperextension mechanisms, palmar ligaments undergo tension and dorsal articulations are subject to shear stresses [92]. The degree of force applied to the wrist and the degree of wrist radial or ulnar deviation determine whether a ligament injury, a fracture, or both occur [92]. Minor injuries, such as ligamentous sprains, frequently result from a low-energy injury [92]. Higher-energy injuries result in either a fracture to one or more of the carpal bones and/or a ligamentous disruption [92]. Variations in bone quality, the direction and magnitude of the deforming force, and the position of the wrist at the time of injury explain the variety of injuries that can occur [92].

Most dorsal perilunate dislocations are the result of an indirect mechanism of injury, usually an extreme extension of the wrist associated with variable degree of ulnar deviation and midcarpal supination [56]. Mayfield and colleagues identified four stages of progressive carpal destabilization in perilunate injuries [56]. Stage I of progressive perilunate instability involves SL dissociation or scaphoid fracture when the distal carpal row is forced into hyperextension [56]. Stage II of progressive perilunate instability involves LC dislocation, where the distal row may translate dorsally and dislocate relative to the lunate, or a capitate fracture may appear [56]. In Stage II, the head of the capitate remains behind and may rotate 180 degrees, a pattern known as scaphocapitate syndrome [56]. Stage III of progressive perilunate instability involves LT disruption or triquetrum fracture as the capitate displaces dorsally [56]. Stage IV of progressive perilunate instability involves lunate dislocation when all perilunate ligaments are torn [56].

Perilunate dislocations are characterized by a progressive disruption of capsular and ligamentous connections of the lunate to the adjacent carpal bones and radius, without associated fractures to the carpus and distal radius [90]. Ligament disruption in perilunate dislocations typically begins radially and propagates around or through the lunate to the ulnar side of the carpus [90]. In pure perilunate dislocations, the distal row dislocates in a dorsal or dorsoradial direction followed by the entire scaphoid and triquetrum [90]. In perilunate fracture–dislocations, only the distal

Classification

Trapezium Fracture Epidemiology: Isolated trapezium fractures account for 1 to 5% of all carpal fractures [26]. The trapezium is the third most common carpal fracture [26]. Twenty percent of trapezium fractures are isolated with a vertical sagittal split [26].

Trapezium Fracture Classification: Trapezial fractures are classified into two main categories: fractures involving the palmar ridge and fractures through the body [27]. Trapezial palmar ridge fractures are subdivided into type I fractures located at the base of the ridge and type II fractures located at the tip of the ridge [27].

Pisiform Fracture Classification: Pisiform fractures are classified into four types: Type 1 transverse, Type 2 sagittal, Type 3 comminuted, and Type 4 pisotriquetral impaction [27].

Clinical Presentation

Carpal fractures other than the scaphoid are exceedingly rare, comprising approximately 1.1% of all fractures [4]. The mean age at injury ranges from 35 to 40 years with a male predominance [58]. Fractures of the scaphoid, hamate, pisiform, and trapezium occur predominantly in younger males, with a mean age of 29 to 43 years and a male predominance ranging from 66% to 100% [58]. Injury mechanisms include sports, direct blow, assault, and road traffic accidents [58]. Patients typically present with wrist pain as the primary complaint [38]. In the acute phase, pain, swelling, and ecchymosis around the carpus may be present [38]. The most constant and dependable sign of carpal injury is well-localized tenderness [38]. Changes in alignment of the hand, wrist, and forearm may be clinically evident on inspection [38]. Swelling over the proximal carpal row suggests a ligament avulsion with or without an associated fracture [38]. With carpal instability or dislocation, gross deformity may be apparent, such as marked dorsal prominence of the entire carpus suggestive of a perilunate dislocation [38].

Compressive stresses applied actively or passively may produce pain at the site of damage and cause a palpable and audible snap, click, shift, catch, or clunk [38]. Stress loading the wrist with compression and motion from radial to ulnar deviation may simulate midcarpal instability (MCI) and produce a “catch-up clunk” as the proximal row of carpal bones snap from flexion to extension [38]. A simple general provocative maneuver for carpal instability is a vigorous grasp that induces pain, an audible clunk or click, a dorsal deformity in the region of the proximal scaphoid, and reduced power with repetitive grip strength testing [87].

Diagnostic Challenges and Missed Diagnosis

Fractures of the carpus other than the scaphoid are frequently missed on initial presentation and require a high index of suspicion with tailored imaging for diagnosis [3]. These fractures are rare but can be devastating if missed [5]. Carpal bone fractures are likely underreported due to complex anatomy and difficulty in plain radiologic interpretation [23]. The injury of the capitate has been diagnosed and reported with undeserved rarity, and a higher index of suspicion would lead to the recognition and treatment of more of these fractures [20]. Trapezium fractures are hard to detect and easily missed on standard radiographs [26]. Isolated trapezoid fractures are rare and often occult on initial radiography, requiring CT for diagnosis [25]. The reported incidence of trapezoid fractures is 0.4% of all carpal fractures, which may be in part because they are underdiagnosed [31]. Coronal fractures of the trapezoid are usually not visible on plain radiographs [31]. Fewer than half of trapezoid fracture cases were diagnosed on initial assessment [31]. Signs and symptoms of a trapezoid fracture may mimic a scaphoid fracture [31]. Delay in diagnosis of trapezoid fractures is common and still achieves excellent results [31]. Trapezoid fractures have nonspecific clinical findings and may be occult on routine radiography in absence of other concurrent pathology [54]. Persistent clinical findings in absence of radiographic fracture may warrant early cross-sectional imaging with MRI instead of (or in addition to) CT rather than prolonged conservative management in patients where there is a high index of suspicion [54]. The isolated trapezium fracture may be difficult to diagnose as the adjacent carpal bones’ shadow obscure the fracture line in routine wrist X rays [78]. Clinicians should maintain a high level of vigilance and consider trapezoid fracture as a possible differential diagnosis when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents [19]. Triquetral body fracture nonunions are rare but can lead to considerable disability and should be part of the differential in patients with ulnar-sided wrist pain after a fall [18]. Stress fractures of the capitate bone must be suspected in cases of insidious and persistent pain in the palm of the hand [32]. Injuries to the hand and wrist are common and can be occult in nature [28]. Delays in diagnosis should be avoided to prevent complications such as nonunion and secondary displacement [28].

