Triquetral Fracture Management
Most triquetral fractures should be treated conservatively with short-arm cast immobilization for 3 weeks, as this approach has proven successful with excellent outcomes and no indication for surgical intervention in the vast majority of cases.
Classification and Fracture Types
Triquetral fractures comprise 15-18% of all carpal bone fractures, making the triquetrum the second most commonly fractured carpal bone 1. There are three main types:
- Dorsal cortical (chip) fractures: Most common and typically benign 1
- Triquetral body fractures: Less common, involving the main body of the bone 1
- Volar cortical fractures: Least common and potentially more problematic 1
Mechanism of Injury
The dorsal chip fracture occurs through a chisel-like mechanism where the dorsoproximal edge of the hamate strikes against the triquetrum during forced wrist extension and ulnar deviation 2, 3. This typically occurs after a fall on an outstretched hand 1.
Conservative Management (First-Line Treatment)
Immobilization in a short-arm cast for 3 weeks is the standard treatment 2, 3. Key points include:
- Bone fragment healing typically requires 6-8 weeks if union occurs 2, 3
- This conservative approach has proven successful with good outcomes 2
- Complete resolution of pain and excellent wrist function can be expected 4
- After immobilization, progressive return to wrist motion and strengthening for an additional 5 weeks is recommended 4
When to Consider Surgical Treatment
Surgery is indicated only for fractures with significant displacement or evidence of instability 1. Specific indications include:
- Symptomatic nonunions causing considerable pain and disability 5
- Fractures with significant displacement 1
- Evidence of carpal instability 1
Surgical options when needed include open reduction internal fixation with or without grafting, or excision of ununited fragments 5.
Important Clinical Considerations
Post-traumatic instability of the wrist joint does not occur with proper conservative management 2, 3. Additional reassuring factors:
- Good vascularization of the triquetrum excludes the possibility of avascular necrosis 2, 3
- All body fractures of the triquetrum result in osseous consolidation with appropriate treatment 2, 3
Potential Complications to Monitor
While uncommon with proper treatment, be aware of:
- Non-union (rare but can be symptomatic) 1, 5
- Triangular fibrocartilage complex injury (associated injury) 1
- Pisotriquetral arthritis (late complication) 1, 4
- Intra-articular fractures within the pisotriquetral joint may be associated with dorsal carpal ligament tears, pisiform subluxation, or FCU dislocation 4
Diagnostic Pitfalls
Triquetral fractures are frequently missed or delayed in diagnosis 4. Ensure proper imaging: