Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture: six cases related to triangular fibrocartilage complex injury

Triquetral Fractures Overview

PURPOSE OF REVIEW

The triquetrum is the second most commonly fractured carpal bone, comprising 15-18% of all carpal bone fractures. This review summarizes the current knowledge of triquetral fractures, including the anatomy and pathophysiology, evaluation and diagnosis, treatment and management, post-treatment outcomes, and complications.

RECENT FINDINGS

Triquetral fractures are frequently caused by impaction of the ulnar wrist after a fall on an outstretched hand or by avulsion of attached ligaments. There are three main types of triquetral fractures: dorsal cortical fractures, triquetral body fractures, and volar cortical fractures. Dorsal cortical fractures are the most common and are usually benign, while volar cortical fractures are the least common and can be problematic. Nonsurgical management is indicated for most triquetral fractures, which usually results in good outcomes. Surgical treatment is indicated for fractures with significant displacement or evidence of instability. Complications of triquetral fractures include non-union, triangular fibrocartilage complex injury, and pisotriquetral arthritis. While less common than scaphoid fractures, triquetral fractures should remain in the differential diagnosis for patients with ulnar-sided wrist pain after falling on an outstretched hand. Most triquetral fractures can be treated with immobilization, though they should be thoroughly evaluated due to their potential to result in instability, loss of motion, and arthrosis. Further research is needed to determine the best method of surgical treatment.

Intra-articular Fracture of the Distal part of the Triquetrum within the Pisotriquetral Joint: Case Report and Review of Literature

Background

Intra-articular fractures of the distal part of the triquetrum within the pisotriquetral joint are uncommon, and can be associated with tears of the dorsal carpal ligaments, pisiform subluxation and/or FCU dislocation. Their diagnosis is difficult and requires a high clinical suspicion and a proper radiological examination including oblique wrist x-rays, computed tomography and MRI scan. These fractures can be delayed diagnosed due to late presentation thus leading to painful nonunion, persistent instability and late pisotriquetral arthritis.

Case Report

We present a case of a 40-year-old male who complained about ulnarsided wrist pain after a fall on his extended wrist during bicycling. The diagnosis of triquetrum fracture was suspected on clinical examination and confirmed using standard and oblique radiographs and CT scan evaluation. He was immobilized in a short-arm cast for 6 weeks followed by a progressive return to wrist motion and subsequent strengthening for another 5 weeks. He reported complete resolution of pain and excellent wrist motion and function one year after the injury, demonstrating a Mayo score of 100.

Conclusion

Isolated intra-articular fractures of the triquetrum within the pisotriquetral joint are rare injuries and may constitute a subcategory of body fractures other than the dorsal cortical (chip), main body and volar lip avulsion fractures. Early clinical suspicion and proper imagine can lead to a successful outcome.

Uncommon carpal fractures

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.

Assessment of dorsal instability of the ulnar head in the distal radioulnar joint: comparison between normal wrist joints and cases of ruptured extensor tendons

In the present study, the adaptability of the distal radioulnar joint (DRUJ) was evaluated using conventional computed tomography (CT) evaluation methods. In addition, we investigated/compared a new method to evaluate dorsal displacement of the ulnar head. Our subjects consisted of 32 healthy volunteers (64 wrists) and 11 patients (13 wrists) with extensor tendon injuries related to dorsal displacement of the ulnar head. To diagnose instability in the DRUJ based on CT scans, the radioulnar line method and the modified radioulnar line method were measured. Instability was evaluated by the new method that the ulnar head was located on the dorsal side from a line involving the peak of Lister's tubercle in parallel to this baseline was regarded as showing abnormal dorsal displacement of the ulnar head. The diagnostic accuracy of each method was calculated. The sensitivities, specificities, false-positive rates, positive predictive values and the negative predictive value of new methods were better than other two methods. The new method that we recommend is simple. Based on the results of this study, an evaluation of normal/abnormal dorsal displacement of the ulnar head in the DRUJ using the new method may be useful for determining the timing of surgery.

Anatomical transosseous fixation of the deep and superficial fibers of the radioulnar ligaments

INTRODUCTION

The triangular fibrocartilage complex is in conjunction with the interosseous membrane the most important stabilizer of the distal radioulnar joint. Lesions of the triangular fibrocartilage complex may cause instability of the distal radioulnar joint with serious consequences. Therefore, the goal is to reconstruct and provide stability to prevent further harm.

SURGICAL TECHNIQUE

Based on the anatomical configuration of the radioulnar ligaments, we present a technique which addresses both the deep and the superficial fibers of the radioulnar ligaments. This surgical procedure can be performed either openly or arthroscopically assisted. Two osseous 2-mm tunnels starting from the ulnar neck to the foveal surface are created. A nonabsorbable suture is passed through the tunnels and the triangular fibrocartilage using a 20-gauge venipuncture needle in order to attach the deep fibers. Then a third osseous tunnel starting from the lateral base of the styloid process to the medial aspect is created. The suture is passed through this tunnel and through the triangular fibrocartilage and around the styloid process palmarily using the same needle as before in order to anchor the superficial fibers anatomically. After reducing the ulna head the sutures are tightened.

CONCLUSION

This technique is quite simple and addresses the anatomical configuration of the radioulnar ligaments.

Midterm functional outcome after dorsal capsular imbrication for posttraumatic instability of the distal radioulnar joint

INTRODUCTION

The dorsal capsular imbrication of the distal radioulnar joint (DRUJ) which was performed because of posttraumatic dorsal instability showed promising functional results after the first postoperative years. Therefore, we hypothesized that patients after capsular imbrication are characterized by good subjective and functional outcome measurements after a midterm period.

MATERIALS AND METHODS

Eleven patients (range 21-50 years of age; median 35 years of age) were examined after capsular imbrication of the DRUJ because of posttraumatic instability with a mean follow-up time of 72 months (range 46-114 months; median 66 months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and functional outcome scores (modified Mayo wrist score (MMWS); Disabilities of the Arm, Shoulder and Hand questionnaire (DASH score)).

RESULTS

A mean DASH score of 6.7 (range 0-22.5) and mean MMWS of 91.8 (range 75-100) were measured. Grip strength reached 96.7 % of the contralateral hand. Range of motion reached at least 93.1 % of the contralateral hand. Eight of 11 patients regarded functional outcome and pain reduction as excellent. Six of 11 patients did not recognize a diagnosed instability of DRUJ as such. Ulnar-sided wrist pain was the apparent symptom in these cases.

CONCLUSIONS

Capsular imbrication of the DRUJ is a reliable and sufficient treatment option in case of posttraumatic dorsal instability. Since DRUJ instability is seldom recognized by the patients as such, a standardised diagnostic algorithm is mandatory to guarantee reliability and efficacy for identifying DRUJ instability.