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Carpal Fractures Other Than the Scaphoid

72 citationsUpdated Oct 2026

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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 [3]. These injuries comprise approximately 1.1% of all fractures [5] and are considered fairly uncommon [6]. Triquetral fractures are the most common carpal fracture other than the scaphoid [1]. Despite their frequency, non-scaphoid carpal fractures are a clinically relevant and underdiagnosed category of wrist trauma [2], particularly in high-risk, young male populations [2]. Fractures of the carpus other than the scaphoid are frequently missed on initial presentation [4], and missed diagnosis can cause a disproportionate amount of morbidity [6]. These fractures are rare but can be devastating if missed [12].

Diagnosis requires a high index of suspicion with tailored imaging [4]. Early magnetic resonance (MR) imaging can exclude carpal fracture when initial radiographs yield negative results [7]. If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid [14]. When a trapezium fracture is identified, additional evaluation for ulnar-sided injuries of the carpus is recommended [11]. Non-scaphoid carpal fractures are frequently associated with significant ligamentous disruption [6] and other carpal bone fractures [6]. Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment [8] and improve long-term functional outcomes [8].

Management depends on the specific fracture pattern, displacement, and associated ligamentous injuries [5]. Physicians must discriminate between non-scaphoid carpal injuries manageable with early return to sport and those requiring aggressive treatment to prevent late disability [13]. Prompt diagnosis and early treatment are crucial to prevent complications such as nonunion, avascular necrosis, and carpal instability [12]. Outcomes for isolated non-scaphoid carpal fractures are generally good [5], whereas nonunion and instability complicate outcomes in cases with concomitant injuries [5].

Anatomy & Pathophysiology

Bony Anatomy

The carpus consists of two rows of eight bones serving as a bridge between the forearm and the hand [45]. The proximal row includes the scaphoid, lunate, and triquetrum [45], while the distal row comprises the trapezium, trapezoid, capitate, and hamate [45]. The pisiform is a sesamoid bone enclosed within the flexor carpi ulnaris tendon sheath and is not theoretically considered part of the proximal row [45]. The distal row articulates with the proximal row and distally with the five metacarpals to form a transverse arch [45]. Specific articulations include the trapezium with the first metacarpal, the trapezoid with the second, the capitate with the third, and the hamate with the fourth and fifth [45]. The capitate and trapezoid are tightly connected to the metacarpals, whereas the metacarpotrapezial joint allows 30 to 40 degrees of flexion–extension and rotation [45].

The proximal carpal row lacks direct tendinous attachments, deriving movement from bone shape, inter-bone interaction, and ligament attachments [45]. In contrast, the distal carpal row is rigid with minimal motion between bones due to stout intercarpal ligaments [43]. The scaphoid bridges the proximal and distal rows [43]. The capitate and hamate exhibit only 2 degrees of intercarpal rotation and less than 2 mm of proximal-distal translation [77]. Notably, no ligaments, palmar or dorsal, exist between the lunate and capitate [77].

Ligamentous Anatomy

Extrinsic carpal ligaments connect the radius or ulna to the carpus [43]. Generally, volar ligaments are stronger than dorsal ligaments [43]. The scapholunate interosseous ligament (SLIL) is the major wrist stabilizer and the most commonly injured wrist ligament [43]. It is C-shaped with dorsal, palmar, and interosseous portions, with the dorsal portion being the strongest and thickest [43]. The lunotriquetral interosseous ligament (LTIL) is also C-shaped, with the volar portion being the thickest and strongest [43]. The capitohamate ligament is a thick structure measuring 5 × 5 mm in cross section, with extensions to the third or fourth metacarpals [43].

The dorsal intercarpal ligament (DIC) passes from the dorsal tubercle of the triquetrum to the distal pole of the scaphoid [43]. It reinforces the elastic dorsal wrist capsule and helps stabilize the scapholunate articulation [43]. 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 [43]. This weak area is vulnerable to instability, allowing the distal carpal row to separate from the lunate during perilunate dislocation [43].

The dorsal scaphotriquetral (DST) ligament spans the dorsal-distal rims of the scaphoid, lunate, and triquetrum [77]. It represents both a robust attachment of the transverse fibers of the DIC to each bone of the proximal row and a labral extension of the interosseous SL and LT ligaments across the dorsal base of the capitate [77]. 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 [77]. Together, the dorsal and palmar scaphotriquetral ligaments complete a near-acetabular shaped articulation for the capitate [77].

The dorsal capsuloligamentous scapholunate septum (DCSS) is a fibrous capsular structure originating from the deep surface of the intracapsular DIC and inserting on the dorsal SLIL [77]. It has been described as an additional stabilizer of the SL joint [77]. The DIC is a critical stabilizer of the proximal carpal row through its connections to the dorsal SL and LT interosseous ligaments and its insertions on the dorsal lunate and dorsal ridge of the scaphoid [77]. A distal component of the DIC inserts on the trapezoid and trapezium, crossing the capitate neck to add stability to the midcarpal joint [77].

The midcarpal joint is crossed by four additional palmar intercarpal ligaments: palmar triquetrohamate, triquetrocapitate, scaphocapitate, and radiopalmar scaphotrapeziotrapezoid [77]. The palmar triquetrohamate and triquetrocapitate ligaments are thick structures playing an important role in midcarpal joint stabilization [77]. Strong ligamentous attachments of the scaphoid to the distal carpal row are considered important stabilizers of the proximal carpal row [77]. Disruption of these scaphoid ligaments has been associated with both dissociative and nondissociative instability patterns of the proximal row [77]. Stout transverse intercarpal ligaments bind the distal carpal row bones to each other, ensuring the rigidity of the transverse carpal arch and protecting carpal tunnel contents [77].

