A Case of Avascular Necrosis of the Capitate Bone …joh.sanei.or.jp/pdf/E51/E51_5_08.pdfAvascular...
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J Occup Health 2009; 51: 451–453 Case Study Received Dec 26, 2008; Accepted Jun 10, 2009 Published online in J-STAGE Aug 6, 2009 Correspondence to: J.I. Kim, Department of Occupational Medicine, College of Medicine, Dong-A University, 3Ga-1, Dongdaesing-dong, Seo-gu, Busan 602-715, Korea (e-mail: [email protected]) A Case of Avascular Necrosis of the Capitate Bone in a Pallet Car Driver Byeong Jin YE, Jung Il KIM, Hyun Jae LEE and Kap Yeol JUNG Department of Occupational Medicine, College of Medicine, Dong-A University, Korea Key words: Avascular necrosis, Capitate Avascular necrosis (AVN) of the capitate bone is very rare. It was first reported by Jonsson in 1942 1) and about 30 additional cases have been reported since. Most of the cases were associated with serious trauma, but in some cases, severe trauma has not played a major etiologic role. In our case, we propose that the cause of the avascular necrosis of the capitate bone was repetitive minor trauma and pressure on the palm that disturbed the blood supply. Case Report A 42-yr-old right-handed man complaining of insidious left wrist and palmar pain for 3 yr visited our hospital. The patient had driven a pallet car in an automobile factory for 17 yr. He did not have any history of major trauma, systemic disease or steroid treatment. On physical examination, there was swelling and tenderness of the left wrist and hand, but there were no limitations in wrist motion or dorsal instability. Laboratory findings for diseases were negative. A radiograph showed normal findings on the left capitate, but Magnetic Resonance Imaging (MRI) image showed necrosis with a low signal intensity on T1-weighted and a slightly low signal intensity on T2-weighted on the left capitate (Fig. 1). We interviewed the patient regarding his occupational history in detail. He had driven a kind of pallet car to provide, lade and arrange automobile accessories for 17 yr in an automobile factory. He worked day and night shifts, and worked for up to 10 h a day, and usually about 55–60 h a week. He normally worked for 8 h a day from 8 a.m. to 5 p.m., working overtime for 2 h on weekdays, and he handled the steering wheel with his left hand. In driving, the posture of the left hand was in dorsi-flexion state. In addition, there was a ball on the steering wheel to facilitate operation (Fig. 2). A bolt was located at the center of the upper part of the ball in the steering wheel. Under this working situation, repetitive minor trauma and consistent pressure was placed on the center of the left palmar area during handling of the steering wheel that might have disturbed blood supply to the capitate bone. Discussion AVN of the capitate is a bone necrosis caused by blockage of blood supply. It has variable etiologies including trauma (fracture, dislocation), surgery, decompression sickness, diabetes mellitus, hemostatic disorder, tumor, irradiation, alcoholism, steroids 2) and so on. Jonsson first reported this condition in 1942. Most cases are associated with direct trauma, in particular, a fracture of the wrist of the capitate sometimes together with a fracture of the scaphoid—the so called naviculocapitate syndrome. However, some cases have no trauma history. Previously reported cases were a clerical worker 3) , a gymnast 4) , a carpenter 5, 6) , a paint sprayer 7) and researchers attributed that the cause of avascular necrosis of the capitate bone to repetitive- motion trauma that disturbed the blood supply. The blood supply to the hand has two pathways. One is extrinsic blood supply from the ulnar artery and radial artery that contribute to branches of the palmar carpal branch. The other is intrinsic (intraosseous) blood supply that is associated with the anterior interosseous artery 8) . Both blood supplies to the capitate bone are derived from the palmar aspect 9) . Therefore, the palmar aspect, if affected by any kind of stress condition, could have an influence on blood supply to capitate. Moreover, the extrinsic blood supply is associated with the palmar wrist capsular and ligamentous structures (flexor retinaculum and flexor policis longus tendon). Injury to these structures, especially on the palmar side, could damage accompanying vessels interfering with the blood supply to the capitate 10) . Researchers have proposed that repetitive-motion trauma and consistent pressure disturbs the blood supply to the capitate bone, considering the hand anatomy and the blood supply. In the present case, there was a big bolt at the center of the steering handle ball oppressed the middle of the palm. The bolt and ball have been replaced with a sleek ball, but it will be necessary to improve the structure of the pallet car so that both hands can be used, and we also consider it necessary to reduce contact stress using gloves with a lot of cushion stuffed into them. We didn’t perform histological examinations and we diagnosed AVN with physical examination and radiologic findings. AVN of the capitate has shown various findings on simple radiography, and as in some other cases 10–14) , the radiograph of the present case showed normal (Table 1), but the MRI showed signal change, and advanced necrosis showed low signal intensity in T1 and T2- weighted images. In the present case, AVN was diagnosed by a low signal intensity in T1-weighted and a slightly
Transcript of A Case of Avascular Necrosis of the Capitate Bone …joh.sanei.or.jp/pdf/E51/E51_5_08.pdfAvascular...
