What is the recommended initial non‑operative management for a triquetral avulsion fracture?

Triquetral Avulsion Fracture Management

For a triquetral avulsion fracture, immobilize the wrist in a short-arm cast or orthosis for 3 weeks, which provides excellent outcomes without need for surgery in the vast majority of cases 1, 2.

Initial Management Algorithm

Immediate Treatment

• Immobilization for 3 weeks using either:
  • Short-arm cast, OR
  • Wrist orthosis

The choice between cast versus orthosis makes no difference in patient-reported outcomes, range of motion, or function 2. This gives flexibility based on patient preference and compliance considerations.

Key Clinical Points

Diagnosis confirmation: The dorsal avulsion/shear fracture (which comprises approximately 93% of all triquetral fractures) is best visualized on the lateral wrist radiograph 1. If the diagnosis remains uncertain, CT can be added for confirmation 1.

Expected timeline:

• Immobilization: 3 weeks 1, 3
• Bony healing: 6-8 weeks 3
• Residual symptoms may persist for several months and are not uncommon 1

Important Caveats and Red Flags

When Conservative Treatment May Not Be Sufficient

Volar cortical fractures require heightened vigilance. Unlike the benign dorsal avulsion fractures, volar triquetral fractures can indicate significant ligamentous injury 4, 5. These fractures:

• Are easily missed on standard radiographs 5
• May involve avulsion of the strong palmar lunotriquetral ligament 1
• Are associated with lunotriquetral ligament tears and carpal instability in the majority of cases 5

If a volar cortical fracture is suspected:

1. Obtain MRI to evaluate for ligamentous injury 1
2. Consider wrist arthroscopy as the gold standard for confirming lunotriquetral ligament rupture 1
3. May require transfixation of the lunotriquetral joint 1

Body Fractures

Triquetral body fractures are much less common but may occur as part of complex carpal injuries like perilunate fracture-dislocations 1. These require:

• CT imaging in addition to standard radiographs 1
• Evaluation for associated injuries
• Possible surgical intervention if significantly displaced or unstable 4

Outcomes

Conservative management of dorsal avulsion fractures results in:

• Good overall patient-reported outcomes 2
• Favorable range of motion 2
• Osseous consolidation in all cases 3
• No risk of avascular necrosis due to excellent vascularization 3
• No posttraumatic instability when properly managed 3

Note: Isolated fractures have slightly better ROM outcomes compared to those with concomitant ipsilateral upper limb injuries 2.