Review Question - QID 217937

This patient has avascular necrosis (AVN) of the proximal pole of the capitate. Initial management should consist of non-operative treatment with immobilization.

AVN of the capitate is a rare condition. It occurs most often secondary to a traumatic injury. There are several unique anatomical features related to the capitate including an irregularity of the blood supply (which is typically palmar-dominant) and retrograde perfusion (analogous to the scaphoid). Initial treatment should be nonoperative with cast immobilization, though recalcitrant cases may be treated with capitate decompression, SC fusion, 4-corner fusion, or vascularized bone graft. A local vascularized graft offers the best chance of restoring perfusion to the capitate and preserving native anatomy.

Peters et al. reviewed AVN of the capitate. In their review of six patients, they reported that four were treated with scaphocapitolunate arthrodesis and two with a four-corner arthrodesis. They showed that three patients had good or excellent results, two fair and one poor, based on a visual analog scale for pain and satisfaction and a Quick-DASH score. They concluded that better results were seen when the arthrodesis fused.

Kazmers et al. reviewed AVN of the capitate. They reported on the outcomes of a 16-year-old girl with posttraumatic capitate AVN who was treated with curettage and medial femoral condyle corticocancellous vascularized bone grafting. They noted that at 18 months after surgery, the patient remains pain-free and had resumed all activities including lifeguarding by 6 months after surgery.

Figure A is an MRI image demonstrating proximal pole capitate AVN.

Incorrect Answers:
Answers 2-5: Initial treatment should be nonoperative with cast immobilization, though recalcitrant cases may be treated with capitate decompression, SC fusion, 4-corner fusion, or vascularized bone graft.