Treatment of Triquetral Fractures
Most triquetral fractures should be treated conservatively with immobilization for 3 weeks, as this approach has proven successful with good functional outcomes and no indication for surgical intervention in the vast majority of cases. 1, 2
Classification and Treatment Algorithm
Triquetral fractures comprise 15-18% of all carpal bone fractures and fall into three main categories that guide treatment decisions 3:
Dorsal Cortical Fractures (Most Common)
- These fractures are benign and respond well to short-term splint or cast immobilization for 3 weeks 1, 2, 4
- The mechanism involves a chisel-like action of the dorsoproximal edge of the hamate striking the triquetrum during falls on an extended and ulnar-deviated wrist 1, 2
- Bony fragment healing occurs within 6-8 weeks if union is achieved 1, 2
- No surgical intervention is indicated for isolated dorsal chip fractures 1, 2
Triquetral Body Fractures
- Non-displaced body fractures require immobilization for 4-6 weeks 4
- All body fractures in follow-up studies resulted in osseous consolidation with conservative treatment 1, 2
- Displaced body fractures are very rare and typically result from perilunate instability, requiring open reduction, internal fixation, and ligament repair 4
Volar Cortical Fractures (Least Common)
- These are the most problematic type and require careful evaluation 3
- May be associated with pisotriquetral joint subluxation, necessitating advanced imaging 5
Diagnostic Evaluation
Obtain standard wrist radiographs initially, but maintain a high index of suspicion for associated injuries requiring CT or MRI 3, 5:
- Look specifically for pisiform subluxation on imaging 5
- Evaluate for triangular fibrocartilage complex (TFCC) injury 3
- Assess for lunotriquetral ligament disruption, particularly if static instability is present 4
Key Management Principles
Conservative treatment with 3 weeks of immobilization is the standard approach, with excellent outcomes and no risk of avascular necrosis due to good vascularization 1, 2:
- Post-traumatic wrist instability was not observed in conservative management cohorts 1, 2
- Surgical treatment is reserved exclusively for significantly displaced fractures or evidence of instability 3, 4
Indications for Surgical Intervention
Surgery is indicated only when:
- Significant displacement of body fractures is present 3
- Perilunate instability pattern exists, requiring ligament reconstruction and K-wire stabilization 4
- Associated pisiform subluxation requires open reduction and lag screw fixation 5
- Complete lunotriquetral ligament disruption with static instability is documented 4
Common Pitfalls to Avoid
Do not overlook associated injuries 3, 4, 5:
- Partial lunotriquetral ligament disruption with dynamic instability can be treated with immobilization alone, but complete disruption requires operative treatment 4
- TFCC injuries may complicate recovery 3
- Pisotriquetral arthritis can develop as a late complication 3
Do not assume surgical treatment is needed - the evidence strongly supports conservative management for the vast majority of triquetral fractures, with surgical intervention reserved for rare displaced body fractures or associated instability patterns 1, 2, 4.