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Capitate bone

The capitate bone is the largest and most centrally positioned of the eight carpal bones in the human wrist, situated in the distal row between the trapezoid laterally and the hamate medially, where it functions as the "keystone" of the wrist due to its extensive articulations and role in maintaining structural stability.^[1]^[2]^[3] Characterized by a rounded proximal head, a narrow neck, and a broader distal body, the capitate articulates proximally with the scaphoid and lunate bones of the proximal carpal row, distally with the bases of the second, third, and fourth metacarpal bones, laterally with the trapezoid, and medially with the hamate, forming seven joint surfaces in total that contribute to wrist mobility and load transmission during grasping and manipulation.^[3]^[2] Its dorsal and palmar surfaces are rough for ligament attachments, including those supporting the transverse carpal arch and carpal tunnel, while the volar surface also provides origin for the oblique head of the adductor pollicis muscle.^[1]^[3] The capitate receives its blood supply primarily from dorsal intercarpal and basal metacarpal arterial arches with retrograde flow, supplemented by palmar and ulnar recurrent anastomoses, though it relies on a single dominant intraosseous vessel, predisposing it to avascular necrosis following fractures.^[2]^[1] Innervation arises from the anterior interosseous branch of the median nerve, the posterior interosseous branch of the radial nerve, and dorsal and deep branches of the ulnar nerve, supporting sensory and proprioceptive functions in the wrist.^[1] Clinically, capitate fractures are uncommon but often occur in high-energy trauma such as perilunate dislocations, with the proximal pole at particular risk for nonunion or osteonecrosis due to its retrograde vascularity, potentially leading to chronic wrist pain and instability if untreated.^[2]^[1]

Structure

Location and articulations

The capitate bone is the largest and most central of the eight carpal bones, situated in the distal row of the carpus within the wrist. It occupies a pivotal position between the lunate bone proximally, the hamate bone medially, the trapezoid bone laterally, and the bases of the second, third, and fourth metacarpal bones distally.^[4]^[2]^[1] Its articulations form multiple synovial joints that stabilize the wrist. The rounded head of the capitate projects proximally into the concavity formed by the lunate and scaphoid bones, articulating directly with the lunate via the lunocapitate joint and with the scaphoid via the scaphocapitate joint. The distal surface articulates primarily with the base of the third metacarpal at the carpometacarpal joint, with smaller facets connecting to the second and fourth metacarpals. Laterally, the capitate forms the trapeziocapitate joint with the trapezoid, while medially, a ridge on its surface articulates with the hamate at the capitohamate joint, fitting into the hamate's configuration without direct involvement of the triquetral fossa.^[4]^[2]^[5] Positioned distally to the radius and ulna, the capitate serves as a key bridge in the carpal arch, linking the forearm's distal ends to the hand's metacarpals and facilitating the overall transmission of forces across the wrist.^[1]^[6]

Surfaces

The capitate bone exhibits a distinctive pyramidal shape, characterized by a rounded head proximally, a constricted waist-like neck in the midportion, and a broader body distally. This morphology positions it centrally within the distal row of carpal bones, facilitating its role as a key articulator in the wrist. The bone's surfaces are adapted for both articular and non-articular functions, with multiple facets for adjacent carpal and metacarpal bones, as well as roughened areas for ligamentous attachments.^[7]^[1] The proximal surface forms the rounded, convex head of the capitate, which articulates with the lunate and scaphoid bones; this surface is covered by articular cartilage to enable smooth midcarpal joint motion. The distal surface is triangular in outline with a palmarly directed apex, presenting concave facets that articulate with the bases of the second, third, and fourth metacarpal bones, thereby transmitting forces from the wrist to the hand. A central ridge on this surface helps separate the articular areas for the second and third metacarpals, enhancing stability during grip activities.^[2]^[1]^[7] The medial surface is concave and features a large, smooth articular facet for the hamate bone, complemented by a roughened region that serves as the attachment site for the capitohamate interosseous ligament, which reinforces the intercarpal joint. Laterally, the surface transitions from a spherical proximal facet for the scaphoid to a concave distal strip articulating with the trapezoid bone, separated by a shallow depression; this area also anchors the dorsal and palmar intercarpal ligaments for wrist cohesion.^[7]^[1] The dorsal (posterior) surface is rough and generally concave, providing attachment points for dorsal intercarpal ligaments that contribute to posterior wrist stability. In contrast, the palmar (anterior) surface is slightly convex and roughened, offering origins for fibers of the oblique head of the adductor pollicis muscle and attachments for palmar intercarpal ligaments, including the radioscaphocapitate ligament, which helps maintain carpal alignment.^[2]^[1]^[7]

