Vascularized Metatarsal Head for Carpal Reconstruction

Creating the ideal articular surface in the hand or wrist is a difficult task. Alloplastic materials are an option in many cases; however, in contrast to large joints, their lifespan in the hand and wrist is limited and lacks long-term follow up. Vascularized joint transfers are not a new concept, particularly in finger reconstruction. We present the case of an 18 year-old male involved in a motorcycle crash who underwent vascularized metatarsal head transfer for capitate reconstruction.

On 8/10/16, an 18 year-old male presented to our trauma bay following a motorcycle crash. On his initial survey, he was noted to have suffered an isolated severe open right wrist injury. Intra-operatively, he was found to have a greater arc injury with complete loss of the capitate. After undergoing open reduction and percutaneous fixation, he was allowed 8 weeks to heal. At 2 months post-op, he returned to the operating room for capitate reconstruction with a free vascularized metatarsal head flap to maintain the mid-carpal joint. He was immobilized for 6 weeks. At 4 months post-op, he reported no pain about the wrist. He achieved 40 degrees of flexion and 30 degrees of extension along with full pronation and supination. He has no donor site sequelae with normal foot, ankle, and toe range of motion.

Capitate fractures are a rare injury to the carpus. As opposed to isolated cases, capitate fractures are more commonly involved in greater arc peri-lunate dislocations. Given its retrograde blood supply, the capitate is particularly at risk for avascular necrosis. As a central entity to the carpus, the capitate is pivotal to maintenance of carpal height and wrist kinematics. Collapse and subsidence of the long finger ray can cause significant disability. Therefore, it is important for the hand surgeon to know the available options for capitate reconstruction. When near total capitate reconstruction is required, we feel the metatarsal head offers the ideal cartilaginous surface while maintaining the appropriate radius of curvature to reconstruct the midcarpal joint.