Specific Clinical Signs by Bone

Anatomical snuffbox tenderness is a sign of scaphoid injury [38]. Tenderness distal to Lister's tubercle is a sign of scapholunate and lunate injury [38]. Tenderness at the dorsal margin, fingerbreadth distal to the ulnar head, is a sign of triquetral, lunotriquetral ligament, and triquetrohamate ligament injury [38]. Localized pain and tenderness are clinical signs of trapezium fractures [29]. Pain with resisted wrist flexion is common in trapezial palmar ridge fractures [27]. Localized pain and tenderness, e.g., at the base of the second metacarpal, are clinical signs of trapezoid fractures [29]. Symptoms and signs of trapezoid fractures can be minimal and imitate a scaphoid fracture [29]. Localized pain and tenderness are clinical signs of capitate fractures [29]. Localized pain and tenderness are clinical signs of hamate fractures, though often minimal [29]. Ulnar nerve lesion is a clinical sign associated with hamate fractures, as the deep branch of the ulnar nerve passes around the hook of the hamate [29]. Tendon rupture is a clinical sign with chronic presentations of hamate fractures [29]. Localized pain and tenderness are clinical signs of pisiform fractures [29].

For trapezium fractures, symptoms include pain and swelling of the first metacarpal base [78], persistent pain in the anatomical snuffbox [78], diffuse pain and swelling in the thumb [78], and pain exacerbated by opposition [78]. Signs include tenderness of the first metacarpal base [78], diffuse tenderness of the thumb [78], subcutaneous prominence at the dorsoradial area [78], deformity in the thenar area [78], tenderness at the thenar area [78], tenderness over the anatomical snuffbox [78], multidirectional limitation in thumb motion [78], and inability to sustain a pinch [78].

Physical Examination and Special Tests

A full examination of the contralateral wrist can often be helpful, particularly when assessing for instability [38]. The scaphoid shift test involves pressure applied over the scaphoid tubercle while the wrist moves from radial to ulnar deviation [38]. The scaphoid shift test is positive if there is a “clunk” as the scaphoid subluxates dorsally out of the scaphoid fossa [38]. Up to 30% of normal wrists have a positive result on the scaphoid shift test [38]. The midcarpal shift test involves pressure applied over the dorsum of the capitate while the wrist moves from radial to ulnar deviation [38]. The midcarpal shift test is positive if there is a “clunk” as the lunate reduces from the palmarflexed position [38]. Lunotriquetral ballottement involves fixing the lunate with the thumb and index finger of one hand while the triquetrum is displaced palmarly and dorsally with the thumb of the other hand [38]. Lunotriquetral ballottement is positive if painful [38]. The lunotriquetral shear test involves dorsally directed pressure to the pisiform and a palmarly directed pressure to the lunate [38]. The lunotriquetral shear test is positive if it results in reproducing the patient's pain along with palpable crepitation or clicking [38]. A positive Kirk–Watson (scaphoid shift) test is highly suggestive of scapholunate instability [87]. The Watson shift test involves reproduction of pain or a palpable clunk with the scaphoid shift test, where dorsally directed pressure over the volar scaphoid tubercle while the wrist is brought from ulnar to radial deviation subluxates or dislocates the scaphoid over the dorsal ridge of the distal radius [61]. Bilateral nonpainful clunks constitute a negative test result for the Watson shift test [61]. Physical examination findings suggestive of a scaphoid fracture include tenderness of the scaphoid in the anatomic snuffbox, pain with axial compression of the first metacarpal, and tenderness at the scaphoid tuberosity [22].

Imaging and Diagnostic Modalities

CT scanning is a more accurate diagnostic tool than plain radiographs for carpal bone fractures [23]. The four standard views commonly employed in the assessment of scaphoid fractures can be used to detect most injuries to the carpus [38]. These standard views include neutral posteroanterior (PA) and lateral radiographs, along with a 45-degree radial oblique (supinated anteroposterior) and a 45-degree ulnar oblique (pronated AP) views [38]. Additional extension and flexion views are advocated for detecting intercarpal ligament injury, along with a clenched-fist and stress views [38]. Some authors also advocate contralateral wrist views because of the wide range of normal alignment [38]. The standard neutral PA and lateral radiographs are useful for determining the presence of clear fractures and assessing carpal alignment, but are often poor for scaphoid fracture detection due to the tubercle overhang on the PA and the overlap on the lateral [38]. The 45-degree radial oblique, 45-degree ulnar oblique, ulnar deviated AP, Ziter's, and carpal box or tunnel views are purported to improve the ability to diagnose a fracture, particularly of the scaphoid [38]. The VISI and DISI patterns of carpal malalignment are commonly detected using standard neutral lateral radiographs [38]. Standard radiographs should demonstrate a constant space between the scaphoid, lunate, and triquetrum, throughout the range of wrist motion [38]. In the coronal (PA) plane, a line drawn through the axis of rotation parallel with the anatomic axis of the forearm will pass through the head and base of the third metacarpal, the capitate, the radial aspect of the lunate, and the center of the lunate fossa of the radius [38]. In the sagittal (lateral) plane with the wrist and hand in a neutral position, a line will pass through the longitudinal axis of the index finger metacarpal, capitate, lunate, and the radius, with the scaphoid lying on an axis at a 45-degree angle to this line [38].