Blood supply

The blood supply of the capitate bone primarily derives from the dorsal intercarpal arch, a branch of the radial artery that contributes the majority of dorsal vascularization; the dorsal basal metacarpal arch; the palmar intercarpal arch, formed by branches of the anterior interosseous artery; and recurrent branches of the deep palmar arch from the ulnar artery.^[8] These extraosseous vessels form anastomotic networks that penetrate the bone through nutrient foramina predominantly located on the distal and palmar surfaces.^[9] Intraosseous perfusion occurs in a predominantly retrograde manner, with 2–4 dorsal vessels entering the concave distal aspect and traveling proximally to supply the head and body, while 1–3 palmar vessels directly perfuse the head region.^[8] Studies using micro-computed tomography have identified dorsal and volar vascular systems without a clear predominance in supply, though anastomoses between these systems occur in approximately 30% of cases.^[10] Earlier anatomic investigations described three intraosseous vascular patterns—palmar-dominant, dorsal-dominant, and balanced—wherein the proximal pole consistently relies on retrograde flow across the waist, rendering it susceptible to ischemia in a watershed zone with relatively sparse direct vascular entry.^[11] However, up to 70% of capitates exhibit at least one direct volar vessel supplying the proximal pole, potentially mitigating risks in this region.^[10] The capitate bone lacks motor innervation but receives sensory innervation to its periosteum and surrounding ligaments from the anterior interosseous branch of the median nerve, the posterior interosseous branch of the radial nerve, and the dorsal and deep branches of the ulnar nerve.^[1] This vascular arrangement underscores the bone's vulnerability to ischemic compromise at the proximal pole due to its dependence on distal-to-proximal flow, particularly following disruptions in the nutrient foramina or waist region.^[10]

Development

The capitate bone originates from undifferentiated mesenchyme within the distal row of the developing carpal region during early embryogenesis.^[12] Chondrification begins around Carnegie stage 18, approximately 44 days post-fertilization (equivalent to 6 weeks gestational age), with condensations of pre-chondrogenic mesenchyme forming the initial cartilage model.^[12] By stage 20 (about 50-51 days, or 7-8 weeks gestational age), the capitate emerges as the first distinct precartilage structure in the wrist, followed by full chondrification by stage 21.^[12] This process aligns with the broader formation of chondrification centers in the hand plate, where the capitate and hamate are among the earliest to develop in the distal carpal row.^[13] Ossification of the capitate occurs through a single primary center, marking it as the first carpal bone to undergo endochondral ossification, with no secondary centers present.^[14] The ossification center typically appears between 1 and 3 months postnatally, though radiographic detection may vary slightly due to individual differences in mineralization.^[14] Ossification initiates earlier in females, often at around 2 months, compared to 3 months in males, reflecting a general sex-based acceleration in skeletal maturation.^[15] The process completes gradually, with the bone achieving full ossification and structural maturity by ages 12-14 years, coinciding with the overall stabilization of carpal growth.^[15] Postnatal growth of the capitate proceeds primarily through appositional bone formation on its surfaces, allowing expansion in size and shape while maintaining its central role in the carpus.^[16] This growth is modulated by mechanical loading from wrist movements, which stimulates periosteal deposition and adaptive remodeling to withstand functional stresses.^[17] The bone reaches its adult dimensions by late adolescence, typically around 16-18 years, after which further changes are minimal.^[16] Developmental variations in the capitate are uncommon but include rare accessory ossicles, such as those occasionally forming at the distal pole due to unfused secondary centers, with an overall incidence of wrist accessory ossicles below 1%.^[18] Congenital fusions, or coalitions, involving the capitate occur infrequently, most notably with the hamate (capitohamate type) or trapezoid, at rates less than 1% of the population and comprising about 15-20% of all carpal coalitions.^[19] These anomalies arise from incomplete separation of chondrification centers during embryogenesis and are usually asymptomatic unless associated with degenerative changes.^[19]

