High Yield Overview

TRIQUETRAL FRACTURES

Second Most Common Carpal Fracture | Dorsal Chip Pattern | FOOSH Mechanism

14-20%Of all carpal fractures

Dorsal ChipMost common pattern

FOOSHTypical mechanism

ConservativeMost treatment non-operative

TRIQUETRAL FRACTURE TYPES

Type I

PatternDorsal chip/avulsion fracture

TreatmentCast immobilization 4-6 weeks

Type II

PatternBody fracture

TreatmentCast, ORIF if displaced

Type III

PatternVolar avulsion fracture

TreatmentAssess for perilunate injury

Critical Must-Knows

Second most common carpal fracture after scaphoid
Dorsal chip fractures are 93% of all triquetral fractures
Best seen on lateral radiograph - dorsal cortex avulsion
FOOSH with ulnar deviation is typical mechanism
Excellent prognosis with conservative treatment for most

Examiner's Pearls

"
Always check lateral view - dorsal chip easily missed on PA
"
Hamate impaction on triquetrum causes dorsal chip
"
Body fractures may indicate perilunate spectrum injury
"
Most dorsal chip fractures heal uneventfully with casting

High-Yield Triquetral Fracture Exam Points

Second Most Common

Triquetral fractures are the second most common carpal fracture (14-20%), after scaphoid fractures. The dorsal chip pattern is by far the most frequent, accounting for over 90% of cases.

Lateral View Essential

Dorsal chip fractures are often missed on PA radiographs. The lateral view is essential - look for a small osseous fragment dorsal to the triquetrum. This is a common exam presentation.

Mechanism of Injury

Two mechanisms cause dorsal chips: 1) Hamate impaction - ulnar deviation drives hamate into triquetrum, avulsing dorsal cortex; 2) Ligament avulsion - strong radiotriquetral or lunotriquetral ligament pulls off bone.

Perilunate Association

Body fractures (not chips) may indicate greater arc perilunate injury. Always assess for carpal malalignment and associated injuries when body fracture is present.

At a Glance: Triquetral Fracture Management

Fracture Type	Frequency	Management	Key Consideration
Type I - Dorsal chip	Over 90%	Cast 4-6 weeks	Excellent prognosis, most common type
Type II - Body fracture	Under 10%	Cast, ORIF if displaced	Assess for perilunate injury
Type III - Volar avulsion	Rare	Address associated injury	Part of perilunate spectrum
Comminuted body	Very rare	Complex reconstruction	High energy, poor prognosis

Mnemonic

TRIQ - Triquetral Fracture Features

Type: mostly dorsal chip

Over 90% are dorsal avulsion fractures

Radiograph lateral

Lateral view essential - missed on PA

Impaction mechanism

Hamate impacts triquetrum with ulnar deviation

Quick healing

4-6 weeks casting, excellent prognosis

Memory Hook:TRIQ - dorsal chip fractures heal Quickly with conservative treatment

Mnemonic

CHIP - Dorsal Chip Features

Common fracture

Second most common carpal injury

Hamate impaction

Ulnar deviation drives hamate into triquetrum

Immobilize in cast

Short arm cast for 4-6 weeks

Prognosis excellent

Most heal without complication

Memory Hook:CHIP fractures have excellent Prognosis with simple Immobilization

Mnemonic

BODY - Body Fracture Red Flags

Beware perilunate

Body fractures may indicate greater arc injury

Overt displacement

Displaced fractures need ORIF

Dedicated CT scan

CT for surgical planning

Yield to surgery

Displaced body fractures require fixation

Memory Hook:BODY fractures Beware - may indicate perilunate injury

Mnemonic

LOOKLateral View Findings

Lateral X-ray best

AP misses dorsal chip

Over lunate

Fragment sits dorsal to lunate

Often small

Easy to miss if not looking

Keep checking Gilula arcs

Rule out perilunate

Memory Hook:LOOK at the lateral view - essential for dorsal chip fractures!