For trapezium fractures, standard scaphoid views are used for primary investigation [29]. Carpal tunnel views are used for tuberosity fractures of the trapezium [29]. Secondary imaging modalities are used for associated complex injuries of the trapezium [29]. For trapezoid fractures, standard scaphoid views are the primary investigation [29]. Oblique views can aid diagnosis of trapezoid fractures [29]. Overlap of carpals can make diagnosis of trapezoid fractures difficult [29]. Coronal fractures of the trapezoid are rarely detected on radiographs [29]. CT or MRI is used for diagnosis in over 80% of trapezoid fracture cases [29]. For capitate fractures, standard scaphoid views are the primary investigation [29]. Lateral views are useful for determining displacement and rotation of the head in capitate fractures [29]. Dynamic studies are used for displacement in capitate fractures [29]. CT or MRI is used for occult fractures of the capitate [29]. For hamate fractures, standard scaphoid views are the primary investigation [29]. Loss of bone contour is suspicious of dislocation in hamate fractures [29]. Three signs indicative of a hook fracture are absence of the hook, sclerosis of the hook, and lack of cortical density [29]. Oblique and carpal tunnel views improve the chance of diagnosing hook fractures [29]. It is important to distinguish a hook fracture from os hamulus proprium [29]. An alternate view with maximal radial deviation of the wrist and maximal abduction of the thumb is used for hamate fractures [29]. CT or MRI is used for suspected hamate fractures [29]. For pisiform fractures, standard scaphoid views are the primary investigation [29]. Lateral views in 20–45 degrees of supination and carpal tunnel views aid diagnosis of pisiform fractures [29]. Subluxation of the pisotriquetral joint is diagnosed with ≥1 of specific criteria [29]. Special radiographs for pisiform fractures include a reverse oblique (45° supination) and a carpal tunnel view [27]. CT scan is still often necessary for pisiform fractures [27].

MRI has the highest sensitivity in detecting an occult scaphoid fracture [34]. MRI is more sensitive than CT and is useful in making the diagnosis of scaphoid fracture, with a normal study as early as 2 days after injury having a negative predictive value of 100% [36]. Plain radiography is approximately 50% sensitive for the detection of a scaphoid fracture and less than 50% for the other carpal bones [36]. If a scaphoid fracture is suggested but radiographs are negative, the wrist should be immobilized and reevaluated in 2 weeks because up to 30% of patients may have positive follow-up radiographs [36]. The carpal tunnel view should be requested to evaluate a potential cause of persistent pain over the ulnar side of the palm [34].

Primary assessment for radiocarpal instability uses standard scaphoid radiographs to detect displacement and associated fractures [50]. Provocative stress tests may be required to demonstrate dynamic radiocarpal instability [50]. In patients with ulnar translation, the radiographic appearance is often dramatic with the lunate positioned just distal to the ulna and a large space between the radial styloid and the scaphoid [50]. If a perilunate injury is also present, the lunate and triquetrum slide ulnarly, opening a gap between the scaphoid and lunate [50]. In some cases, the ulnar shift is subtle, and a decrease in the ulnocarpal index may provide the only clue to diagnosis [50]. CT may be required to better define associated bony injuries [50]. MRI can be used to determine the extent of ligamentous disruption [50]. Primary assessment for perilunate dislocation uses standard scaphoid radiographs [97]. Disruption of Gilula's lines on the PA view is indicative of an altered intercarpal relationship in perilunate dislocation [97]. The “Spilled teapot sign” on the lateral view is due to palmar rotation of the lunate and disruption of the lunate–capitate articulation [97]. A triangular appearance of the lunate secondary to rotation is a sign of perilunate dislocation [97]. Increased ulnocarpal translation is defined as >50% of lunate uncovering and is seen in 80% of perilunate injuries [97].

Investigations

Carpal fractures other than the scaphoid are frequently missed on initial presentation, necessitating a high index of suspicion and tailored imaging for diagnosis [3]. Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging [14]. Stress loading the wrist with compression and motion from radial to ulnar deviation may simulate midcarpal instability and produce a “catch-up clunk” as the proximal row of carpal bones snap from flexion to extension [38].

Plain radiography: Standard scaphoid views include neutral posteroanterior and lateral radiographs, along with a 45-degree radial oblique and a 45-degree ulnar oblique view [38]. The standard neutral PA and lateral radiographs are useful for determining the presence of clear fractures and assessing carpal alignment [38]. However, these views are often poor for scaphoid fracture detection due to the tubercle overhang on the PA and the overlap on the lateral [38]. The 45-degree radial oblique, 45-degree ulnar oblique, ulnar deviated AP, Ziter's, and carpal box or tunnel views are purported to improve the ability to diagnose a fracture [38]. Additional extension and flexion views are advocated for detecting intercarpal ligament injury [38]. A clenched-fist view and stress views are also advocated for detecting intercarpal ligament injury [38]. Some authors advocate contralateral wrist views because of the wide range of normal alignment [38]. Additional views in maximal radial and ulnar deviation are used if the diagnosis of VISI or DISI patterns is in doubt [38].

For trapezium fractures, standard scaphoid views for primary investigation are recommended [29]. Carpal tunnel views are recommended for tuberosity fractures of the trapezium [29]. Overlap of carpals can make diagnosis of trapezoid fractures difficult on radiographs [29]. Lateral views are useful for determining displacement and rotation of the capitate head [29]. Dynamic studies are used for displacement assessment in capitate fractures [29]. Loss of bone contour on radiographs is suspicious of dislocation in hamate fractures [29]. An alternate view with maximal radial deviation of the wrist and maximal abduction of the thumb is used for hamate fracture diagnosis [29].

Standard scaphoid views will detect most triquetral fractures [59]. Dorsal avulsion fractures of the triquetrum are often found on the oblique or lateral views [59]. PA radiographs of the wrist are useful in identifying transverse body fractures of the triquetrum [59]. PA radiographs often do not detect avulsion fractures of the triquetrum due to the normal superimposition of the dorsal lip on the lunate [59]. An oblique pronated lateral radiograph projects the triquetrum even more dorsal to the lunate and can aid diagnosis [59]. Fractures of the lunate can be difficult to detect on plain radiography [52]. Fractures of the triquetrum in children often are subtle flake avulsion or impingement fractures that require good oblique radiographs for recognition [36].