Function

Role in wrist kinematics

The capitate bone is integral to wrist flexion and extension, primarily through its articulation with the lunate at the midcarpal joint, where it glides relative to the proximal row to facilitate the typical 70–90° arc of motion.^[20] During these movements, the rounded head of the capitate functions as a fulcrum, serving as the approximate center of rotation for the distal carpal row and enabling coordinated flexion of approximately 80° and extension of 70° relative to the forearm.^[21] This gliding action, combined with contributions from the scaphoid (flexing 70% of the capitate's amount) and lunate (46%), ensures smooth proximal-distal row interactions without excessive shear.^[20] In radial-ulnar deviation, the capitate translates laterally as part of the distal carpal row, which shifts palmarly during radial deviation and dorsally during ulnar deviation, with the overall range constrained by ligaments such as the radioscaphocapitate and triquetrocapitate to about 20–30°.^[22] This translation, rather than significant rotation, maintains carpal alignment, with midcarpal contributions accounting for 90% of radial deviation and 50% of ulnar deviation.^[22] The capitate's central position stabilizes this motion, preventing excessive lateral drift through its ligamentous tethers to adjacent bones.^[23] Circumduction of the wrist, a composite motion integrating flexion-extension and radial-ulnar deviation, involves the capitate in a coupled pattern where it undergoes minimal intrinsic rotation due to its pivotal, central location within the carpus.^[23] This limited rotation allows the distal row to follow a conical path around the capitate head, supporting fluid, multiplanar hand positioning without compromising stability.^[22] Beyond kinematics, the capitate facilitates load transmission across the wrist, bearing 20–30% of the axial forearm load to the second and third metacarpals during gripping tasks, thereby distributing compressive forces from the proximal row.^[24] This role underscores its importance in maintaining structural integrity under dynamic loads, with the distal row acting as a unified transmitter.^[23]

Biomechanical contributions

The capitate bone exhibits a composition dominated by trabecular bone within its central body, which facilitates shock absorption during compressive loading, while a surrounding cortical shell provides structural strength and resistance to tensile forces. This architecture is evident in micro-CT analyses of hominoid capitates, where trabecular bone volume fraction (BV/TV) is lowest in humans compared to other hominoids, with cortical thickness increasing distally to enhance load-bearing capacity. The cortical component has a Young's modulus of approximately 18 GPa, typical for carpal bones in finite element models, enabling elastic deformation under physiological stresses without fracture.^[25]^[26] In wrist biomechanics, the capitate serves as a primary conduit for force transmission, channeling approximately 50% of compressive loads from the radius through the midcarpal joint to the index and middle metacarpals, as indicated by load distribution studies across the lunocapitate (29%) and scapho-capitate (19%) articulations. This central role positions the capitate within the wrist's load path, where shear forces concentrate at the narrow neck region, potentially leading to translational stresses during multi-planar motions like flexion-extension.^[27] Ligamentous attachments further bolster the capitate's stability against displacement. The radioscaphocapitate ligament, originating from the radial styloid and inserting on the palmar capitate, forms a sling that restrains volar subluxation of the proximal carpal row relative to the capitate. Complementarily, the dorsal intercarpal ligament, spanning from the triquetrum to the scaphoid and trapezoids, restricts excessive extension by limiting dorsal translation and maintaining alignment during radial-ulnar deviation.^[28]^[22] Evolutionarily, the capitate's trabecular architecture shows conserved patterns across hominoids, with anisotropic orientations proximally in humans and orangutans reflecting adaptations for manipulative behaviors, including tool use that imposes targeted compressive loads via the thumb and dart-thrower's motion. In contrast to the thicker cortices in knuckle-walking apes like gorillas, human capitates exhibit relatively lower BV/TV and thinner distal shells, optimized for precision gripping rather than high-impact locomotion, as quantified in comparative micro-CT studies.^[25]