Overview and Epidemiology

Definition

Triquetral fractures are fractures of the triquetral (triquetrum) carpal bone, located on the ulnar side of the proximal carpal row. The most common pattern is a dorsal cortical avulsion (chip fracture), though body fractures also occur.

Epidemiology

Incidence: Second most common carpal fracture (14-20% of all carpal fractures)
First: Scaphoid fractures (70-80%)
Age distribution: Young to middle-aged adults
Gender: Male predominance
Mechanism: Usually FOOSH with ulnar deviation

Fracture Patterns

Dorsal Chip Fractures (Over 90%)

Small cortical avulsion from dorsal surface
Usually under 5mm in size
Best seen on lateral radiograph
Excellent prognosis with conservative treatment

Body Fractures (Under 10%)

Through substance of triquetrum
May be associated with perilunate injuries
Higher energy mechanism
May require surgical treatment

Volar Avulsion (Rare)

Usually associated with perilunate dislocation
Part of greater arc injury pattern
Requires assessment for carpal instability

Understanding triquetral anatomy and fracture patterns is essential for diagnosis and management.

Anatomy/Biomechanics

Osseous Anatomy

Shape and Configuration

Pyramidal shape: Triangular when viewed from ulnar aspect
Largest bone: Of the proximal carpal row by volume
Dorsal surface: Site of most common fracture pattern
Volar surface: Pisiform articulation

Articular Surfaces

Lunate (medial): Part of intercalated segment
Hamate (distal): Articulates with proximal hamate pole
Pisiform (volar): Small sesamoid articulation
TFCC (proximal): Through ulnocarpal complex

Surface Features

Dorsal ridge: Site of ligament attachments
Volar groove: Pisiform articulates here
Hamate facet: Distal articular surface

Blood Supply

Vascular Pattern

Multiple dorsal and volar nutrient vessels
No single dominant vessel (unlike lunate)
Lower risk of AVN than other carpals
Reliable healing potential

Vessel Entry Points

Dorsal surface: Primary blood supply
Volar surface: Secondary vessels
Non-articular surfaces: Additional supply

Biomechanics

Carpal Kinematics

Part of proximal row "intercalated segment"
Moves with scaphoid and lunate as functional unit
Limited independent motion
Ulnar border of proximal row

Load Transmission

Transmits force from ulnar carpus
Less load than radial side
Pisiform modifies force transmission
Hamate contact with ulnar deviation

Mechanism of Dorsal Chip

Two mechanisms produce dorsal chip fractures:

Hamate Impaction (Primary)

Wrist falls into extension and ulnar deviation
Hamate dorsal pole impacts triquetral dorsum
Shearing force avulses dorsal cortex

Ligamentous Avulsion

Strong radiotriquetral ligament pulls off bone
Lunotriquetral ligament may contribute
Traction injury rather than impaction

Both mechanisms produce similar fracture patterns.

Classification Systems

Anatomical Classification

The most practical classification based on fracture location:

Type I - Dorsal Cortical Fracture (Chip)

Over 90% of all triquetral fractures
Small dorsal cortical avulsion
Usually under 5mm fragment
Excellent prognosis
Treatment: Cast immobilization 4-6 weeks

Type II - Body Fracture

Through the body of triquetrum
Less than 10% of fractures
May indicate higher energy injury
Assess for associated injuries
Treatment: Cast if undisplaced, ORIF if displaced

Type III - Volar Avulsion

Rare isolated injury
Usually part of perilunate spectrum
Ligamentous origin (pisotriquetral, ulnotriquetral)
Treatment: Address associated carpal injury

Type IV - Comminuted Body

High-energy mechanism
Significant fragment displacement
Poor soft tissue envelope
Treatment: Complex reconstruction, may need external fixation

This classification guides treatment selection and prognosis.

