What is the management for a suspected triquetrum fracture with soft tissue swelling and point tenderness?

Management of Suspected Triquetrum Fracture

For a suspected triquetrum fracture with soft tissue swelling and point tenderness, initial management should include immobilization with a short arm cast or splint for 3-4 weeks, followed by progressive mobilization. 1, 2

Diagnostic Approach

1. Initial Imaging:

   • Standard wrist radiographs (posterior-anterior, lateral, and oblique views) should be performed first 3
   • Point tenderness over the triquetrum should be correlated with imaging findings

2. If radiographs are nondiagnostic but clinical suspicion remains high:

   • MRI without IV contrast or CT without IV contrast is recommended 3
   • MRI is preferred due to higher sensitivity for bone marrow edema and soft tissue injuries 3

3. Fracture Classification:

   • Dorsal cortical chip fractures (most common, 80-85%)
   • Body fractures (less common)
   • Volar cortical fractures (rare) 1

Treatment Algorithm

For Dorsal Chip Fractures:

• Conservative management with immobilization for 3-4 weeks 2, 4
• Short arm cast or removable splint
• No surgical intervention typically required 4
• Healing of bone fragments takes 6-8 weeks 5

For Body Fractures:

• Non-displaced: Immobilization for 4-6 weeks 2
• Displaced (rare): May require open reduction and internal fixation 2

For Fractures with Ligamentous Instability:

• If associated with perilunate instability: Surgical repair may be necessary 2

Pain Management

• NSAIDs for pain control
• Acetaminophen as an alternative
• Avoid prolonged immobilization beyond recommended periods to prevent stiffness

Rehabilitation Protocol

1. Acute Phase (0-3 weeks):

   • Immobilization in cast/splint
   • Elevation and ice for swelling control

2. Intermediate Phase (3-6 weeks):

   • Progressive wrist range of motion exercises
   • Gentle strengthening exercises

3. Advanced Phase (6+ weeks):

   • Progressive strengthening
   • Return to normal activities as tolerated

Prognosis and Complications

• Most triquetrum fractures heal well with conservative management 1, 4
• Potential complications include:
  • Non-union (rare)
  • Triangular fibrocartilage complex injury
  • Pisotriquetral arthritis 1
  • Wrist stiffness if immobilized too long

Follow-up Recommendations

• Clinical reassessment at 2-3 weeks to evaluate healing
• Radiographic follow-up at 6-8 weeks to confirm healing
• Consider MRI if symptoms persist despite appropriate treatment

Special Considerations

• Triquetrum is the second most commonly fractured carpal bone (15-18% of carpal fractures) 1
• Most fractures occur from falls on an outstretched hand with the wrist in extension and ulnar deviation 4, 5
• Good vascularization of the triquetrum means avascular necrosis is rarely a concern 5

The management approach should focus on appropriate immobilization followed by gradual rehabilitation, as surgical intervention is rarely needed for these fractures unless there is significant displacement or associated ligamentous instability.