MRI: MRI is more sensitive than CT for making the diagnosis of carpal fractures [36]. Magnetic resonance imaging has the highest sensitivity in detecting an occult scaphoid fracture [34, 35]. A normal MRI study as early as 2 days after injury has a negative predictive value of 100% for scaphoid fracture [36]. MRI can be helpful in the diagnosis of early avascular changes in the lunate [52]. Correlation of the patient’s clinical and plain radiographic findings with MRI helps to differentiate Kienböck disease from ulnar impaction [52]. To determine the extent of ligamentous disruption in radiocarpal instability, MRI can be used [50]. MRI's exceptional soft tissue contrast and direct multiplanar acquisition enables accurate evaluation of the articular cartilage, radioulnar ligaments, and the TFCC without ionizing radiation [77]. Whether or not contrast improves the accuracy of MRI is controversial [77]. A prospective study comparing MRI with magnetic resonance arthrography in 60 consecutive patients demonstrated sensitivity and specificity for a TFCC tear of 68% and 60% for MRI versus 95% and 100% for MRA [77]. Noncontrast MRI was 98% accurate in identifying arthroscopically confirmed tears and perforations of the articular disc [77]. MRI can be used to assess DRUJ instability through anatomic measurements [77]. Dynamic "4D" imaging may become an important tool to identify lesions and instability of the ulnocarpal joint and DRUJ [77]. Arthroscopy, computed tomography, or magnetic resonance imaging can be very helpful as an adjunct to standard x-rays to better delineate the nature of the midcarpal joint [51]. Arthroscopy, computed tomography, or magnetic resonance imaging can be used to identify the presence or absence of a type II lunate facet [51].

CT: CT scanning is a more accurate diagnostic tool than plain radiography for carpal bone fractures [23]. CT for further delineation of triquetral body fractures is useful [59]. Occult triquetral fractures can be identified when CT and MRI are used in the detection of occult scaphoid fractures [59]. Secondary imaging modalities are often not necessary for triquetral fractures, although CT is useful for body fractures [59]. To better define associated bony injuries in radiocarpal instability, CT may be required [50]. CT or MRI is used for occult capitate fractures [29]. CT or MRI may be required to see lunate fractures [52].

Specific Fracture Imaging Challenges: Isolated trapezoid fractures are often occult on initial radiography, requiring CT for diagnosis [25]. None of the coronal pattern of trapezoid fractures could be seen on plain radiographs [31]. All sagittal trapezoid fractures could be seen on plain posteroanterior or oblique radiographs [31]. Special oblique and carpal tunnel views have been used for trapezoid fracture diagnosis [31]. Associated scaphoid fractures have been reported with trapezium fractures [29]. Secondary imaging modalities are used for associated complex injuries in trapezium fractures [29]. Associated fractures occur in a third of trapezoid fracture cases [29]. Symptoms and signs of trapezoid fracture can be minimal and imitate a scaphoid fracture [29]. Localizing signs for trapezoid fracture can be poor [31]. Plain radiographs do not always reveal trapezoid fractures [31]. Symptoms experienced with trapezoid fracture may be relatively mild [31]. Delay in diagnosis of trapezoid fracture is common and still achieves excellent results [31]. Most diagnoses of trapezoid fracture were made on the basis of the CT scan [31]. Retrospective review revealed 5 cases in which a trapezoid fracture could be seen on the plain radiograph [31].

Fractures of the lunate may be nondisplaced, displaced with large fragments, avulsed, especially the dorsal pole, or comminuted [52]. VISI may be seen with palmar chip fractures of the lunate [57]. Palmar lunate fractures are probably the result of a wrist extension injury, with the fragment being avulsed by the short radiolunate ligament [57]. During injury, the hyperextended capitate loads the dorsal portion of the lunate and the lunate rotates dorsally, causing an avulsion fracture of the palmar lip [57]. If in conjunction with lunotriquetral ligament injury, VISI deformity may be the result of palmar lunate fractures [57]. Fractures of the body of the lunate usually occur from direct axial compression as the head of the capitate is driven proximally into the lunate [57]. A thorough radiographic workup including advanced imaging or arthroscopic inspection must be performed for lunate fractures [57]. The carpus needs to be reduced, and the scapholunate ligament needs to be repaired primarily to the lunate [57]. CT or MRI may be required to see the fracture of the lunate [52].