Clinical significance

Fractures and injuries

Capitate fractures represent a rare injury, accounting for 1-2% of all carpal bone fractures.^[29] In children, capitate fractures are the second most common carpal bone injury after the scaphoid.^[29] These fractures are often underdiagnosed due to their occult nature and the superimposition of carpal bones on standard radiographs.^[30] They typically result from high-energy trauma and are frequently associated with other carpal injuries, particularly scaphoid fractures in the context of perilunate dislocations.^[31] The most common type of capitate fracture involves the waist or body, comprising the majority of cases and often occurring in high-energy falls onto an outstretched hand.^[31] Head and neck fractures account for a significant portion of reported cases and are commonly seen in conjunction with scaphoid waist fractures as part of transscaphoid-transcapitate perilunate fracture-dislocations.^[30] Chip avulsions, which involve small fragments at the dorsal or volar poles, are less frequent and usually arise from ligamentous avulsion forces.^[31] The primary mechanism of injury is hyperextension of the wrist combined with ulnar deviation, transmitting axial loads through the capitate during falls on an outstretched hand.^[30] This pattern is prevalent in sports such as gymnastics, where repetitive or acute dorsiflexion under load can precipitate the fracture, as evidenced in case reports of adolescent athletes.^[32] Isolated capitate fractures are uncommon, with most cases linked to greater arc perilunate injuries involving the scaphoid.^[30] Diagnosis begins with clinical suspicion in patients presenting with dorsal wrist pain and swelling following trauma, though initial plain radiographs have low sensitivity, often missing up to 100% of fractures on posteroanterior views due to bone overlap.^[31] Lateral radiographs may reveal disruption of the normal colinearity between the radius, lunate, and capitate, but computed tomography (CT) is essential for confirming occult fractures, providing 100% sensitivity and detailing fragment displacement.^[31] The overall incidence underscores the need for advanced imaging in high-suspicion cases, as capitate injuries comprise only 1-2% of carpal fractures but carry risks of delayed diagnosis.^[29] Management of nondisplaced capitate fractures involves immobilization in a short-arm thumb spica cast for 4-6 weeks to promote union, with serial imaging to monitor progress. For displaced fractures, particularly those at the neck or body, open reduction and internal fixation (ORIF) using Herbert screws is the standard approach, allowing stable compression and preserving vascularity.^[33] Early surgical intervention yields union rates of 80-90% in appropriately selected cases, reducing the risk of malunion or displacement.^[34] Postoperative immobilization follows ORIF, typically for an additional 4 weeks, with emphasis on the retrograde blood supply that may complicate healing if not addressed promptly.^[30]