J Occup Health 2009; 51: 451–453
Case Study
Received Dec 26, 2008; Accepted Jun 10, 2009Published online in J-STAGE Aug 6, 2009Correspondence to: J.I. Kim, Department of OccupationalMedicine, College of Medicine, Dong-A University, 3Ga-1,Dongdaesing-dong, Seo-gu, Busan 602-715, Korea(e-mail: [email protected])
A Case of Avascular Necrosis of the CapitateBone in a Pallet Car Driver
Byeong Jin YE, Jung Il KIM, Hyun Jae LEE and Kap Yeol JUNG
Department of Occupational Medicine, College of Medicine,Dong-A University, Korea
Key words: Avascular necrosis, Capitate
Avascular necrosis (AVN) of the capitate bone is veryrare. It was first reported by Jonsson in 19421) and about30 additional cases have been reported since. Most ofthe cases were associated with serious trauma, but in somecases, severe trauma has not played a major etiologicrole.
In our case, we propose that the cause of the avascularnecrosis of the capitate bone was repetitive minor traumaand pressure on the palm that disturbed the blood supply.
Case Report
A 42-yr-old right-handed man complaining of insidiousleft wrist and palmar pain for 3 yr visited our hospital.The patient had driven a pallet car in an automobilefactory for 17 yr. He did not have any history of majortrauma, systemic disease or steroid treatment. Onphysical examination, there was swelling and tendernessof the left wrist and hand, but there were no limitationsin wrist motion or dorsal instability. Laboratory findingsfor diseases were negative. A radiograph showed normalfindings on the left capitate, but Magnetic ResonanceImaging (MRI) image showed necrosis with a low signalintensity on T1-weighted and a slightly low signalintensity on T2-weighted on the left capitate (Fig. 1).
We interviewed the patient regarding his occupationalhistory in detail. He had driven a kind of pallet car toprovide, lade and arrange automobile accessories for 17yr in an automobile factory. He worked day and nightshifts, and worked for up to 10 h a day, and usually about55–60 h a week. He normally worked for 8 h a day from8 a.m. to 5 p.m., working overtime for 2 h on weekdays,and he handled the steering wheel with his left hand. Indriving, the posture of the left hand was in dorsi-flexionstate. In addition, there was a ball on the steering wheelto facilitate operation (Fig. 2). A bolt was located at thecenter of the upper part of the ball in the steering wheel.
Under this working situation, repetitive minor trauma andconsistent pressure was placed on the center of the leftpalmar area during handling of the steering wheel thatmight have disturbed blood supply to the capitate bone.