Other Considerations: Armistead et al., using CT, showed occult fractures of the lunate in some patients with Kienböck disease [52]. The staging classification of Kienböck disease proposed by Lichtman et al. is based on radiographs and MRI [52]. More recently, Bain and Beggs classified Kienböck disease based on arthroscopic determination of the functional status of the involved articular surfaces [52]. Immobilization in a cast has been recommended if Kienböck disease is considered to be quite early (stage I or II, before sclerosis, fragmentation, or collapse occurs) [52]. Such management includes casting of the wrist for several weeks, if warranted, followed by repeated radiographs in search of occult fracture or avascular changes of the lunate or other disorders that become apparent later [52]. This treatment generally may be difficult for patients to accept because it requires 4 months or more of immobilization with an uncertain outcome [52]. Reports regarding nonoperative treatment of Kienböck disease are difficult to evaluate because staging at the time of diagnosis often is unspecified [52]. Hultén described a condition known as the ulna-minus variant [52]. Hultén found in 78% of patients with Kienböck disease that the ulna was shorter than the radius at their distal articulation [52]. This was true in only 23% of normal wrists [52]. In no patient with Kienböck disease was the ulna longer than the radius at the distal articulation [52]. 16% of the control group had a so-called ulna-plus variant [52]. A more recent study by Ring et al. compared 166 wrists with Kienböck disease [52]. Lunate revascularization using a variety of pedicled bone grafts has been effective in preserving the lunate architecture [52]. These revascularization procedures usually require protection of the scaphocapitate or scaphotrapeziotrapezoid joint or with an external fixator [52]. Excision of the lunate can give short-term relief [52]. Prosthetic lunate replacement also provide relief [52]. Limited intercarpal fusions can prevent proximal carpal migration after lunate excision and can help decrease pressure on lunate prostheses [52]. When secondary arthritic changes have developed throughout the wrist (stage IV), treatment usually is proximal carpal row resection or wrist arthrodesis [52]. CT or MRI may be required to see the fracture [52]. Nondisplaced and nondisplaced comminuted fractures can be treated with cast immobilization [52]. Fractures with more than 1 mm offset and avulsion fractures usually require open reduction [52]. Internal fixation techniques vary depending on the requirements of the individual situation and may include Kirschner wires, small cannulated screws, and suture anchors [52]. Trauma to the lunate may be sufficient to damage the circulation, leading to osteonecrosis of the lunate [52]. Gelberman et al. described three patterns of vessels entering the lunate [52]. The lunates believed to be most at risk for osteonecrosis are those with a single vessel or one surface exposed to the blood supply, representing about 20% of lunates [52]. Kienböck disease is a painful disorder of the wrist of unknown cause in which radiographs eventually show osteonecrosis of the carpal lunate [52]. It occurs more frequently between the ages of 15 and 40 years and in the dominant wrist of men engaged in manual labor [52]. Armistead et al., using CT, showed occult fractures of the lunate in some patients [52]. If untreated, the disease usually results in fragmentation of the lunate, collapse with shortening of the carpus, and secondary arthritic changes throughout the proximal carpal area [52]. Symptoms can develop 18 months before radiographs show evidence of the disease [52]. The staging classification of Kienböck disease proposed by Lichtman et al., based on radiographs and MRI, has been useful when planning treatment [52]. Because the natural course of Kienböck disease is unpredictable, the treatment of established Kienböck disease cannot be rigid

Treatment

General Principles

Prompt diagnosis and early treatment are crucial to prevent complications such as nonunion, avascular necrosis, and carpal instability [5]. Accurate diagnosis and management of hand and carpal fractures are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [14]. Treatment algorithms must balance fracture stability and immobilization with preservation of tendon gliding and joint mobilization to obtain optimal clinical outcomes [28]. Carpal fractures are predominantly treated nonoperatively, with 12.4% treated with primary surgery in a recent study year [93]. For non-scaphoid carpal fractures, nonoperative management usually consists of 3 to 6 weeks in a cast or brace [93].

Triquetral Fractures

Triquetral avulsion fractures are considered wrist sprains and are treated symptomatically [22]. These injuries are managed with a splint for comfort only and active self-assisted stretches as comfort allows to limit stiffness [59]. Stretching exercises help limit the potential for wrist stiffness in triquetral avulsion fractures [22]. Triquetral body fractures associated with carpal disruption often require internal fixation [59].

Capitate Fractures

Undisplaced capitate fractures heal without immobilization or with a scaphoid cast [29]. Nonunion of the capitate is rare when the fracture is undisplaced [29]. Displaced capitate fractures or those with dislocation are treated with open reduction and internal fixation (ORIF) [29]. Avascular necrosis (AVN) is possible with displaced capitate fractures [29]. In scaphocapitate syndrome, where the capitate head may be rotated 180°, open reduction and internal fixation (ORIF) through a dorsal approach is required [22]. The capitate is generally fixed with a headless screw in scaphocapitate syndrome [86]. If capitate fixation is not performed in scaphocapitate syndrome, the distal fragment of the scaphoid tends to migrate medially, making its reduction and stabilization difficult [86]. Most cases of scaphocapitate syndrome treated by open reduction through a dorsal approach and internal fixation with Kirschner wires or screws healed uneventfully 2 to 6 months after surgery [86]. Transient avascular changes in the proximal pole of the capitate are common in scaphocapitate syndrome, but healing usually occurs [86]. Nonunion of the capitate, previously described as the most common complication, was rare in a cohort of 53 patients [16]. Complete fracture healing with no signs of avascular necrosis or post-traumatic carpal arthritis was obtained at 26 months in a case of isolated capitate fracture with dorsal dislocation of the proximal pole [17]. Timely recognition and thoughtful management of capitate fractures, including the use of advanced imaging and individualized surgical strategies, may help reduce the risk of long-term complications and support favorable outcomes in select cases [8].

Trapezium Fractures

Undisplaced trapezium fractures are treated with a scaphoid cast [29]. Navicular cast immobilization for 4 to 6 weeks is recommended as initial treatment for isolated trapezium fractures [26]. Conservative management with immobilization results in satisfactory outcomes for minimally displaced trapezoid fractures [25]. Displaced trapezium fractures or dislocations are treated with closed reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF) [29]. Fixation techniques for trapezium fractures are used only when it is not possible to reduce the displaced fracture or the residual articular step-off is too high [26]. A closed, isolated dislocation of the trapezium with no associated fracture can be treated with closed reduction and percutaneous wire fixation [37]. A recent report describes the use of arthroscopy for trapezium fractures [29]. 60% of trapezium fractures are reported to have an unsatisfactory outcome [29]. Nonunion of trapezium ridge fractures is managed with excision [29].

Trapezoid Fractures

Undisplaced trapezoid fractures (<2 mm displacement) are treated with a scaphoid cast [29]. Excellent results are often achieved even with delayed treatment of undisplaced trapezoid fractures [29]. Displaced trapezoid fractures, dislocations, or delayed unions are treated with open reduction and internal fixation (ORIF) or excision [29].