Vascular Anatomy

Circulation to the carpus comprises extraosseous and intraosseous vasculature via dorsal and palmar systems, which are branches of the radial, ulnar, anterior interosseous, and deep palmar arch arteries [78]. The extraosseous supply forms an anastomotic network of dorsal and palmar transverse arches connected longitudinally by the radial, ulnar, and anterior interosseous arteries [78]. The three dorsal transverse arches include the radiocarpal, intercarpal, and basal metacarpal arches [78]. The three palmar transverse arches include the radiocarpal, intercarpal, and deep palmar arches [78]. The presence of these transverse arches is inconsistent in cadaveric specimens [78].

The incidence of avascular necrosis following carpal injury is related to complex intraosseous blood supply [78]. The scaphoid, capitate, and about 20% of all lunates are supplied by a single vessel, increasing their risk of avascular necrosis [78]. 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 [78]. The trapezoid and 50% of hamates lack an intraosseous anastomosis and are at risk of avascular fragments [78].

The scaphoid is supplied by branches of the radial artery, with the dorsal branch supplying 70–80% proximally [78]. There are no perforators at the waist, cartilage, or SL ligament of the scaphoid [78]. The lunate receives a volar branch supplying 20–30% distally [78]. Approximately 80% of lunates receive vessels from palmar and dorsal surfaces [78], while approximately 20% receive vessels from the palmar surface only [78]. The triquetrum receives branches from the ulnar artery, dorsal intercarpal arch, and palmar intercarpal arch [78]. Dorsal vessels supply 60% of the triquetrum, while palmar vessels supply 40% [78]. Dorsal–palmar anastomoses are found in 86% of triquetra [78].

The pisiform receives branches from the ulnar artery [78], with proximal–distal anastomoses present [78]. The trapezium receives branches from the radial artery, with dorsal supply predominating [78]. The trapezoid receives dorsal vessels supplying 70% and palmar vessels supplying 30% [78]. The capitate receives branches from the dorsal intercarpal arch, dorsal basal metacarpal arch, palmar intercarpal arch, and ulnar recurrent artery [78]. In one-third of cases, the supply to the capitate head is solely from the palmar side [78]. Dorsal–palmar anastomoses are found in 30% of capitates [78]. The hamate receives branches from the dorsal intercarpal arch, ulnar recurrent artery, and ulnar artery [78]. Dorsal vessels supply the dorsal 30–40% of the hamate [78]. Dorsal–palmar anastomoses are found in 50% of hamates, but there are no anastomoses with medial vessels [78].

Neurovascular Anatomy

Innervation of the carpus is via the anterior interosseous and the posterior interosseous nerves [78].

Biomechanics and Kinematics

The wrist joint’s motion planes include flexion, extension, radial deviation, ulnar deviation, and circumduction [43]. There is minimal carpal motion with pronosupination [43]. Approximately 62° of wrist extension occurs through the radiocarpal joint [43], while 62% of wrist flexion occurs through the midcarpal joint [43]. The midcarpal joint is mostly responsible for 20° of radial deviation and 40° of ulnar deviation [43]. It is also responsible for the “dart thrower’s motion,” which involves moving from radial extension into ulnar flexion positioning of the wrist [43]. The radius bears 80% of the axial load transmitted through the radiocarpal joint, while the ulna bears 20% in neutral ulnar variance [43].

The proximal row of carpal bones forms an intercalated segment between the distal carpal row and the distal radius, bound into a functional unit by the SLIL and LTIL [43]. During wrist flexion from neutral, the distal row flexes and ulnarly deviates slightly while the scaphoid pronates [43]. The proximal row flexes differentially, with more rotation through the scaphoid, followed by the triquetrum and the lunate [43]. The proximal row translates dorsally during wrist flexion [43]. During wrist extension from neutral, the distal row extends and radially deviates slightly while the scaphoid supinates [43]. The proximal row extends differentially, with more motion in the scaphoid, followed by the triquetrum and then the lunate [43]. The proximal row translates palmarly during wrist extension [43].

The wrist can be considered a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [73]. The two principal articulations are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [73]. All bones of each carpal row rotate in the same plane during any direction of global wrist motion [73]. In all but pure flexion/extension of the uninjured wrist, the proximal and distal rows move in divergent directions [73]. Division of either of the proximal row’s interosseous ligaments in isolation does not result in a postural deformity of the lunate [73]. Similar “collapse” deformities of proximal row alignment (VISI or DISI) can occur with or without disruption of an interosseous ligament [73]. The dart-thrower’s path of radial extension to ulnar flexion defines the transition between flexion and extension of the scaphoid and lunate [73]. This motion occurs almost exclusively through the midcarpal joint [73].

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 [73]. The triquetrum buffers lunate rotation and prevents ulnar translation [73]. The radius of curvature of the lunate is longer than that of the scaphoid [74]. Consequently, the scaphoid needs to rotate more than the lunate to reach the limits of flexion-extension [74]. The capitate stays concentrically reduced in the acetabular fossa of the midcarpal joint throughout flexion and extension [74]. During radial deviation, the trapezium and trapezoid push the scaphoid into flexion, resulting in flexion and ulnar deviation of the entire proximal row [74]. During ulnar deviation, the hamate exerts compression onto the triquetrum, inducing extension, ulnar deviation, and slight pronation of the entire proximal row [74]. The scaphoid adopts an extended posture during ulnar deviation [74].