Discussion
AVN of the capitate is a bone necrosis caused byblockage of blood supply. It has variable etiologiesincluding trauma (fracture, dislocation), surgery,decompression sickness, diabetes mellitus, hemostaticdisorder, tumor, irradiation, alcoholism, steroids2) and soon. Jonsson first reported this condition in 1942. Mostcases are associated with direct trauma, in particular, afracture of the wrist of the capitate sometimes togetherwith a fracture of the scaphoid—the so callednaviculocapitate syndrome. However, some cases haveno trauma history. Previously reported cases were aclerical worker3), a gymnast4), a carpenter5, 6), a paintsprayer7) and researchers attributed that the cause ofavascular necrosis of the capitate bone to repetitive-motion trauma that disturbed the blood supply.
The blood supply to the hand has two pathways. Oneis extrinsic blood supply from the ulnar artery and radialartery that contribute to branches of the palmar carpalbranch. The other is intrinsic (intraosseous) blood supplythat is associated with the anterior interosseous artery8).Both blood supplies to the capitate bone are derived fromthe palmar aspect9). Therefore, the palmar aspect, ifaffected by any kind of stress condition, could have aninfluence on blood supply to capitate. Moreover, theextrinsic blood supply is associated with the palmar wristcapsular and ligamentous structures (flexor retinaculumand flexor policis longus tendon). Injury to thesestructures, especially on the palmar side, could damageaccompanying vessels interfering with the blood supplyto the capitate10). Researchers have proposed thatrepetitive-motion trauma and consistent pressure disturbsthe blood supply to the capitate bone, considering thehand anatomy and the blood supply.
In the present case, there was a big bolt at the center ofthe steering handle ball oppressed the middle of the palm.The bolt and ball have been replaced with a sleek ball,but it will be necessary to improve the structure of thepallet car so that both hands can be used, and we alsoconsider it necessary to reduce contact stress using gloveswith a lot of cushion stuffed into them.
We didn’t perform histological examinations and wediagnosed AVN with physical examination and radiologicfindings. AVN of the capitate has shown various findingson simple radiography, and as in some other cases10–14),the radiograph of the present case showed normal (Table1), but the MRI showed signal change, and advancednecrosis showed low signal intensity in T1 and T2-weighted images. In the present case, AVN was diagnosedby a low signal intensity in T1-weighted and a slightly
452 J Occup Health, Vol. 51, 2009
low signal intensity in T2-weighted images.Miliez et al.15) proposed a radiographic classification
system based on the location of involvement in thecapitate. In type I, the most frequent, the involvement islimited to the proximal pole of the capitate, type IIinvolves the body, and the type III, the entire capitate.The present case was type II.
In conclusion, in the present case, we suggest that oneof the causes of the avascular necrosis of the capitatebone was repetitive minor trauma and pressure on thehand and wrist. In addition, if a patient feels pain in thehand or wrist consistently, even when the simpleradiograph shows a normal finding, we suggest checkingthe MRI.
Acknowledgments: This paper was supported by Dong-A University Research Fund in 2007.
References 1) Jonsson G. Aseptic bone necrosis of the os capitum
(os magnum). Acta Radio1 1942; 23: 562–4. 2) Jeffrey D, Urman JD, Abeles M, Houghton AN,
Rothfield NF. Aseptic necrosis presenting as wrist painin SLE. Arthritis Rheum 1977; 2: 825–8.
3) Murakam H, Nishida J, Ehara S, Furumachi K,Shimamura T. Revascularization of avascular necrosisof the capitate bone. Am J Roentgenol 2002; 179: 664–6.
4) Murakami S, Nakajima H. Aseptic necrosis of thecapitate bone in two gymnasts. Am J Sports Med 1984;12: 170–3.
5) Arcalis Arce A, Pedemonte Jansana JP, MassonsAlbareda JM. Idiopathic necrosis of the capitate. ActaOrthop Belg 1996; 62: 46–8.
6) Rahme H. Idiopathic avascular necrosis of the capitatebone—Case report. Hand 1983; 15: 274–5.
7) James ET, Burke FD. Vibration disease of the capitate.