Hamate Fractures

Undisplaced hamate fractures are treated with a cast, with mixed results reported and union rates of only 50% in some series [29]. Small hamate fractures without articular impaction can be treated with closed reduction of the carpometacarpal joint and 4 weeks of Kirschner wire (K-wire) immobilization [22]. Larger hamate fractures and fractures with articular impaction are treated with open reduction and screw fixation [22]. Displaced hamate fractures, dislocations, or those with nerve lesions are treated with excision or open reduction and internal fixation (ORIF) ± decompression of Guyon's canal [29]. Some authors advocate bone grafting to preserve the pulley effect on the flexor tendons following hamate excision [29]. Nonunion of hamate fractures, more common with hook fractures, can lead to chronic pain and little finger flexor tendon injury and is managed with excision or ORIF ± bone grafting [29]. Surgery for hamate hook fractures is elective and usually consists of excision of the hook of the hamate [22].

Lunate Fractures

Nonoperative management in cast for approximately 4 weeks is suitable for most isolated lunate fractures [79]. Nondisplaced and nondisplaced comminuted lunate fractures can be treated with cast immobilization [52]. A transverse fracture of the lunate body will heal if it remains nondisplaced, particularly in adolescents [79]. Nonunion of lunate body fractures is rarely reported [79]. Indications for open reduction and internal fixation (ORIF) of lunate fractures include displacement and/or associated carpal instability [79]. Lunate fractures with more than 1 mm offset and avulsion fractures usually require open reduction [52]. If there is evidence of separation of the lunate fragments by the capitate, union will not occur and the risk of avascular necrosis (AVN) is markedly increased [79]. Distraction with an external fixator may facilitate reduction of the lunate fragments, particularly in the chronic setting [79].

Internal fixation techniques for lunate fractures may include Kirschner wires, small cannulated screws, and suture anchors [52]. Body lunate fractures may be fixed with headless compression screws and/or Kirschner wires [57]. Comminuted lunate fractures may require a cancellous bone graft harvested from the distal radius [57]. Distraction and temporary scaphocapitate pinning may take pressure off the healing lunate when internal fixation is performed [57]. Volar lunate fragments are reduced through an extended carpal tunnel approach exposing the volar lunate [57]. Volar pole lunate fractures are often too small for screw fixation and may be secured with a suture anchor to capture both bone and palmar ligaments [57]. Carpal reduction and stabilization by pinning the scapholunate and lunotriquetral ligaments may be needed for volar lunate fractures [57]. A pin from the scaphoid into the capitate is placed to hold the proximal row reduced and to decrease compressive loads across the lunate [57]. If there is severe comminution with an unreconstructible lunate or chronic injury with arthritis, proximal row carpectomy or scaphocapitate fusion may be indicated [57].

Pisiform Fractures

Acute non- to minimally displaced pisiform fractures are treated with a short-arm cast (SAC) for 4-6 weeks [27]. Widely displaced pisiform fractures with loss of flexor carpi ulnaris (FCU) continuity are treated with pisiform excision and FCU repair [27]. Chronic, symptomatic nonunion or arthritic pisotriquetral joint is treated with pisiform excision [27].

Complex Injuries and Salvage Procedures

Primary wrist fusion is recommended in cases of significant displacement with unsalvageable devascularized fragments [33].

Complications

Nonunion: Nonunion is a recognized complication of carpal fractures other than the scaphoid [4]. It is also a potential complication if diagnosis and treatment are delayed [5]. Delays in diagnosis can lead to nonunion [28]. Nonunion of the capitate was previously described as the most common complication but was rare in a cohort of 53 patients [16]. Triquetral body fracture nonunions are rare but can lead to considerable disability [18].

Instability: Instability is a complication of carpal fractures other than the scaphoid in cases with concomitant injuries [4]. Carpal instability is a potential complication if diagnosis and treatment are delayed [5].

Avascular Necrosis: Avascular necrosis is a potential complication of carpal fractures other than the scaphoid if diagnosis and treatment are delayed [5].

Other Considerations: Delays in diagnosis can lead to secondary displacement [28]. Damage of the joint surface between the trapezium and the base of the first metacarpal or scaphoid could cause pain and restriction of movements [26]. Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index 1 year after the injury [6].

Recovery

Other Considerations: Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated [99].