Classification Summary

Type	Location	Frequency	Stability
Type I	Dorsal cortex	Over 90%	Stable
Type II	Body	Under 10%	Variable
Type III	Volar cortex	Rare	Usually part of perilunate
Type IV	Comminuted	Very rare	Unstable

Classification determines treatment approach and expected outcome.

Clinical Assessment

History

Mechanism of Injury

FOOSH: Fall onto outstretched hand with ulnar deviation
Direct blow: Rare, usually dorsum of wrist
Sports injury: Contact sports, ball sports
Motor vehicle accident: Dashboard injury

Key History Points

Exact mechanism and position of wrist
Energy of injury (height of fall, impact speed)
Immediate symptoms and swelling pattern
Prior wrist injuries or symptoms
Hand dominance and occupational demands

Physical Examination

Inspection

Swelling over ulnar wrist
May be subtle with dorsal chip fractures
Compare to contralateral side
Assess for skin integrity

Palpation

Triquetral tenderness: Over dorsal ulnar wrist
Anatomic snuffbox: Negative (rules out scaphoid)
DRUJ: Assess for associated injury
Pisiform: May have concomitant tenderness

Range of Motion

Limited by pain in acute setting
Ulnar deviation particularly painful
Assess forearm rotation (DRUJ involvement)

Neurovascular Assessment

Usually preserved
Check ulnar nerve function
Document baseline for comparison

Special Tests

Watson Test (Scaphoid Shift)

Should be negative
If positive, consider additional carpal injury

Ballottement Test

Lunotriquetral stability assessment
Compare to contralateral side
Positive = LT instability

Triquetral Shear Test

Direct pressure on triquetrum
Pain suggests triquetral pathology
Specific for triquetral injury

ECU Subluxation Test

Assess extensor carpi ulnaris
May have associated injury
Supinate and ulnar deviate wrist

Clinical examination guides imaging and treatment decisions.

Investigations

Plain Radiographs

Standard Views

PA view: May miss dorsal chip fractures
Lateral view: Essential - shows dorsal fragment
Oblique views: Additional perspective

Lateral View (Critical)

The lateral radiograph is essential for dorsal chip diagnosis:

Small osseous fragment dorsal to carpal silhouette
Usually located at level of triquetrum
May be overlooked if not specifically sought
Best identified with true lateral positioning

PA View Findings

Body fractures may be visible
Carpal alignment assessment
Scapholunate and lunotriquetral intervals
Often normal with isolated dorsal chip

Signs of Associated Injury

Scapholunate widening (SL injury)
LT overlap or widening
Carpal arc disruption
DISI or VISI pattern on lateral

CT Scanning

Indications

Suspected body fracture not clear on X-ray
Surgical planning for displaced fractures
Assessment of comminution
Evaluation for perilunate injury

Key CT Findings

Fracture line orientation
Fragment size and displacement
Articular involvement
Associated carpal injuries

MRI

Indications

Suspected ligamentous injury
Occult fracture not seen on X-ray/CT
LT ligament assessment
TFCC evaluation

Findings

Bone marrow edema in fracture
Ligament integrity assessment
Associated soft tissue injury

Bone Scan

Limited Role

Rarely needed
May detect occult fracture
Superseded by MRI for most indications

Investigations are summarized below.

Imaging Strategy for Triquetral Fractures

Modality	Primary Role	Key Advantage	Limitation
Lateral X-ray	Dorsal chip diagnosis	Quick, essential view	May miss body fractures
PA X-ray	Body fracture, alignment	Carpal assessment	Misses dorsal chips
CT scan	Surgical planning	Fracture detail	Radiation, cost
MRI	Ligament assessment	Soft tissue detail	Cost, availability

The lateral radiograph is the most important view for dorsal chip diagnosis.

