Management of Triquetral Fracture with Loose Cast and Thumb Pain
Recasting with proper technique and attention to thumb positioning is appropriate for this patient with a triquetral fracture, followed by a 6-week immobilization period and subsequent rehabilitation.
Assessment of Current Situation
The patient presents with:
- Right wrist fracture (possible triquetral fracture)
- X-ray showing soft tissue swelling
- Loose cast causing discomfort
- Thumb pain from current cast
Appropriate Management Plan
Immediate Management
- Remove the current loose cast
- Perform clinical assessment of:
- Neurovascular status (particularly median nerve function)
- Skin condition under the cast
- Range of motion limitations
- Specific location of thumb pain
Recasting Procedure
- Apply a well-molded short arm cast with proper technique 1:
- Use minimal cast padding to achieve optimal cast index (ratio of sagittal to coronal width)
- Position the wrist in slight flexion and ulnar deviation to maintain reduction
- Ensure the cast properly supports the triquetrum (located on the ulnar side of the wrist)
- Pay special attention to thumb positioning to relieve pressure and pain
- Apply a 3-point mold to maintain proper alignment
Immobilization Duration
- Maintain cast immobilization for 6 weeks 2
- This duration is appropriate for triquetral fractures to ensure proper healing
- For triquetral chip fractures, conservative therapy with 3 weeks immobilization may be sufficient, but given the uncertainty about fracture type, 6 weeks is safer 2
Follow-up Plan
- Schedule follow-up visit at 1-2 weeks to:
- Obtain radiographs to confirm maintained alignment 3
- Assess for any cast-related complications
- Ensure proper fit of the new cast
- Final cast removal at 6 weeks
Post-Cast Rehabilitation
- After cast removal, initiate active finger motion exercises to prevent stiffness 1
- Recommend wrist motion exercises three times daily 3
- Consider a removable wrist splint for an additional 2-4 weeks if fracture line remains visible on radiographs 3
Important Considerations
Imaging Recommendations
- If there is uncertainty about the fracture type, consider obtaining a complete 3-view radiographic examination (PA, lateral, and oblique) 1
- If radiographs remain equivocal, CT without IV contrast may be appropriate to confirm the diagnosis and extent of the fracture 1
Cast-Related Complications to Monitor
- Instruct the patient not to insert anything down the cast to prevent skin breakdown 3
- Monitor for signs of:
- Median nerve compression (numbness/tingling in thumb, index, and long fingers)
- Excessive swelling
- Skin breakdown
- Pain that is unresponsive to appropriate analgesia
Patient Education
- Explain the expected recovery timeline (full return to activities typically at 3 months) 3
- Provide clear instructions on cast care
- Discuss warning signs that require immediate attention
By following this approach, the patient should achieve proper healing of the triquetral fracture with minimal complications and optimal functional recovery.