Avascular necrosis and complications

Avascular necrosis (AVN) of the capitate bone most commonly arises from disruption of its retrograde blood supply following trauma, such as fractures that interrupt vascular flow to the proximal pole, which is particularly vulnerable due to the intraosseous vessels entering distally and flowing proximally.^[35] Idiopathic AVN is rare, with the majority of cases linked to post-traumatic etiology, though associations with steroid use, gout, or Gaucher's disease have been noted in isolated reports.^[36] The true incidence remains unknown but is considered low overall, with AVN reported as a complication in untreated or delayed-diagnosis capitate fractures, where the tenuous proximal pole supply predisposes to ischemia. The condition progresses through stages adapted from the Ficat classification used for other osteonecrotic sites: stage I features normal radiographs but magnetic resonance imaging (MRI) evidence of bone marrow edema; stage II shows sclerosis and cystic changes without collapse; stage III involves subchondral fracture; and stage IV demonstrates bone collapse with secondary degenerative changes.^[37] Patients typically present with chronic wrist pain, stiffness, reduced range of motion, and occasional swelling, often delaying diagnosis until advanced stages.^[38] Key complications include nonunion, occurring in 19% to 56% of isolated capitate fractures due to impaired vascularity and mechanical instability, as well as secondary osteoarthritis affecting adjacent structures like the lunate and third metacarpal base from altered load distribution and cartilage degeneration. Advanced AVN can lead to carpal collapse patterns analogous to scaphoid nonunion advanced collapse, involving progressive joint space narrowing and instability between the scaphoid, capitate, and lunate.^[39] Treatment strategies depend on disease stage and aim to preserve joint function where possible. For early-stage AVN (pre-collapse), core decompression with or without bone grafting addresses intraosseous hypertension and promotes revascularization, though evidence specific to the capitate is limited to case reports showing pain relief and delayed progression.^[38] In more advanced cases, partial capitate resection arthroplasty removes necrotic proximal pole tissue arthroscopically, providing pain relief and functional improvement in short-term follow-up without compromising overall wrist stability.^[40] Vascularized bone grafts, often pedicled from the distal radius or second metacarpal base, are preferred for revascularization in stages I-III, with case series demonstrating union, pain reduction, and grip strength gains at 12-18 months post-surgery.^[41] Recent long-term evaluations of capitate-related interventions report satisfactory outcomes in approximately 80% of cases at 9-16 years, including maintained motion and minimal arthritis progression.^[42] Additionally, capitate shortening osteotomy serves as an adjunctive procedure in Kienböck's disease (lunate AVN) to redistribute ulnar load and prevent further lunate collapse, yielding improved pain scores and lunate geometry in stage IIIA cases with neutral ulnar variance.^[43]

Etymology and nomenclature

Etymology

The term "capitate" derives from the Latin capitātus, meaning "having a head" or "formed like a head," which stems from caput, the Latin word for "head." This nomenclature specifically alludes to the bone's rounded, head-like proximal articular surface, which articulates with the lunate bone and contributes to its distinctive morphology.^[44]^[45]^[46] The use of the term in anatomical literature emerged during the Renaissance period of systematic dissection and naming. Andreas Vesalius, in his seminal 1543 work De humani corporis fabrica, cataloged the carpal bones numerically rather than descriptively, designating the capitate as the seventh in sequence from the scaphoid to the hamate. The specific name "capitatum" (Latin for capitate) was formalized later by anatomist Bernhard Siegfried Albinus in 1726, highlighting the bone's prominent, knob-like head as a key identifying feature in osteological descriptions.^[47] Linguistically, the capitate bone's name exemplifies the descriptive tradition in osteology, where terms are drawn from classical languages to evoke morphological traits. While a direct Greek translation exists as κεφαλωτό οστό (kephalōtó ostó, literally "head-shaped bone"), derived from kephalē meaning "head," this equivalent is infrequently employed in contemporary anatomical texts, with the Latin form predominating due to historical conventions in Western medical nomenclature.^[48]^[49]

Alternative names

The capitate bone, the largest of the carpal bones, has historically been referred to by several alternative names reflecting its size and position. The Latin term os magnum, meaning "great bone," was commonly used in early anatomical descriptions owing to its prominence and size among the carpals; this name dates back to classical and medieval texts and persists in some older literature but is now considered obsolete.^[2]^[3] The English equivalent, "magnum bone," served as a direct translation and appeared frequently in 19th-century anatomical works, such as those describing wrist structure in English-language treatises. In positional terms, it has been described as the "central carpal" in radiographic imaging and surgical discussions to emphasize its location at the center of the distal carpal row.^[1] Similarly, "third carpal" denotes its sequential position in that row (following the trapezium and trapezoid) within certain clinical and anatomical contexts.^[50] Nomenclature for the bone evolved toward greater specificity with the establishment of standardized terminology; the Basle Nomina Anatomica of 1895 adopted os capitatum (leading to the modern English "capitate"), replacing earlier descriptive terms like os magnum in favor of those highlighting its head-like proximal feature, though the shift was gradual in adoption across texts.^[51]^[47]

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