Management Algorithm

Conservative Management

Indications

All dorsal chip fractures (Type I)
Undisplaced body fractures (Type II)
No carpal instability
Elderly or low-demand patients

Protocol for Dorsal Chip Fractures

Immobilization

Short arm cast or splint
Wrist in neutral position
Duration: 4-6 weeks
May use removable splint for compliant patients

Follow-Up

Week 2: Clinical review, comfort check
Week 4-6: Assess tenderness, repeat X-ray
Week 6: If non-tender, begin mobilization

Expected Outcomes

Excellent prognosis for dorsal chip fractures
Union in 4-6 weeks
Full function typically restored
Rare persistent symptoms

Symptomatic Non-Union

Occurs in minority of cases
Persistent dorsal wrist pain
May require fragment excision
Generally straightforward procedure

Conservative management is successful for the vast majority of triquetral fractures.

Most triquetral fractures are managed conservatively with excellent results.

Surgical Technique

Fragment Excision for Symptomatic Non-Union

Indications

Symptomatic dorsal chip non-union
Persistent pain after 3-6 months of conservative treatment
Confirmed by imaging as source of symptoms

Patient Positioning

Supine with arm table
Tourniquet on upper arm
Wrist pronated for dorsal access

Surgical Technique

Incision

Small longitudinal incision (2-3 cm)
Over dorsal ulnar wrist
Centered on palpable fragment if detectable

Exposure

Incise extensor retinaculum between EDM and ECU
Retract tendons appropriately
Identify dorsal chip fragment in capsule
Usually embedded in dorsal ligament complex

Excision

Carefully isolate fragment
Excise completely with curette or rongeur
Preserve as much ligament as possible
Debride any fibrous tissue
Check for additional fragments

Closure

Repair retinaculum loosely
Standard skin closure
Soft dressing and splint

Postoperative Care

Splint 1-2 weeks
Early ROM exercises
Full activity 4-6 weeks

Fragment excision is a straightforward procedure with excellent outcomes.

Surgical intervention is rarely needed but provides reliable outcomes when indicated.

Complications

Complications of Dorsal Chip Fractures

Symptomatic Non-Union

Most common complication
Occurs in 5-10% of dorsal chips
Persistent dorsal wrist pain
Treatment: Fragment excision with good results

Extensor Tendon Irritation

Fragment may abrade overlying tendons
EDC or EDM most commonly affected
Presents as tendon pain or snapping
Treatment: Fragment excision

Dorsal Wrist Impingement

Large fragment blocks extension
Mechanical symptoms with wrist motion
Treatment: Surgical excision

Complications of Body Fractures

Malunion

Rare with appropriate treatment
May alter carpal kinematics
Can lead to secondary arthritis

Nonunion

More common than with dorsal chips
May require bone grafting
Associated with inadequate immobilization

Post-Traumatic Arthritis

Uncommon with isolated triquetral fractures
More common with associated injuries
May require salvage procedures

Lunotriquetral Instability

Can develop after body fractures
LT ligament may be injured at time of fracture
Presents with ulnar wrist pain and clicking
Treatment: LT repair or fusion

Complications of Surgical Treatment

Wound Complications

Infection (rare)
Dehiscence
Scar sensitivity

Hardware Issues

Screw prominence
K-wire migration
May require removal

Tendon Injury

ECU or EDM at risk
Usually prevented with careful technique
Repair if identified intraoperatively

Complication Summary

Complication	Frequency	Prevention	Management
Symptomatic non-union	5-10% of chips	Adequate immobilization	Fragment excision
Tendon irritation	Rare	Complete excision	Remove fragment
LT instability	Rare with body Fx	Recognize at injury	Ligament repair/fusion
Arthritis	Rare	Anatomic reduction	Activity modification to fusion

Complications are uncommon, and outcomes are generally excellent.