Pathophysiology and Injury Mechanisms

Carpal fractures other than the scaphoid account for 15% to 41% of carpal fractures, with triquetral fractures being the most common [1]. These injuries are exceedingly rare and comprise approximately 1.1% of all fractures [5]. Non-scaphoid carpal fractures are a clinically relevant and underdiagnosed category of wrist trauma, particularly in high-risk, young male populations [2]. They are frequently missed on initial presentation and require a high index of suspicion with tailored imaging for diagnosis [4]. Although fairly uncommon, these fractures can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety and frequent association with significant ligamentous disruption or other carpal bone fractures [6].

Carpal injuries most frequently occur in young active patients and are not very common overall [38]. When compared to fractures of the distal radius and hand, fractures of the carpus are uncommon, particularly those injuries not involving the scaphoid [56]. Carpal fractures account for 2.8% of all fractures with an annual incidence of 37.5/10⁵ population per year [56]. The mean age at the time of injury for all carpal fractures ranges from 35 to 40 years, with a male predominance [56]. Fractures of the carpus have a type A fracture curve with a bimodal distribution involving younger males and older females [56]. A fall from standing height accounts for almost two-thirds of all carpal injuries [56]. Scaphoid fractures and fractures of the triquetrum account for over 90% of all carpal fractures [56].

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% [56]. Triquetral fractures occur at a mean age of 51 years with an approximately equal gender distribution, fitting a type A fracture distribution curve [56]. Most carpal fractures are the consequence of a fall onto an outstretched hand [90]. 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 [90].

Perilunate-pattern or “lesser arc” injuries occur when only ligaments are injured without fracture [90]. Carpal fractures or ligamentous injuries may occur in an arc around the lunate [90]. Fractures of the scaphoid, capitate, triquetrum, or radial styloid, or all four, in conjunction with perilunate instability, are known as “greater arc” injuries [90]. Strong anterior to posterior compression injuries may result in axial-pattern disruption of the carpus [90]. Axial-pattern injuries propagate both radially and ulnarly, separating the carpus on both sides of the capitate [90]. Avulsions may occur owing to localized forced concentration, commonly causing avulsion injuries at the volar or dorsal aspect of the triquetrum secondary to ligament insertions [90]. Trapezial, hamate, and pisiform fractures may also occur as avulsion injuries [90].

Carpal injuries generally occur in young individuals with high functional demands [90]. They are frequently missed at initial presentation [90]. The small size of the fractured carpal bone complicates surgical reduction and potentially compromises its vascular supply [90].

Classification

Lunate Fractures: Lunate fractures have an incidence reported between 1.1% and 6.5% of carpal bone fractures [124].

Triquetral Fractures: Triquetral fractures represent 7% to 20% of carpal fractures [124].

Trapezium Fractures: Isolated trapezium fractures account for 1% to 5% of all carpal fractures, making the trapezium the third most common carpal bone to fracture [29]. Twenty percent of trapezium fractures are isolated with a vertical sagittal split [29]. Trapezial fractures are classified into two main categories: fractures involving the palmar ridge and fractures through the body [118]. Palmar ridge fractures are further subdivided into type I fractures located at the base of the ridge and type II fractures located at the tip of the ridge [118].

Pisiform Fractures: Pisiform fractures are classified into four types: Type 1 transverse, Type 2 sagittal, Type 3 comminuted, and Type 4 pisotriquetral impaction [118]. Transverse pisiform fractures are the most common type of pisiform fracture [118].

Peri-lunate Dislocations: Peri-lunate dislocations and fracture-dislocations are classified according to dorsal or palmar displacement and stages I, IIA, and IIB [127].

Clinical Presentation

Epidemiology and Demographics

Triquetral fractures occur at a mean age of 51 years with an approximately equal gender distribution [56]. Non-scaphoid carpal fractures are particularly prevalent in high-risk, young male populations [2]. Isolated scaphoid and other carpal fractures exhibit different demographics in terms of age and gender [20]. A high-energy mechanism of injury was associated with multiple carpal fractures [20].

General Clinical Findings

Patients with an injury to the carpus commonly present with wrist pain as their primary complaint [32]. Pain, swelling, and ecchymosis around the region of the carpus may be present in the acute phase [32]. The most constant and dependable sign of carpal injury is well-localized tenderness [32]. Swelling over the proximal carpal row is suggestive of a ligament avulsion with or without an associated fracture [32]. With carpal instability or dislocation, a gross deformity may be apparent, such as a marked prominence of the entire carpus dorsally which is suggestive of a perilunate dislocation [32].

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 [32]. 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 [32]. Carpal fractures other than the scaphoid are frequently missed on initial presentation [4]. Fractures of the carpal bones excluding the scaphoid can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety [6]. Carpal bone fractures are likely underreported due to complex anatomy and difficulty in plain radiologic interpretation [35]. Injuries to the hand and wrist can be occult in nature [22]. Delays in diagnosis should be avoided to prevent complications such as nonunion and secondary displacement [22].

