My Wrist Tried to Quit on Me
Author: William Denq, MD, CAQ-SM and Tabitha Ford, MD
Peer-Reviewer and Final Editor: Alex Tomesch, MD, CAQ-SM
A 26 year old soccer player presents to the ED with ulnar sided wrist swelling and pain after sustaining a fall on an outstretched hand.
Image 1. Images courtesy of Jeffrey Daniels with permission.
What is the diagnosis?
Dorsal triquetral fracture (Image 2). This is a dorsal avulsion of the triquetrum that is commonly caused by a fall on an outstretched hand (FOOSH) with ulnar deviation. A direct blow to the dorsal wrist, although rarer, can also cause a triquetral fracture [1].
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Pearl: The triquetrum is the second most common carpal fracture. The first is the scaphoid [2].
What physical exam findings would you expect?
Swelling of the ulnar aspect of the dorsal wrist, point tenderness distal to ulnar styloid. Wrist flexion and extension will worsen the pain [3]. Radial flexion of the wrist can allow for palpation of the triquetrum (see Image 3).
Image 3. Radial flexion of the wrist can allow for identification of the triquetrum by palpation. Author’s own images.
What is your management in the ED?
Pain and swelling control is recommended while the patient is in the ED. A volar splint with the wrist in slight extension should be applied (see Image 4). Immobilization for 4-6 weeks will help with bony or fibrous union [5].
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Pearl: Displaced fractures >1-2 mm or those with ligamentous injury may require operative management.
Image 4. Demonstration of volar short arm splint. Illustrated by Tabitha Ford.
References:
[1] Höcker K, Menschik A. Chip fractures of the triquetrum. Mechanism, classification and results. J Hand Surg Br. 1994;19(5):584–8. https://doi.org/10.1016/0266-
[2] Suh N, Ek ET, Wolfe SW. Carpal Fractures. J Hand Surg Am. 2014;39(4):785–91. https://doi.org/10.1016/j.
[3] Christie BM, Michelotti BF. Fractures of the carpal bones. Clin Plast Surg. 2019;46(3):469–77. https://doi.org/10.1016/j.cps.
[4] Urch EY, Lee SK. Carpal fractures other than scaphoid. Clin Sports Med. 2015;34(1):51–67. https://doi.org/10.1016/j.csm.
[5] Guo, R.C., Cardenas, J.M. & Wu, C.H. Triquetral Fractures Overview. Curr Rev Musculoskelet Med 14, 101–106 (2021). https://doi.org/10.1007/
Extra info below:
Management:
-Dorsal cortex avulsion fracture (95% of triquetral fractures)
-Ulnar gutter splint and routine orthopedic referral within 1-2 weeks
-Typically nonoperative management
-Body fracture or volar avulsion fracture
-Ulnar gutter splint (Figure 3) or volar/dorsal short arm splint (Figure 4) and urgent orthopedic follow-up within 3 days
-Displaced fractures (>1-2mm) or those with ligamentous injury require operative management
Image 5. Demonstration of ulnar gutter splint. Illustrated by Tabitha Ford.
Image 6. Demonstration of volar short arm splint. Illustrated by Tabitha Ford.