Postoperative Care

Conservative Treatment Protocol

Immobilization Phase (0-6 Weeks)

Week 0-2

Short arm cast or thermoplastic splint
Wrist neutral position
Immediate finger motion
Elevate to reduce swelling

Week 2-4

Continue immobilization
May switch to removable splint if compliant
Begin gentle finger exercises if not already

Week 4-6

Clinical review
Assess tenderness over triquetrum
Radiograph to confirm position
If non-tender, may discontinue splint

Rehabilitation Phase (6-12 Weeks)

Week 6-8

Begin active wrist ROM
Avoid resisted activities
Progress as tolerated

Week 8-12

Progressive strengthening
Return to normal activities
Sport-specific training if applicable

Surgical Treatment Protocol

Immediate Postoperative (0-2 Weeks)

Volar splint
Wound care
Finger motion
Elevation

Early Mobility (2-6 Weeks)

Removable splint
Gentle wrist ROM
Avoid loading
Suture removal at 10-14 days

Progressive Loading (6-12 Weeks)

Discontinue splint
Progressive strengthening
K-wire removal at 6 weeks if applicable
Return to activities 8-12 weeks

Follow-Up Schedule

Timepoint	Conservative	Surgical
Week 2	Comfort check	Wound check
Week 6	X-ray, assess healing	X-ray, ROM
Week 12	Final if healed	Final if healed
As needed	Symptomatic review	Hardware concerns

Most patients achieve full recovery with straightforward rehabilitation.

Outcomes and Prognosis

Dorsal Chip Fractures

Healing Rate

Over 95% heal with conservative treatment
Union typically at 4-6 weeks
Fibrous union may be asymptomatic

Functional Outcomes

Excellent ROM recovery (95-100% of normal)
Full grip strength return
Return to previous activity level
High patient satisfaction

Symptomatic Non-Union Rate

5-10% develop symptoms
Persistent dorsal wrist pain
Easily treated with excision
Excellent results after excision

Body Fractures

Healing Rate

Good healing with appropriate treatment
Union at 6-8 weeks typical
Higher nonunion rate if inadequately treated

Functional Outcomes

Good outcomes with anatomic reduction
May have some residual stiffness
Depends on associated injuries
Return to previous activity in most

Associated Injury Impact

Perilunate spectrum injuries have worse prognosis
LT instability may persist
May require additional procedures

Prognostic Factors

Favorable Factors

Dorsal chip pattern
Isolated injury
Early treatment
Compliant patient

Unfavorable Factors

Body fracture with displacement
Associated perilunate injury
Delayed diagnosis
High-energy mechanism

Return to Activity

Conservative Treatment

Sedentary work: 1-2 weeks with splint
Light manual: 6-8 weeks
Heavy manual: 8-12 weeks
Contact sports: 8-12 weeks

Surgical Treatment

Similar timelines
May be slightly longer for body ORIF
Athlete return at 3-4 months

The prognosis for triquetral fractures is excellent overall.

Evidence Base

Level V

📚 Garcia-Elias M. Carpal Instabilities and Dislocations

Key Findings:

Triquetral fractures are second most common carpal fracture
Dorsal chip represents over 90% of cases
Lateral radiograph essential for diagnosis
Excellent prognosis with conservative treatment

Clinical Implication: The high prevalence and excellent prognosis of dorsal chip fractures means most triquetral injuries can be managed non-operatively.

Source: Green's Operative Hand Surgery, 8th ed

Level IV

📚 Hocker K et al. Chip Fractures of the Triquetrum

Key Findings:

Mechanism is hamate impaction or ligament avulsion
93% are dorsal chip fractures
Conservative treatment successful in vast majority
Fragment excision effective for symptomatic non-union

Clinical Implication: Understanding mechanism explains fracture pattern and guides the expectation that most heal with simple immobilization.

Source: J Hand Surg Eur 1994

Level IV

📚 Levy M et al. Fractures of the Triquetral Bone

Key Findings:

Body fractures may indicate perilunate injury
Displaced body fractures require ORIF
Associated carpal injuries determine prognosis
Isolated body fractures have good outcomes

Clinical Implication: Body fractures require careful assessment for associated injuries that may alter management.

