Updated: 11/7/2018

Triquetrum Fracture

Topic
Review Topic
0
0
https://upload.orthobullets.com/topic/322147/images/body_ap.jpg
https://upload.orthobullets.com/topic/322147/images/dorsal_cortical_ir_oblique.jpg
https://upload.orthobullets.com/topic/322147/images/dorsal_cortical_lateral_pooping_duck..jpg
https://upload.orthobullets.com/topic/322147/images/ligaments.jpg
https://upload.orthobullets.com/topic/322147/images/physical_exam.jpg
Introduction
  • Epidemiology
    • incidence
      • second most common carpal bone fracture
      • accounts for up to 15% of all carpal fractures
  • Pathophysiology
    • mechanism of injury
      • based on type of fracture
        • 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
  • Associated conditions
    • perilunate dislocations (seen in 12-25% of triquetral fractures)
    • radius or ulna fractures
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
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
      • PA
      • 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
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
  • 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
 

Please rate topic.

Average 1.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
ARTICLES (2)
Topic COMMENTS (0)
Private Note