Specific Bone Findings

Tenderness of the scaphoid in the anatomic snuffbox is suggestive of a scaphoid injury [19]. Pain with axial compression of the first metacarpal is suggestive of a scaphoid injury [19]. Tenderness at the scaphoid tuberosity is suggestive of a scaphoid injury [19]. Tenderness distal to Lister's tubercle is suggestive of scapholunate and lunate injury [32]. Tenderness at the dorsal margin, fingerbreadth distal to the ulnar head, is suggestive of triquetral, lunotriquetral ligament, and triquetrohamate ligament injury [32].

Localized pain and tenderness are clinical findings for trapezium fractures [23]. Symptoms and signs of trapezoid fractures can be minimal and imitate a scaphoid fracture [23]. Localized pain and tenderness are clinical findings for capitate fractures [23]. Localized pain and tenderness are clinical findings for hamate fractures, though often minimal [23]. Ulnar nerve lesion is a clinical finding associated with hamate fractures due to the deep branch of the ulnar nerve passing around the hook of the hamate [23]. Tendon rupture is a clinical finding with chronic presentations of hamate fractures [23]. Localized pain and tenderness are clinical findings for pisiform fractures [23].

A trapezium fracture is more likely to be present than a scaphoid fracture if initial radiographs are negative, despite high levels of clinical suspicion for scaphoid injuries [14]. Trapezium fractures are hard to detect and easily missed on standard radiographs [29]. Fractures of the trapezoid bone are the rarest of carpal fractures [26]. Capitate fractures have been diagnosed and reported with undeserved rarity [104]. Hamate hook fractures are often diagnosed months after injury as a nonunion causing tenderness with direct pressure [19]. Acute hamate hook fractures tend to heal but often go undiagnosed [19].

Associated Injuries and Complex Patterns

Non-scaphoid carpal fractures are frequently associated with significant ligamentous disruption or even other carpal bone fractures [6]. Tuberosity fractures of the trapezium are associated with fractures of the hook of the hamate or with dislocation of the hamate [23]. Articular surface fractures of the trapezium can be associated with dislocation or fracture–dislocation of the first carpometacarpal joint [23]. Associated scaphoid fractures are reported in cases of trapezium fracture [23]. Associated fractures occur in a third of trapezoid fracture cases [23]. Direct blow or crush injuries to the capitate are often associated with injury to the other carpal bones and/or the metacarpals [23]. Fracture-dislocation of the ring and little metacarpal joints often results in fracture of the hamate [19]. Associated fracture or fracture–dislocation of metacarpals is frequent with hamate flake or avulsion fractures [23].

A lunate fracture may be associated with an unstable fracture of the scaphoid [16]. Scaphocapitate syndrome refers to a greater arc injury pattern in which force passes from the scaphoid to the capitate neck, resulting in both scaphoid and capitate fractures [19]. In scaphocapitate syndrome, the capitate head may be rotated 180° [19]. The divergent trapezium-trapezoid joint with scaphoid fracture is a complex carpal injury pattern [36]. Comminuted lunate fractures can be combined with distal radius fracture and scaphoid fracture [37].

Perilunate dislocations are often associated with a polytrauma, with 1 in 10 sustaining an associated upper-limb injury [114]. In around 16% of perilunate dislocation cases, the clinical presentation includes median nerve symptoms and signs [114]. Ulnar neuropathy, arterial injury, or tendon disruption may also be seen in perilunate dislocations [114]. Some perilunate dislocations may be seen several months or years after the initial injury [114]. Patients with delayed presentation of perilunate dislocation are more likely to present because of increasing nerve symptoms or tendon rupture than because of wrist deformity [114].

Diagnostic Challenges and Imaging Implications

Fractures of the carpus other than the scaphoid require a high index of suspicion with tailored imaging for diagnosis [4]. Early magnetic resonance imaging can exclude carpal fracture when initial radiographs are negative [7]. Pisiform and hamulus fractures are not seen on standard two or three view wrist examination [21]. Coronal fractures of the trapezoid are rarely detected on radiographs [23]. CT or MRI is used for diagnosis in over 80% of trapezoid fracture cases [23]. Overlap of carpals can make diagnosis of trapezoid fractures difficult [23]. Standard radiographs are often poor for scaphoid fracture detection due to the tubercle overhang on the PA view and the overlap on the lateral view [32]. Plain radiography is approximately 50% sensitive for the detection of a scaphoid fracture and less than 50% for the other carpal bones [30]. Normal radiographs do not preclude the presence of a scaphoid fracture [30]. Up to 30% of patients with suspected scaphoid fractures may have positive follow-up radiographs if reevaluated in 2 weeks [30]. MRI has a negative predictive value of 100% for scaphoid fracture when performed as early as 2 days after injury [30].

The literature suggests that 16% to 25% of perilunate dislocations are missed initially [114]. Lesser arc injuries are commonly missed because of the lack of an obvious osseous pathology and inexperience of the initial observer [114]. Clinical findings for carpal instability can be subtle, and classic features may not be apparent without provocative stress testing [98]. A simple general provocative maneuver 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 [98]. A positive Kirk–Watson (scaphoid shift) test is highly suggestive of scapholunate instability [98]. The Kirk–Watson test may reposition the entire proximal carpal row if the row, rather than the individual scaphoid, is unstable [98]. In individuals with lax ligaments, there may be false-positive signs of dorsal subluxation of the scaphoid that are not pathologic [98]. Generalized ligamentous laxity may be present in patients with true scapholunate dissociation [98].