Source: J Bone Joint Surg Br 1979

Level IV

📚 Whalen JL et al. Triquetral Fractures: Mechanism and Location

Key Findings:

Two mechanisms: impaction and avulsion
Lateral view critical for diagnosis
PA view may be normal with dorsal chip
Conservative treatment successful

Clinical Implication: Always obtain and carefully review lateral radiograph when triquetral fracture is suspected.

Source: J Hand Surg Am 1985

Level V

📚 Saunders WA. Triquetral Fractures and Nonunion

Key Findings:

Non-union occurs in minority of cases
Most non-unions are asymptomatic
Symptomatic non-union responds to excision
Excellent outcomes after fragment removal

Clinical Implication: Fragment excision for symptomatic non-union is a reliable procedure with predictably good outcomes.

Source: Hand Clin 2000

The evidence supports conservative management for most triquetral fractures with excellent expected outcomes.

Viva Scenarios

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Missed Triquetral Fracture

EXAMINER

"A 25-year-old man presents 2 weeks after a fall onto his hand. He has ongoing ulnar wrist pain. PA radiograph was reported as normal. How do you evaluate this patient?"

EXCEPTIONAL ANSWER

This is a common scenario where a triquetral fracture may have been missed on initial imaging. **Clinical Assessment:** I would take a detailed history of the mechanism - a fall onto an outstretched hand with ulnar deviation is the typical mechanism for triquetral fracture. I would examine for point tenderness over the triquetrum on the dorsal ulnar wrist, and perform a ballottement test to assess lunotriquetral stability. **Imaging Review:** The key issue here is that dorsal chip fractures of the triquetrum are frequently missed on PA radiographs. I would specifically request and review a lateral wrist radiograph. On the lateral view, I would look for a small osseous fragment dorsal to the carpus, at the level of the triquetrum. This is the characteristic appearance of a dorsal chip fracture. **Diagnosis:** If the lateral view confirms a dorsal chip fracture, this explains the ongoing symptoms. Dorsal chips are the most common pattern (over 90%) and are second only to scaphoid fractures in carpal fracture frequency. **Management:** For a dorsal chip fracture diagnosed at 2 weeks, I would recommend short arm cast immobilization for an additional 4 weeks (total 6 weeks from injury). The prognosis is excellent, with over 95% healing with conservative treatment. **Follow-Up:** I would review at 6 weeks. If still tender, I would continue immobilization and arrange follow-up imaging. If non-tender, mobilization can begin. I would counsel the patient that 5-10% develop symptomatic non-union, which can be effectively treated with fragment excision if needed.

KEY POINTS TO SCORE

Lateral view is essential - chips missed on PA

Second most common carpal fracture

Dorsal chip over 90% of triquetral fractures

Excellent prognosis with conservative treatment

COMMON TRAPS

✗Not obtaining or reviewing lateral radiograph

✗Assuming normal PA means no fracture

✗Missing associated carpal injuries

LIKELY FOLLOW-UPS

"How long would you immobilize this patient?"

"What would you do if there is persistent pain at 6 weeks?"

"How do you counsel about the risk of non-union?"

VIVA SCENARIOChallenging

Triquetral Body Fracture Assessment

EXAMINER

"A 30-year-old motorcyclist presents after a crash. X-rays show a displaced triquetral body fracture. How do you approach this injury?"

