Capitate fracture

[secretmum41]

I've namechanged for this as it's very outing.

Dd has fractured her wrist. Cutting a long story short we were told her radius was fractured, then at fracture clinic the following day were told there was no fracture, 4 days later we were told her scaphoid was fractured, fracture clinic following day said scaphoid wasn't fractured .... now 3 months down the line an MRI scan has shown her capitate bone is fractured and NOT healed.

We're obviously livid but that's another story.

I'm wondering if anyone had any personal/professional advice on if the bone is now likely to heal and how long it may take? We've seen 2 specialists (1 a hand specialist) and both have never seen this bone fractured in their 10+ years careers so don't know exactly what to do. A ct scan has showed the break is still very much there but shows some small healing. Dd has now been put in a plaster cast for a few weeks, hoping that the bone will heal further.

I'm not keen on the wait and see approach given that we're now over 14 weeks since the injury happened and it's still nowhere near healed.

TIA

It's not surprising that they haven't seen it before, as it accounts for only 2% of wrist fractures. Apparently, it's a tricky one to mend, because there is a low blood supply to the capitate bone. If it doesn't heal in its own after casting, they may need to screw the two pieces of bone together.

This is a handy article.

Thanks lougle

I read that article, along with a few others, last week when they finally found the fracture. I was hoping to find information of real life experiences as no professional we've seen has come across it...

They're probably a lot more common than we realise but we'd only know if routinely using MRI to assess childhood wrist injuries instead of x-rays. Most childhood capitate fractures probably just heal up and so we never know about them. Your DD's obviously hasn't healed and so has been discovered, albeit belatedly.

It sounds from your post that the fracture is trying to heal and so hopefully a period of immobilisation will help nature run its course. It's very unusual to find a fracture that doesn't heal in a child because they are already turning over bone at a fast rate.

DOI: I'm an orthopaedic surgeon - not a hand specialist - who has probably seen quite a few children with capitate fractures but never knowingly!

Thanks john!

I think I'm very clouded at the farce of everything that has happened. I knew a bone was fractured, but no one would listen. The swelling was colossal! Dd's whole hand was numb for over 3 weeks, but no one would listen and just dismissed the numbness! Being told 2 bones are fractured, then next day being told they're not .... being sent away in a splint but told to try not to wear it, take it off as much as possible. The whole while I knew something was fractured and that dd should be in plaster.

I definitely appreciate the fact that this fracture doesn't usually show on an X-ray but all professionals absolutely did not isten to myself or dd. If they had, we wouldn't be in this situation now.

I really do hope the fracture heals further, or that the specialist seeks further advice! It seems he has no clue so just wants to wait and see. I though he might have asked around further afield for information.

I can see how it might have happened. The wrist clearly looked broken but the x-rays didn't show anything, hence people "seeing" breaks that weren't actually there (radius scaphoid capitate). A lot of injured wrists we send away in splints might actually have small fractures but - as a general rule - the ones that aren't visible on x-ray are less likely to "matter". It sounds as if your DD's wrist has been an exception to that rule.

Although the specialist you've seen says s/he hasn't this injury before, they will have managed lots of other carpal bone fractures. The principles of managing a capitate will be the same as for a scaphoid, hamate, etc. Your DD is probably getting the right treatment now even if the process so far hasn't been very smooth.

Try and see the cast as an active treatment (rather than just "wait and see") as you're best avoiding invasive treatments (screw fixation, bone grafting...) unless these are really necessary.

Wow I have never ever seen a capitate fracture. Ever. (In the job for 15+ years)

No advice but hope it all works out for your daughter

john .... you're right about seeing breaks that aren't there ... the second consultant we saw said just that.

The fractures were seen by the radiographer/radiologist. I'm just trying to concentrate on moving forward though, as difficult as that is, but I just think that after 14 weeks the bone should be healed, especially in a child. At the moment there's still a 2mm gap in the bone.

bum - from reading online and real life experience it seems you join the masses 😂

Apparently the fracture is very rare, even rarer in children, and even rarer to have just the capitate fracture - usually it occurs alongside another carpal bone ....

Hi, just a quick update ....

We are NO FURTHER FORWARD!!

Dd has now been in plaster for a LONG time .. she’s now having an MRI arthogram to see more about what is going on. Hopefully we’ll have information soon!

We’re all fed up ☹️

Wow - I can see why you're fed up. Hope the MRI arthogram provides a conclusive diagnosis and a way forward.

Sounds awful. You're presumably being seen by a specialist hand surgeon already?

john .... we’re being seen by a hand specialist - who has never seen this fracture in his career and who said he didn’t know what to do or how this bone would heal.
We’ve literally been let down at every single turn. He referred dd for an urgent mri arthogram at the end of November, I rang up almost 3 weeks later after hearing nothing, to be told the mri team didn’t think it would be of any benefit so they weren’t going to do it. Our hand specialist didn’t bother getting back to us! If I hadn’t rang the mri department to chase it up we could still be sitting here now .. waiting and wondering.