A scapholunate gap of more than 3 mm is suggestive of instability [98]. A scapholunate gap of over 5 mm is diagnostic of scapholunate dissociation if there is a positive cortical ring sign [98]. An increased scapholunate angle is found on the lateral view in scapholunate instability [98]. Dynamic scapholunate dissociation is characterized by normal radiographs of the wrist, but with axial loading of the wrist a widening of the scapholunate gap is seen [98]. Static instability is characterized by a widening of the scapholunate gap in an unloaded wrist and a scapholunate angle greater than 60 degrees [98].

Disruption of Gilula's lines on the PA view is indicative of an altered intercarpal relationship suggestive of perilunate dislocation [114]. The “spilled teapot sign” on the lateral view is due to palmar rotation of the lunate and disruption of the lunate–capitate articulation [114]. A triangular appearance of the lunate secondary to rotation is suggestive of perilunate dislocation [114]. Increased ulnocarpal translation is defined as >50% of lunate uncovering and is seen in 80% of perilunate injuries [114]. Subtle signs of disruption in perilunate dislocation may include loss of carpal height and increased intercarpal spaces [114]. It is essential to assess for associated fractures of the carpus and distal radius in suspected perilunate dislocation [114]. Stress radiographs or an examination under anesthesia may be necessary for the diagnosis of perilunate dislocation [114]. Secondary imaging modalities including CT and MRI are often necessary for the assessment of perilunate dislocation [114]. Arthrography and arthroscopy are useful in determining the extent of perilunate injury [114]. A full examination of the contralateral wrist can often be helpful, particularly when assessing for instability [32]. Changes in alignment of the hand, wrist, and forearm may be clinically evident on inspection of the extremity [32]. Tendon displacements with audible snaps are easily produced by some persons but are seldom symptomatic [32].

Investigations

General Diagnostic Challenges

Carpal fractures other than the scaphoid are frequently missed on initial presentation, necessitating a high index of suspicion and tailored imaging [4]. Although these fractures are uncommon, they can cause disproportionate morbidity due to their subtlety and frequent association with significant ligamentous disruption or other carpal bone fractures [6]. Early recognition of uncommon carpal disruptions guides appropriate surgical treatment and improves long-term functional outcomes [8]. Clinicians must maintain vigilance for trapezoid fractures when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents [31]. If initial radiographs are negative, a trapezium fracture is more likely than a scaphoid fracture, despite high clinical suspicion for scaphoid injuries [14]. Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [18].

Plain Radiography

Plain radiography is less than 50% sensitive for detecting carpal fractures other than the scaphoid [30]. The four standard views used for scaphoid assessment—neutral posteroanterior, lateral, 45-degree radial oblique, and 45-degree ulnar oblique—can detect most carpal injuries [32]. Standard neutral posteroanterior and lateral radiographs assess carpal alignment and clear fractures but are often poor for scaphoid detection due to tubercle overhang on the PA view and overlap on the lateral view [32]. The 45-degree radial oblique, 45-degree ulnar oblique, ulnar deviated AP, Ziter's, and carpal box or tunnel views purportedly improve fracture diagnosis, particularly of the scaphoid [32].

Trapezium: Standard scaphoid views are the primary investigation [23]. Carpal tunnel views are used for trapezium tuberosity fractures [23]. If localized uptake is present in the trapezium area, additional radiographic studies may be necessary to confirm or exclude the fracture [70].

Trapezoid: Standard scaphoid views are the primary investigation, though carpal overlap can make diagnosis difficult [23]. Oblique views aid in diagnosis [23].

Capitate: Standard scaphoid views are the primary investigation [23]. Lateral views determine displacement and rotation of the capitate head [23].

Hamate: Standard scaphoid views are the primary investigation [23]. Oblique and carpal tunnel views improve the chance of diagnosing hamate hook fractures [23]. An alternate view with maximal radial deviation of the wrist and maximal abduction of the thumb is also used for hamate hook fracture diagnosis [23].

Pisiform: Standard scaphoid views are the primary investigation [23]. Lateral views in 20–45 degrees of supination and carpal tunnel views aid in diagnosis [23].

Triquetrum: Standard scaphoid views detect most triquetral fractures, with dorsal avulsion fractures often found on oblique or lateral views [57]. PA radiographs identify transverse body fractures but often miss avulsion fractures due to normal superimposition of the dorsal lip on the lunate [57]. An oblique pronated lateral radiograph projects the triquetrum more dorsal to the lunate, aiding in the diagnosis of triquetral avulsion fractures [57].

MRI

Early magnetic resonance (MR) imaging can exclude carpal fracture when initial radiographs are negative [7]. MRI is used for the diagnosis of occult capitate fractures [23] and suspected hamate fractures [23]. MRI may be required to see lunate fractures that are difficult to detect on plain radiography [49] and can be helpful in diagnosing early avascular changes in the lunate [49]. Fractures of the trapezoid may be appropriately treated without surgical intervention, as suggested by a case series where MRI was used for diagnosis [17].

CT

CT scanning is a more accurate diagnostic tool than plain radiography for carpal bone fractures [35]. CT or MRI is used for the diagnosis of trapezoid fractures in over 80% of cases [23]. Computed tomography is recommended over plain radiography alone in case of clinical suspicion for trapezoid fractures [115]. A CT scan of the wrist revealed a minimally displaced fracture of the trapezoid extending in the axial plane when radiographic evaluation was normal [26]. An unusual coronal fracture of the body of the trapezium was found on computed tomography examination after plain radiographs failed to demonstrate any bony pathology [113].