Key Evidence

• [L5] Carpal fractures other than the scaphoid account for 15% to 41% of carpal fractures, with triquetral fractures being the most common. [1] (10.1016/j.csm.2019.12.006)
• [L5] Fractures of the carpal bones excluding the scaphoid represent 30% to 40% of all osseous injuries to the wrist. [2] (10.1016/s0749-0712(21)00119-0)
• [L5] Fractures of the carpus other than the scaphoid are frequently missed on initial presentation and require a high index of suspicion with tailored imaging for diagnosis. [3] (10.5435/jaaos-d-20-00062)
• [L4] Carpal fractures other than the scaphoid are exceedingly rare and comprise approximately 1.1% of all fractures; management depends on the specific fracture pattern, displacement, and associated ligamentous injuries, with outcomes generally good for isolated injuries but complicated by nonunion and instability in cases with concomitant injuries. [4] (10.1016/j.jhsa.2013.10.030)
• [Paper] Carpal fractures other than the scaphoid are rare but can be devastating if missed; prompt diagnosis and early treatment are crucial to prevent complications such as nonunion, avascular necrosis, and carpal instability. [5] (10.1016/j.csm.2014.09.006)
• [L4] Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury. [6] (10.1177/17531934231202012)
• [L5] The paper provides a comprehensive review of carpal fractures in athletes excluding the scaphoid, emphasizing the need for physicians to discriminate between injuries manageable with early return to sport and those requiring aggressive treatment to prevent late disability. [7] (10.1016/j.hcl.2009.05.013)
• [L5] Timely recognition and thoughtful management of capitate fractures, including the use of advanced imaging and individualized surgical strategies, may help reduce the risk of long-term complications and support favorable outcomes in select cases. [8] (10.2106/jbjs.rvw.25.00112)
• [L5] Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes. [9] (10.1177/15589447261475382)
• [L4] When a trapezium fracture is identified, we recommend additional evaluation for ulnar-sided injuries of the carpus. [10] (10.5435/jaaosglobal-d-22-00270)
• [L4] Isolated scaphoid and other carpal fractures exhibit different demographics in terms of age and gender, which may be related to differences in the mechanism of injury, and a high-energy mechanism of injury was associated with multiple carpal fractures. [12] (10.1016/j.jhsa.2010.11.009)
• [L4] Closed treatment with a splint or cast should be successful for nondisplaced carpal fractures associated with a carpal coalition. [15] (10.1016/j.jhsg.2026.101009)
• [L4] Nonunion of the capitate, which was previously described as the most common complication, was rare in this cohort. [16] (10.1016/j.jhsa.2016.07.099)
• [Case_report] Complete fracture healing was obtained with no signs of avascular necrosis or post-traumatic carpal arthritis at 26 months. [17] (10.1007/s11552-011-9337-5)
• [L4] Triquetral body fracture nonunions are rare but can lead to considerable disability and should be part of the differential in patients with ulnar-sided wrist pain after a fall. [18] (10.1016/j.jhsg.2020.12.002)
• [L4] Clinicians should maintain a high level of vigilance and consider trapezoid fracture as a possible differential diagnosis when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents. [19] (10.1016/j.jhsg.2023.09.001)
• [L4] The injury has been diagnosed and reported with undeserved rarity, and a higher index of suspicion would lead to the recognition and treatment of more of these fractures. [20] (10.2106/00004623-196244080-00003)
• [L4] It is necessary to accurately perform surgical reduction, despite the lesion being old, because the trapezoid is closely involved in the forming of an arch-shaped hand and the fracture is intra-articular. [21] (10.1007/s004020050427)
• [L5] Carpal bone fractures are likely underreported due to complex anatomy and difficulty in plain radiologic interpretation; CT scanning is a more accurate diagnostic tool. [23] (10.1016/j.hcl.2009.08.014)
• [L5] Acute proximal row carpectomy is an option for some patients with complex carpal fracture dislocations, particularly those with fracture of the lunate, concomitant scaphoid fracture and scapholunate ligament injury, or preexisting wrist arthritis. [24] (10.1007/s12593-014-0162-2)
• [Paper] Isolated trapezoid fractures are rare and often occult on initial radiography, requiring CT for diagnosis; conservative management with immobilization results in satisfactory outcomes for minimally displaced fractures. [25] (10.1007/s12593-014-0165-z)
• [L4] [26] (10.1055/s-0039-1683846)
• [L4] [27] (10.1016/j.hcl.2006.07.007)
• [L4] [31] (10.1016/j.jhsa.2012.02.046)
• [Case_report] Stress fractures of the capitate bone must be suspected in cases of insidious and persistent pain in the palm of the hand. [32] (10.1016/j.jht.2023.09.006)
• [Case_report] They recommend primary wrist fusion in cases of such significant displacement with unsalvageable devascularized fragments. [33] (10.1016/j.otsr.2016.12.023)
• [Case_report] This case demonstrates that a closed, isolated dislocation of the trapezium with no associated fracture can be safely and effectively treated with closed reduction and percutaneous wire fixation. [37] (10.1155/2016/1798941)
• [L3] Carpal malalignment is related to dorsal tilt following a distal radial fracture, and reducing the fracture and improving dorsal tilt will reduce carpal malalignment. [42] (10.1302/0301-620x.102b1.bjj-2019-0738.r1)
• [L5] The authors report a case of a trapezium fracture associated with carpometacarpal dislocation that was successfully fixed using closed reduction and percutaneous Kirschner-wire fixation with a good functional outcome. [45] (10.4076/1757-1626-2-8304)
• [L5] [54] (10.1016/j.radcr.2020.03.014)
• [L5] Triquetro-lunate fusions are the commonest type of fusions in the carpal region. [65] (10.1016/0020-1383(95)00192-1)
• [L5] [78] (10.1016/j.ijscr.2020.12.072)
• [L4] Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated. [99] (10.2106/00004623-195638020-00012)

See Also

• Scaphoid Fracture
• Proximal Row Carpectomy

References

[1] Carpal Fractures Other than Scaphoid in the Athlete. Clinics in Sports Medicine. 2020. DOI: 10.1016/j.csm.2019.12.006

[2] FRACTURES OF THE CARPAL BONES. Hand Clinics. 1997. DOI: 10.1016/s0749-0712(21)00119-0

[3] Evaluation and Management of Carpal Fractures Other Than the Scaphoid. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00062

[4] Carpal Fractures. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.10.030

[5] Carpal Fractures Other than Scaphoid. Clinics in Sports Medicine. 2015. DOI: 10.1016/j.csm.2014.09.006

[6] Carpal fractures: epidemiology, classification and treatment of 6542 fractures from the Swedish Fracture Registry. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231202012

[7] Carpal Fractures in Athletes Excluding the Scaphoid. Hand Clinics. 2009. DOI: 10.1016/j.hcl.2009.05.013

[8] Capitate Fracture: Diagnostic Challenges, Treatment Strategies, and Long-Term Complications. JBJS Reviews. 2025. DOI: 10.2106/jbjs.rvw.25.00112

[9] Capitate Fracture-Dislocation: An Unusual Pattern of Carpal Injury. HAND. 2026. DOI: 10.1177/15589447261475382

[10] Trapezial Fractures and Associated Fractures of the Ulnar Carpus: A Ring-Bone Model. JAAOS: Global Research and Reviews. 2023. DOI: 10.5435/jaaosglobal-d-22-00270

[12] Prevalence of Carpal Fracture in Singapore. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.009

[14] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[15] Unilateral Incomplete Coalition of the Capitate, Trapezoid, and Trapezium with Trapezoid Fracture. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101009

[16] Capitate Fractures: A Review of 53 Patients. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.099