Instead dd had another ct scan, and is now going for the mri arthogram after all. She still has her cast on and is in constant pain even with the cast. When the cast is taken off the pain becomes agonising.

I just want dd fixed ☹️

@Secretmum41 I'm afraid the system in a lot of hospitals is a bit shambolic at the moment. Did the CT show that the fracture is healing? The MRI is usually intended to look at the soft tissues (ligaments etc) and so it sounds as if someone wants to see if the pain is caused by ligament damage instead.

If its any consolation, I broke my capitate. And my scaphoid. And 3 other carpal bones (plus some other weird injuries of the elbow/forearm/wrist). I had screws through capitate and scaphoid, wires and 16 weeks in plaster.
My original hand surgeon was rubbish, but the guy who did my wrist fusion privately was fantastic. If private is an option, I'd gladly give you his name

john .... she had her first mri early November which showed the capitate fracture. This was the first time it was found since the injury mid July. She then had a ct scan a few weeeks later which showed some signs of healing. She had another ct scan about 6 weeks later which the consultant said showed the fracture was now healed .... then he showed us where the bone was still fractured but as it could only be seen on 2 images, he felt certain the bone was actually healed
Due to dd still being in intense pain in the wrist area, he sent her for an mri arthogram ... which she’s just had today. We’re just hoping it shows up exactly what’s going on.

cm ... that sounds awful ... but kind of more in keeping with a capitate fracture. We get our latest results on Friday, if we get no further forward with the consultant, I’m going to ask to be referred to a specialist hand centre in Leeds. Do you mind me asking how much you paid for your private treatment?

This has gone on now since mid july! I can’t let this run on like this any more now.

I'm not sure how much it cost, but I had quite a lot done - compression garments to get the swelling down from CRPS, tests to try and establish the nerve damage pattern, the fusion, splints etc. He did offer to do treatment on the NHS as a tertiary referral though as my injury was complex

Okay so it sounds as if the bone healed once it was eventually immobilised in a cast, which is what would be expected. The pain now needs an explanation - it is certainly unusual to be in severe pain even when in a cast. They are presumably looking for evidence of ligamentous damage on the MR arthrogram. If that is normal, I suspect they'll start thinking about something like complex regional pain syndrome (CRPS per @CMOTDibbler's post). There are a number of treatments for this and - although the course varies a lot between individuals - outcomes tend to be better for children than for adults. Hopefully they'll settle on an answer one way or the other soon.

BTW, DO NOT GOOGLE CRPS. The stories online are not representative of the many people who either recover or manage it successfully. Even one of the trustees of CRPS UK said this to me.
Cross the bridge of that if you come to it, and I'd be happy to talk then if needed

@CMOTDibbler Yes - agreed, particularly as most people (and particularly children) make a good recovery. The OP's daughter is also still some way from actually having a diagnosis.

Thanks cm ... I’m not doing anything until we know exactly what is wrong with dd. It’s bad enough dealing with the unknown, never mind the realms of possibilities that may never be

john ... dd’s arm was only put in a cast 14.5 weeks after the injury occurred! Surely by that time, it’s too late for the bone to repair?

Her CT scan 14 weeks after the injury showed very small signs of healing ... her latest ct scan, 23 weeks after the injury showed more signs of healing but a fracture could still be seen on 2 of the images. Surely this means the fracture has not healed?

Her cast was taken off yesterday for the mri ... she’s in agony. She can’t even touch the wrist area even lightly. She can’t hold a pen. She can’t hold her arm above her. If she sits with her arm resting on her knee, she can’t turn her forearm and hand over to show you the palm of her hand facing up (hope that makes sense!) ... is this normal? It just seems so extreme.

@Secretmum41 It's not necessarily too late for the fracture to heal at that stage. It's difficult to know without seeing the scan but, if only 2 images out of (say) 30 showed evidence of fracture, then that suggests that around 95% of the fracture has healed. It should be very comfortable at this stage and probably as good as if it were 100% healed.

It's not "normal" for someone to be in so much pain at any stage, nevermind so long after the original injury. Even freshly broken limbs aren't usually this painful on very light touch.

Saw the wrist specialist at fracture clinic yesterday for results of mri arthogram .... have to say, he was very sketchy/cagey, we felt he was hiding something.

Mri shows a ttfc tear .... now seeing specialist for that on Monday. I’ve obviously googled it, and it doesn’t look good given that we’re 6 months post injury.

We’ve been let down at every stage.

How is her pain doing?

Pain is still very bad. She can’t grip at all, can’t bear anything other than a light touch to wrist, can’t move (bend/flex) wrist, can’t turn arm over from palm face down to palm face up.

It’s just awful.

Can she do the palm up/down if someone moves it for her?

Ask the specialist on Monday why she can't do this directly, and ask about pain control.

Has she had her elbow imaged?