Updated: 5/13/2021

Triquetrum Fracture

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  • summary
    • Triquetrum fractures are common carpal fractures that are often associated with other injuries to the wrist.
    • Diagnosis is confirmed with orthogonal views of the wrist.
    • Treatment is generally nonoperative but injuries associated with wrist instability require surgical fixation.
  • Epidemiology
    • Incidence
      • second most common carpal bone fracture
      • accounts for up to 15% of all carpal fractures
    • Associated conditions
      • perilunate dislocations (seen in 12-25% of triquetral fractures)
      • radius or ulna fractures
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • dorsal cortical fractures
          • impaction
            • most common mechanism
            • usually a fall onto wrist in dorsiflexion and ulnar deviation
            • ulnar styloid can act as a chisel driven into the dorsal cortex of the triquetrum
          • avulsion
            • results from extreme palmar flexion with radial deviation
              • due to attachment of dorsal radiotriquetral and triquetroscaphoid ligaments
          • shearing force
            • results from shearing of proximal edge of the hamate against the distal dorsal triquetrum during wrist extension
        • body fractures
          • sagittal fractures
            • results from axial dislocations or anterior-posterior crush injury
          • medial tuberosity fractures
            • results from direct blow
          • transverse proximal pole fractures
            • associated with perilunate dislocations
          • transverse body fractures
            • associated with perilunate dislocations
          • comminuted fractures
            • results from high-energy trauma
        • palmar cortical fractures
          • avulsion of palmar ulnar triquetral ligament and LTIO ligament
          • shearing force from pisiform
  • Anatomy
    • Osteology
      • triquetrum is a wedge-shaped carpal bone located in the proximal row
      • articulates with
        • hamate
        • pisiform
        • lunate
    • Ligaments
      • extrinsic
        • ulnotriquetral ligament
          • originates from the palmar aspect of the triangular fibrocartilage complex (TFCC)
          • inserts on the palmar aspect of the triquetrum
        • dorsal radiotriquetral (radiocarpal) ligament
          • originates from the dorsal distal radius
          • inserts on the dorsal ridge of the triquetrum
      • intrinsic
        • palmar and dorsal lunotriquetral ligaments
          • palmar ligament is thicker and stronger
          • distal fibers blend with scapholunate ligament to form palmar and dorsal scaphotriquetral ligaments
        • triquetrocapitate and triquetrohamate ligaments
          • blend with ulnocapitate ligament to form ulnar arm of arcuate ligament
        • dorsal intercarpal ligament
          • originates from ulnar aspect of dorsal triquetrum
          • inserts on dorsal rim of the scaphoid, trapezium, and trapezoid
    • Blood Supply
      • receives blood supply from nutrient arteries to non-articular surfaces
  • Classification
    • Triquetrum Fractures Classification
      Dorsal cortical fractures
      Most common (accounts for up to 93%)
      • Mechanism includes avulsion, shearing force, or impaction
      Body fractures
      • Second most common
      • Subtypes: sagittal, medial tuberosity, transverse proximal pole, transverse body, comminuted
      Palmar cortical fractures
      • Mechanism includes avulsion or shearing force
      Risk of instability
  • Presentation
    • Physical exam
      • swelling/deformity of ulnar wrist
      • pain with palpation directly over triquetrum
      • pain with wrist flexion and extension if dorsal cortical fracture
  • Imaging
    • Radiographs
      • recommended views
        • lateral
          • useful for visualizing dorsal cortical fractures
        • IR oblique
          • useful for visualizing dorsal cortical fractures
      • optional views
        • radial deviation
          • may be helpful in identifying palmar cortical fractures
      • findings
        • "pooping duck" sign
          • represents dorsal cortical fractures
    • CT
      • indications
        • obtain if high suspicion of triquetral fracture
    • MRI
      • indications
        • recommended for palmar cortical fractures due to concern for carpal instability
        • obtain if concern for extrinsic intercarpal ligament injuries or occult fracture
  • Differential
    • Trapezial fracture
    • Hook of Hamate fracture
    • Pisiform fracture
    • Lunate dislocation
  • Diagnosis
    • Radiographic
      • diagnosis confirmed by history, physical exam, and radiographs
  • Treatment
    • Nonoperative
      • immobilization for 4-6 weeks
        • indications
          • dorsal cortical fractures without evidence of instability
          • nondisplaced body fractures
          • palmar cortical fractures without evidence of instability
    • Operative
      • ORIF
        • indications
          • dorsal cortical fractures with evidence of instability
          • displaced body fractures
          • palmar cortical fractures with evidence of instability
  • Techniques
    • Immobilization for 4-6 weeks
      • short arm cast with thumb free
    • Open reduction internal fixation
      • approach
        • dorso-ulnar approach
          • radial to ECU
      • soft tissue
        • longitudinal capsulotomy
      • instrumentation
        • interfragmentary screws
        • suture anchors
          • if ligamentous injury requiring repair
        • K wires
          • if instability
  • Complications
    • Non-union
      • rare in triquetral body fractures
      • can perform excision if symptomatic
    • Persistent carpal instability
    • Pisotriquetral arthritis
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