[17] Isolated Capitate Fracture with Dorsal Dislocation of Proximal Pole: A Case Report. HAND. 2011. DOI: 10.1007/s11552-011-9337-5

[18] Excision of a Rare Triquetral Body Fracture Nonunion. Journal of Hand Surgery Global Online. 2021. DOI: 10.1016/j.jhsg.2020.12.002

[19] Isolated Trapezoid Fracture in Adolescent Goalkeepers: A Scoping Review of the Literature and a Report of Two Cases. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.09.001

[20] Fractures of the Capitate. The Journal of Bone & Joint Surgery. 1962. DOI: 10.2106/00004623-196244080-00003

[21] A case of old trapezoid fracture. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s004020050427

[22] Aaos Comprehensive Orthopaedic Review 3. Wrist Fractures and Dislocations, Carpal Dissociation, and Distal Radius Fractures > I. Carpal Fractures.

[23] Carpal Bone Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.08.014

[24] Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-014-0162-2

[25] Isolated Fracture of the Trapezoid. A Rare Injury. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-014-0165-z

[26] The Uncommon Trapezium Fracture: A Case Series. Journal of Wrist Surgery. 2019. DOI: 10.1055/s-0039-1683846

[27] Carpal Fractures Excluding the Scaphoid. Hand Clinics. 2006. DOI: 10.1016/j.hcl.2006.07.007

[28] Orthopaedic Knowledge Update Trauma. Hand/Carpal Fractures and Dislocations > Summary.

[29] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Uncommon Carpal Fractures.

[31] Trapezoid Fractures: Report of 11 Cases. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.02.046

[32] Stress fracture of capitate bone—A case report of an unusual fracture. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.09.006

[33] Pancarpal dissociation with palmar Capitate fracture-dislocation: Case report. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.12.023

[34] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > CARPAL FRACTURES AND INSTABILITY.

[35] Miller S Review Of Orthopaedics. CARPAL FRACTURES AND INSTABILITY.

[36] Campbell S Operative Orthopaedics 4 Volume Set. OVERCORRECTION OSTEOTOMY AND LIGAMENTOUS REPAIR OR RECONSTRUCTION > SCAPHOID AND CARPAL FRACTURES.

[37] Traumatic Isolated Trapezium Dislocation without Fracture: A Case Report and Review of the Literature. Case Reports in Orthopedics. 2016. DOI: 10.1155/2016/1798941

[38] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Signs and Symptoms of Carpal Fractures and Dislocations.

[41] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Carpal Fractures and Dislocations.

[42] Prospective investigation of the relationship between dorsal tilt, carpal malalignment, and capitate shift in distal radial fractures. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b1.bjj-2019-0738.r1

[45] Trapezium fracture - a common technique to fix a rare injury: a case report. Cases Journal. 2009. DOI: 10.4076/1757-1626-2-8304

[46] Aaos Comprehensive Orthopaedic Review 3. Carpal Instability* > II. Anatomy and Biomechanics (See Chapter 92).

[48] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy and Applied Anatomy Relating to Carpal Fractures and Dislocations.

[50] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Assessment of Radiocarpal Instability.

[51] Green S Operative Hand Surgery. Radioscapholunate Arthrodesis.

[52] Campbell S Operative Orthopaedics 4 Volume Set. MALPOSITIONED NONUNION OF SCAPHOID FRACTURES ("HUMPBACK" DEFORMITY) > FRACTURES OF THE LUNATE AND KIENBÖCK DISEASE.

[54] Isolated trapezoid fracture: four cases of a rare fracture on MRI. Radiology Case Reports. 2020. DOI: 10.1016/j.radcr.2020.03.014

[56] Green S Operative Hand Surgery. PATHOMECHANICS OF CARPAL LIGAMENT INJURIES.

[57] Green S Operative Hand Surgery. Fractures of the Lunate > Mechanism of Injury and Radiographic Presentation.

[58] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Assessment of Carpal Fractures and Dislocations.

[59] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Other Carpal Fractures.

[61] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > 2. Scaphoid fractures > 4. Carpal instability.

[65] An atypical fracture of a triquetral-lunate synostosis. Injury. 1996. DOI: 10.1016/0020-1383(95)00192-1

[66] Green S Operative Hand Surgery. WRIST BIOMECHANICS > Carpal Kinematics.

[68] Campbell S Operative Orthopaedics 4 Volume Set. MALPOSITIONED NONUNION OF SCAPHOID FRACTURES ("HUMPBACK" DEFORMITY) > DISTAL RADIOULNAR AND ULNOCARPAL JOINT INJURIES.

[70] Green S Operative Hand Surgery. Intrinsic Ligaments > Intercarpal Ligaments.

[71] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Neurovascular Anatomy of Carpal Fractures and Dislocations.

[77] Green S Operative Hand Surgery. Chronic Perilunate Instability (SL Plus LT Instability) > Magnetic Resonance Imaging.

[78] Isolated comminuted trapezium fracture. International Journal of Surgery Case Reports. 2021. DOI: 10.1016/j.ijscr.2020.12.072

[79] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Treatment of Lunate Fractures.

[81] Green S Operative Hand Surgery. FRACTURES OF CARPAL BONES OTHER THAN THE SCAPHOID.

[86] Green S Operative Hand Surgery. Chronic Perilunate Instability (SL Plus LT Instability) > Transscaphoid–Transcapitate–Perilunate Fracture-Dislocations.

[87] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Assessment of Scapholunate Dissociation.

[90] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Perilunate Dislocations.

[92] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy of Carpal Fractures and Dislocations.

[93] Rockwood And Green S Fractures In Adults. 9: Principles of Nonoperative Management of Fractures > Carpal Fractures.

[97] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Assessment of Perilunate Dislocation and Fracture–Dislocation.

[99] Fractures of the Triquetrum. The Journal of Bone & Joint Surgery. 1956. DOI: 10.2106/00004623-195638020-00012