Clinical Examination

Tenderness in the anatomical snuffbox is suggestive of scaphoid injury [32]. Tenderness on the dorsal margin, fingerbreadth distal to the ulnar head, is suggestive of triquetral, lunotriquetral ligament, and triquetrohamate ligament injury [32]. Localized pain and tenderness are present in trapezium fractures [23], trapezoid fractures (e.g., at the base of the second metacarpal) [23], capitate fractures [23], hamate fractures (often minimal) [23], pisiform fractures [23], and triquetral fractures (localized over the triquetrum) [57]. Ulnar nerve lesion is a clinical finding associated with hamate fractures as the deep branch of the ulnar nerve passes around the hook of the hamate [23]. Ulnar nerve lesion is also a clinical finding associated with pisiform fractures as the terminal branch divides at the pisiform [23].

Other Considerations

This case demonstrates an example of rapid recognition of unknown wrist pathology that could not be confirmed by plain radiographs in the presence of a suspected boxer's fracture [67]. This case illustrates the importance of accurate diagnosis by fluoroscopy of the wrist in order to identify additional instabilities and fractures in severe hand trauma [24].

Treatment

General Principles

Prompt diagnosis and early treatment are crucial to prevent complications such as nonunion, avascular necrosis, and carpal instability [12]. Treatment algorithms must balance fracture stability and immobilization with preservation of tendon gliding and joint mobilization to obtain optimal clinical outcomes [22]. Carpal fractures are predominantly treated nonoperatively, though there has been a steady increase in the numbers treated operatively [105]. In a study year analyzed by the Swedish Fracture Registry, 12.4% of carpal fractures were treated with primary surgery [105]. There is very little information in the literature about the optimal treatment of non-scaphoid fractures [105].

Triquetral Fractures

Triquetral avulsion fractures are considered wrist sprains and are treated symptomatically [19]. These injuries are managed with a splint for comfort only and active self-assisted stretches as comfort allows to limit stiffness [57]. Stretching exercises help limit the potential for wrist stiffness in triquetral avulsion fractures [19]. Triquetral body fractures associated with carpal disruption often require internal fixation [57]. Perilunate fracture-dislocations are seen in 12% to 25% of triquetral injuries [102].

Trapezium Fractures

Undisplaced trapezium fractures are treated with a scaphoid cast [23]. Navicular cast immobilization for 4 to 6 weeks is recommended as initial treatment for isolated trapezium fractures [29]. Displaced trapezium fractures or dislocations are treated with closed reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF) [23]. Open reduction and internal fixation is advocated for trapezium fractures with either articular displacement of 2 mm or carpometacarpal subluxation [40]. Nonunion of ridge fractures of the trapezium is managed with excision [23]. 60% of trapezium fractures are reported to have an unsatisfactory outcome [23].

Trapezoid Fractures

Undisplaced trapezoid fractures with less than 2 mm displacement are treated with a scaphoid cast [23]. Displaced trapezoid fractures, dislocations, or delayed unions are treated with open reduction and internal fixation (ORIF) or excision [23]. Excellent results are often achieved even with delayed treatment of trapezoid fractures [23]. An isolated trapezoid fracture was managed conservatively with a short arm splint for 6 weeks, resulting in near complete union and full functional recovery [26].

Capitate Fractures

Undisplaced capitate fractures heal without immobilization or with a scaphoid cast [23]. Nonunion is rare when capitate fractures are undisplaced [23]. Displaced capitate fractures or dislocations are treated with open reduction and internal fixation (ORIF) [23]. Avascular necrosis (AVN) is possible with displaced capitate fractures [23]. In scaphocapitate syndrome, the capitate head may be rotated 180°, requiring open reduction and internal fixation (ORIF) through a dorsal approach [19]. The capitate is generally fixed with a headless screw in the treatment of scaphocapitate syndrome [97]. 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 [97]. Primary bone grafting may be indicated in comminuted capitate fractures [97]. Surgical treatment is justified for asymptomatic non-union of the capitate due to the risk of spontaneous flexor tendon rupture [106]. A capitate fracture united with excellent range of wrist motion following internal fixation with Herbert screws [55].

Hamate Fractures

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 [19]. Undisplaced hamate fractures are treated with a cast, with union rates reported at only 50% in some series [23]. Larger hamate fractures and fractures with articular impaction are treated with open reduction and screw fixation [19]. 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 [23]. Surgery for hook of the hamate fractures is elective and usually consists of excision of the hook [19]. Nonunion of hook fractures can lead to chronic pain and little finger flexor tendon injury, managed with excision or ORIF ± bone grafting [23]. Some authors advocate bone grafting following excision of the hamate hook to preserve the pulley effect on the flexor tendons [23].

Lunate Fractures

Nonoperative management in cast for approximately 4 weeks is suitable for most isolated lunate fractures [88]. Nondisplaced and nondisplaced comminuted lunate fractures can be treated with cast immobilization [49]. Indications for open reduction and internal fixation (ORIF) of lunate fractures include displacement and/or associated carpal instability [88]. Fractures with more than 1 mm offset and avulsion fractures usually require open reduction [49]. If there is evidence of separation of the lunate fragments by the capitate, union will not occur and the risk of avascular necrosis is markedly increased [88]. Internal fixation techniques for lunate fractures may include Kirschner wires, small cannulated screws, and suture anchors [49]. Body fractures of the lunate may be fixed with headless compression screws and/or Kirschner wires [53]. Comminuted lunate fractures may require a cancellous bone graft harvested from the distal radius [53]. Distraction and temporary scaphocapitate pinning may take pressure off the healing lunate when internal fixation is performed [53]. If there is severe comminution with an unreconstructible lunate or chronic injury with arthritis, proximal row carpectomy or scaphocapitate fusion may be indicated [53]. Volar fragments of the lunate are reduced through an extended carpal tunnel approach [53]. Volar pole fractures are often too small for screw fixation and may be secured with a suture anchor to capture both bone and palmar ligaments [53]. Nonunion of a lunate body fracture is rare, as most will progress to Kienböck's disease [88].