Fig. 2. The pallet car and the ball on the steering wheel.
Fig. 1. MRI shows low signal in the T1-weighted image(T1WI)(Lt) and a slightly lowsignal in the T2-weighted image(T2WI)(Lt) on the left capitate.
453Byeong Jin YE, et al.: Avascular Necrosis of the Capitate Bone
J Hand Surg 1984; 9: 169–70. 8) Niesten JA, Verhaar JAN. Idiopathic avascular necrosis
of the capitate-a case report and a review of theliterature. Hand Surg 2002; 7: 159–61.
9) Panagis JS, Gelberman RH, Taleisnik J, BaumgaertnerM. The arterial anatomy of the human carpus. Part II:The intraosseous vascularity. J Hand Surg 1983; 8:375–82.
10) Vander Grend R, Dell PC, Glowczewskie F, Leslie B,LRuby LK. Intraosseous blood supply of the capitateand its correlation with aseptic necrosis. J Hand Surg1984; 9: 677–83.
11) David P. Postsurgical rehabilitative management ofavascular necrosis in the capitate. J ManipulativePhysiol Ther 2004; 8: 519–24.
Table 1. Case reports on avascular necrosis of the capitate
Reporters Reporting years Age Sex Occupation/Hobby X-ray finding
Ichchou L 2008 32 F Unknown Sclerotic & cystic changeHumphrey C.S 2006 5 M Unknown Irregular ossificationDavid P 2004 46 F Maintenance worker NormalJeffrey W 2002 23 F Housewife Collapse & fragmentationMurakami H 2002 20 M Clerical worker Increasing densityNiesten J.A 2002 21 F Hairdresser Increasing densityMansberg 2000 14 M Unknown NormalThompson NS 1998 26 M Unknown Fragmentation & sclerosisArcalis Arce A 1996 38 M Carpenter Sclerotic & cystic changeKutty S 1995 44 F Housewife Increasing densitySmet L 1993 32 M Construction laborer Completely destroyedLapinsky AS 1992 18 M Unknown Sclerotic changeMilliez P.Y 1991 20 F College student Increasing density
22 F Unknown Increasing density29 M Warehouseman Increasing density
Wounlund J 1989 20 M Carpenter NormalHaygood TM 1989 25 M jet ski NormalBolton-Maggs B.G 1984 18 M Bus conductor Sclerotic & cystic changeVander Grend R 1984 28 M Pneumatic tool used Transverse fracture
26 M Unknown Normal22 F Unknown Normal21 M Karate Transverse fracture
James E.T.R 1984 29 M vibrating tool used Sclerotic changeMurakami S 1984 18 M College gymnast Small sequestral change
19 F College gymnast Sclerotic changeRahme H 1983 19 M Carpenter Irregular & cystic changeRobert B 1982 17 F Ice-cream parlor LysisWallace E 1981 19 M Unknown proximal chip fractureJohn H 1980 17 F Unknown Flattening & irregularityJeffrey D 1977 20 F Unknown Sclerotic & cystic changeJonsson G 1942 22 F Nursing student Transverse fracture
12) Mansberg R, Lewis G, Kirsh G. Avascular necrosisand fracture of the capitate bone: Unusual scintigraphicfeatures. Clin Nucl Med 2000; 5: 372–3.
13) Wounlund J, Lohmann M. Aseptic necrosis of thecapitate secondary to Gaucher’s disease: A case report.J Hand Surg [Br]. 1989; 3: 336–7.
14) Haygood TM, Eisenberg B, Hays MB, García JF,Williamson MR. Avascular necrosis of the capitatedemonstrated on a 0.064 T magnet. Magn ResonImaging 1989; 5: 571–3.
15) Millies PY, Kinh Kha H, Thomine JM. Idiopathicaseptic osteonecrosis of the capitate bone. Literaturereview apropos of three new cases. Int Orthop 1991;15: 85–94.
