This article has Open Peer Review reports available.
Isolated displaced non-union of a triquetral body fracture: a case report
© Rasoli et al; licensee BioMed Central Ltd. 2012
Received: 23 August 2011
Accepted: 10 February 2012
Published: 10 February 2012
Fractures of the body of the triquetral bone are the second most common carpal fractures, and these fractures can be missed on plain X-ray. Although non-union of triquetral body fractures is very rare, such cases are associated with considerable morbidity and reduction in functional activity.
We report the case of a 29-year-old Caucasian British man who sustained an isolated displaced triquetral body fracture that resulted in non-union, who was treated surgically. We describe an original operative management for this debilitating injury. An open reduction and internal fixation using double headed compression screws was performed, without bone grafting, and with early immobilization of the wrist.
We propose this novel approach and advocate early clinical suspicion of triquetral body fractures in patients with a history of fall on an outstretched hand and ulnar sided wrist pain. We recommend evaluation using computed tomography or magnetic resonance imaging scanning.
Triquetral fractures are the second most common carpal fractures after fractures of the scaphoid. There are two broad types, those involving the dorsal aspect of the bone (chip fractures), and those involving the body. Triquetral body fractures are less common of the two, and these fractures can be associated with non-union. Although non-union of triquetral body fractures is rare, with only three cases described so far in the medical literature [1–3], they are associated with considerable morbidity and reduction in functional activities. These fractures can also be missed on plain X-rays .
We report a case of displaced isolated triquetral body fracture that resulted in non-union, treated successfully with open reduction and internal fixation using compression screws without bone grafting, and with early mobilization of the wrist. To the best of our knowledge, this scenario has not been previously described in the literature.
Although non-union of triquetral body fractures is rare, such cases can lead to considerable disability. After extensive systematic review of the literature, searching Embase, Medline, Cochrane, Cinhal, and Google search engines, we could identify only three previous reports of non-union of triquetral body fracture [1–3]. This low incidence could be attributed to the rich vascular supply of the triquetrum, which may explain the low risk of developing avascular necrosis in these fractures. Durbin  reported treating triquetral non-union with immobilization in plaster cast, which was unsuccessful and the patient remained symptomatic. Abboud et al. initially treated the non-union with cast immobilization, which did not respond, and subsequently carried out an open reduction and internal fixation using headless compression screws, with iliac bone autograft . Kawakami et al. also achieved successful bone reunion of the triquetral fragments with open reduction and internal fixation using headless compression screws and iliac bone graft .
In our patient, we carried out open reduction and internal fixation, but we did not use a bone graft. Kawakami et al. further treated their patient with eight weeks post-surgical immobilization . In our patient, we did not use post-surgical immobilization. In our patient the fracture was missed on radiograph and a diagnosis made by CT scan (Figure 3). A previous report found that only 20% of triquetral fractures were shown on radiographs .
Given the morbidity associated with non-union of triquetral body fractures we encourage a high index of suspicion for these fractures in people who have fallen on an outstretched hand with ulnar sided wrist pain. We recommend that patients with persistent ulnar sided pain and disability should be further investigated for this injury. CT and MRI have a high sensitivity in allowing visualization of both bony and soft tissue injury and morphology of the fracture to determine the need for early fixation and to reduce morbidity in this group of patients.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal
- Abboud JA, Beredjikilian PK, Bozenka DJ: Nonunion of a triquetral body fracture. A case report. J Bone Joint Surg Am. 2003, 85-A: 2441-2444.PubMedGoogle Scholar
- Durbin FC: Non-union of the triquetrum. J Bone Joint Surg Br. 1950, 32: 388-PubMedGoogle Scholar
- Kawakami Y, Fujioka H, Kurosaka M: Treatment of non-union of a triquetral body fracture. J Hand Surg Br. 2007, 32: 717-718.View ArticleGoogle Scholar
- Welling RD, Jacobson JA, Jamadar DA, Ching S, Caoili EM, Jebson PJ: MDCT and radiography of wrist fractures: radipgraphic sensitivity and fracture patterns. AJR Am J Roentgenol. 2008, 190: 10-16. 10.2214/AJR.07.2699.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.