Associated Injuries and Complex Patterns

Fracture displacement leading to a predictable collapse pattern of carpal instability must be recognized so that appropriate management can be provided [22]. Scaphoid fractures associated with perilunate fracture-dislocations should be repaired [19]. All patients with an acute perilunate injury should undergo immediate closed reduction [96]. If a successful closed reduction is obtained for an acute perilunate injury, the hand and wrist should be splinted to rest the tissues [96]. If reduction cannot be obtained in a closed fashion for an acute perilunate injury, open reduction is required [96]. For lesser arc injuries that are reducible closed, K-wire fixation is preferred over conservative treatment in cast [96]. A dorsal midline approach is preferred to expose and realign the bones in acute perilunate injuries, with an additional palmar approach for neurovascular problems [96]. If a scaphoid fracture is present in a greater arc injury, it can be reduced through the dorsal approach, temporarily stabilized with K-wires, and fixed with a cannulated screw [96]. The lunate should be positioned collinear with the radius and capitate during reduction of perilunate dislocations [96]. Reduction in a stepwise manner beginning at the lunotriquetral joint is performed in a reverse Mayfield direction [96]. The dorsal scapholunate ligament is reattached with a small suture anchor during the treatment of perilunate dislocations [96]. Associated radial styloid fractures should be reduced anatomically and stabilized with K-wires or a compression screw [96]. A dorsal approach to the wrist provides adequate exposure for reduction of carpal bones, internal fixation of the scaphoid, and lunotriquetral repair [128].

Complications

Missed Diagnosis: Non-scaphoid carpal fractures represent an underdiagnosed category of wrist trauma that is frequently missed on initial presentation [2, 4]. The subtlety of these injuries contributes to this frequent diagnostic oversight [6]. Delayed diagnosis can lead to secondary displacement and nonunion [22], while missed diagnosis specifically results in nonunion, avascular necrosis, and carpal instability [12].

Nonunion: Nonunion is a recognized complication of non-scaphoid carpal fractures, particularly in cases with concomitant injuries [5]. In the context of capitate fractures, nonunion was previously described as the most common complication [111]; however, in a cohort of 53 patients, nonunion of the capitate was rare [111].

Instability: Instability is a complication of non-scaphoid carpal fractures, particularly in cases with concomitant injuries [5]. Fracture displacement leading to a predictable collapse pattern of carpal instability is a complication that must be recognized for appropriate management [22].

Recovery

Light activity (weeks): Clinical and functional recovery for triquetral fractures typically occurs long before roentgenographic evidence of bony union is demonstrated [129]. In cases of simultaneous scaphoid and trapezium fractures, clinical and radiological evidence of union was present after six weeks of immobilisation [9, 10].

Full activity (months): By sixteen weeks, patients with simultaneous scaphoid and trapezium fractures demonstrated a full range of movement of the wrist and thumb and normal grip [9]. In a case of unusual combined scaphoid and lunate fracture, bone union of both fractures was achieved with preserved wrist range of motion and grip strength at 10 months post-surgery [41].

Complete recovery / outcome plateau (months): In a case of isolated capitate fracture with dorsal dislocation of the proximal pole, complete fracture healing was obtained with no signs of avascular necrosis or post-traumatic carpal arthritis at 26 months [71]. In a case report of trapezoid bone fracture, the patient was pain-free with full motion of the wrist at the 12-month follow-up evaluation [69].

Functional milestones: In a case of trans-triquetral dorsal perilunate fracture dislocation, the functional outcome was fair with a Mayo wrist score of 75/100 at four-year follow-up [61]. In a case of transscaphoid transcapitate transtriquetral perilunate fracture–dislocation, the functional outcome was good with a Mayo wrist score of 85 out of 100 at the 2-year follow-up evaluation [66].

Other Considerations: In a small series of trapezium fractures, all patients had irregularities of the trapezio-metacarpal joint radiologically at follow-up [72]. In a case of non-dislocation lunate fracture combined with distal radius fracture, patients suffering persistent wrist swelling after trauma should be carefully examined and followed up [130].

