An unusual transcapitate fracture of the wrist

A patient sustained a crush-type hyperextension injury to his wrist, and presented to the emergency department (ED) with wrist pain, swelling, and paresthesias along the median and superficial radial nerve distributions. His initial radiographic study was interpreted as showing a radial styloid fracture. The next day, he returned for a scheduled revisit with continued wrist pain and swelling. He also had loss of two-point discrimination in the median nerve distribution and loss of thumb opposition. Repeat radiographs were interpreted as showing not only a radial styloid fracture, but also a fracture of the capitate with the proximal fragment rotated 180 degrees in the sagittal plane. The patient was admitted for surgery, and did well, with good return of function. The unusual position of the capitate fracture obscured the common signs of fracture recognition and thus went unnoticed on the patient's initial ED visit. However, in light of the patient's disproportionate symptoms with seemingly negative diagnostic study results, appropriate follow-up care was given, and definitive treatment was appropriately rendered.