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)
• [L4] Non-scaphoid carpal fractures are a clinically relevant and underdiagnosed category of wrist trauma, particularly in high-risk, young male populations. [2] (10.1007/s00068-026-03164-x)
• [L5] Fractures of the carpal bones excluding the scaphoid represent 30% to 40% of all osseous injuries to the wrist. [3] (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. [4] (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. [5] (10.1016/j.jhsa.2013.10.030)
• [L5] Fractures of the carpal bones excluding the scaphoid are fairly uncommon but can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. [6] (10.1007/s00068-015-0618-5)
• [Paper] On obtaining negative results on initial radiographs, early magnetic resonance (MR) imaging can exclude carpal fracture. [7] (10.1016/j.mric.2015.04.006)
• [L5] Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes. [8] (10.1177/15589447261475382)
• [L5] Clinical and radiological evidence of union of the fractures of the scaphoid and trapezium was present after six weeks, and by sixteen weeks the patient had a full range of movement of the wrist and thumb and normal grip. [9] (10.1016/s0266-7681(85)80072-3)
• [L5] After six weeks immobilisation, there was clinical and radiological evidence of union of the fractures of the scaphoid and trapezium. [10] (10.1016/s0266-7681_85_80072-3)
• [L4] When a trapezium fracture is identified, we recommend additional evaluation for ulnar-sided injuries of the carpus. [11] (10.5435/jaaosglobal-d-22-00270)
• [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. [12] (10.1016/j.csm.2014.09.006)
• [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. [13] (10.1016/j.hcl.2009.05.013)
• [L3] If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid, despite high levels of clinical suspicion for scaphoid injuries. [14] (10.1007/s10140-019-01702-2)
• [L5] The senior author has seen similar cases where a lunate fracture has been associated with an unstable fracture of the scaphoid. [16] (10.1177/1753193411406640)
• [L4] Additionally, this short case series suggests that these fractures may be appropriately treated without surgical intervention, in contrast to previous studies. [17] (10.1016/j.radcr.2020.03.014)
• [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. [20] (10.1016/j.jhsa.2010.11.009)
• [L4] These fractures are not seen on standard two or three view wrist examination. [21] (10.1016/s0736-4679(98)00016-x)
• [L5] This case illustrates the importance of accurate diagnosis by fluoroscopy of the wrist in order to identify additional instabilities and fractures in severe hand trauma. [24] (10.1016/j.jhsb.2005.09.025)
• [Paper] [26] (10.1007/s12593-014-0165-z)
• [L4] [29] (10.1055/s-0039-1683846)
• [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. [31] (10.1016/j.jhsg.2023.09.001)
• [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. [35] (10.1016/j.hcl.2009.08.014)
• [L5] The divergent trapezium-trapezoid joint with scaphoid fracture is not described in the literature yet. [36] (10.1055/s-0038-1630143)
• [L5] For comminuted lunate fractures, early identification and intervention can preserve most of the function of the wrist joint. [37] (10.1097/md.0000000000034393)
• [L4] Based on the good results obtained with surgical intervention, the authors advocate open reduction and internal fixation for fractures with either articular displacement 2 mm or carpometacarpal subluxation. [40] (10.1053/jhsu.2002.33705)
• [L5] At 10 months post-surgery, bone union of both fractures was achieved with preserved wrist range of motion and grip strength. [41] (10.1016/j.jhsa.2005.12.018)
• [L5] The fracture united and the patient achieved an excellent range of wrist motion. [55] (10.1016/0363-5023(90)90008-f)
• [L5] At four-year follow-up, the functional outcome was fair, with a Mayo wrist score of 75/100. [61] (10.1016/j.jhse.2007.05.012)
• [L5] At the 2-year follow-up evaluation, the functional outcome was good with a Mayo wrist score of 85 out of 100. [66] (10.1016/j.jhsa.2006.01.002)
• [L5] This case demonstrates an example of rapid recognition of unknown wrist pathology that could not be confirmed by plain radiographs in the presence of a suspected boxer's fracture. [67] (10.1016/j.ajem.2014.03.050)
• [L5] At the 12-month follow-up evaluation, the patient is pain-free with full motion of the wrist. [69] (10.1016/0363-5023(94)90062-0)
• [L4] If there is localized uptake in the area of the trapezium, additional radiographic studies may be necessary to confirm or exclude this fracture. [70] (10.1016/s0363-5023(88)80110-2)
• [Case_report] Complete fracture healing was obtained with no signs of avascular necrosis or post-traumatic carpal arthritis at 26 months. [71] (10.1007/s11552-011-9337-5)
• [L4] In this small series all patients had irregularities of the trapezio-metacarpal joint radiologically at follow-up. [72] (10.1016/0266-7681(85)90023-3)
• [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. [104] (10.2106/00004623-196244080-00003)
• [L5] This complication justifies surgical treatment of asymptomatic non-union of the capitate. [106] (10.1016/j.hansur.2016.05.005)
• [L4] Nonunion of the capitate, which was previously described as the most common complication, was rare in this cohort. [111] (10.1016/j.jhsa.2016.07.099)
• [L5] An unusual coronal fracture of the body of the trapezium was found on computed tomography examination after plain radiographs failed to demonstrate any bony pathology. [113] (10.1016/s0363-5023(98)80104-4)
• [L4] These fractures may be underdiagnosed, and computed tomography is recommended over plain radiography alone in case of clinical suspicion. [115] (10.1016/j.jhsa.2012.02.046)
• [L4] [118] (10.1016/j.hcl.2006.07.007)
• [L4] [124] (10.1016/0266-7681(88)90180-5)
• [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. [126] (10.1007/s12593-014-0162-2)
• [L4] [127] (10.1016/j.otsr.2016.01.004)
• [L3] A dorsal approach to the wrist provides adequate exposure for reduction of carpal bones, internal fixation of the scaphoid, and lunotriquetral repair. [128] (10.1016/j.jhsa.2005.07.007)
• [L4] Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated. [129] (10.2106/00004623-195638020-00012)
• [L5] Patients suffering persistent wrist swelling after a trauma should be carefully examined and followed up. [130] (10.1097/md.0000000000013574)

See Also

• Scaphoid Fracture
• Distal Radius Fracture
• Proximal Row Carpectomy
• Kienböck's Disease

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