EXCEPTIONAL ANSWER

A triquetral body fracture from a high-energy mechanism requires careful assessment for associated injuries. **Initial Assessment:** First, I would ensure this patient has been assessed for other injuries given the mechanism. Motorcyclists commonly have multiple injuries. I would complete the trauma workup before focusing on the wrist. **Radiographic Analysis:** For the wrist specifically, I would carefully assess the radiographs for: - Carpal alignment on the PA view - looking for scapholunate or lunotriquetral widening - Gilula's arcs - any disruption suggests ligamentous injury - Lateral view - assessing for DISI or VISI pattern Triquetral body fractures may be part of a greater arc perilunate injury pattern, so I need to exclude this. **Advanced Imaging:** I would obtain a CT scan to characterize the fracture pattern, assess displacement, and evaluate for additional carpal injuries. If there is any concern for ligamentous injury, MRI would be helpful. **Classification:** This is a Type II triquetral fracture (body fracture). With displacement, it requires surgical fixation to restore anatomy and carpal stability. **Surgical Planning:** If the fracture is isolated and displaced, I would plan for ORIF through a dorsal approach. I would reduce the fracture anatomically and fix with a headless compression screw if bone stock permits, or K-wires for smaller fragments. **Associated Injuries:** If imaging reveals perilunate instability, I would address the entire carpal injury - typically with open reduction, ligament repair, and stabilization of the carpal bones. **Postoperative Care:** Splinting for 2 weeks, then protected ROM. K-wire removal at 6 weeks if used. Full activity at 3 months.

KEY POINTS TO SCORE

High-energy mechanism - assess for polytrauma

Body fractures may indicate perilunate injury

CT for surgical planning

ORIF for displaced body fractures

COMMON TRAPS

✗Not assessing for perilunate instability

✗Treating as isolated injury without full evaluation

✗Using conservative treatment for displaced body fracture

LIKELY FOLLOW-UPS

"What would you do if imaging reveals lunotriquetral widening?"

"What are the fixation options for body fractures?"

"How do you approach a perilunate injury pattern?"

VIVA SCENARIOStandard

Symptomatic Triquetral Non-Union

EXAMINER

"A patient returns 6 months after a triquetral dorsal chip fracture, still complaining of dorsal wrist pain with gripping. Radiographs confirm non-union. How do you manage this?"

EXCEPTIONAL ANSWER

This patient has developed symptomatic non-union of a triquetral dorsal chip fracture, which occurs in approximately 5-10% of cases. **Clinical Assessment:** I would confirm that the symptoms correlate with the fracture location by examining for point tenderness directly over the dorsal triquetrum. I would also assess for extensor tendon irritation, as the fragment may abrade the overlying EDM or EDC tendons. **Imaging:** The radiographs confirm the non-union. I would look at the fragment size and position. If there is any concern about body involvement or additional pathology, CT or MRI would be helpful, but is not usually necessary for a straightforward dorsal chip non-union. **Treatment Options:** The standard treatment for symptomatic dorsal chip non-union is surgical excision. This is a straightforward procedure with excellent outcomes. **Surgical Technique:** Through a small dorsal incision between the 4th and 5th extensor compartments, I would: 1. Incise the retinaculum, protecting EDM and ECU 2. Identify the fragment within the dorsal capsule 3. Excise the fragment completely 4. Debride any fibrous tissue 5. Close the retinaculum loosely **Postoperative Care:** - Soft dressing and splint for 1-2 weeks - Begin ROM immediately after splint removal - Return to full activity at 4-6 weeks **Expected Outcome:** Fragment excision for symptomatic non-union has excellent results. Over 95% of patients have complete pain relief and return to full function. I would counsel the patient that this is a reliable procedure with low complication risk and predictably good outcomes.

KEY POINTS TO SCORE

Symptomatic non-union in 5-10% of dorsal chips

Fragment excision is treatment of choice

Simple procedure with excellent outcomes

Quick recovery and return to function

COMMON TRAPS

✗Continuing prolonged conservative treatment for symptomatic non-union

✗Not confirming symptoms correlate with fragment

✗Missing extensor tendon involvement

LIKELY FOLLOW-UPS

"Can you describe the surgical approach for fragment excision?"

"What is the expected recovery timeline?"

"How would you manage an associated tendon injury?"

MCQ Practice Points

Fracture Frequency

Q: What is the second most common carpal fracture? A: Triquetral fractures are the second most common carpal fracture (14-20%), after scaphoid fractures which account for 70-80% of all carpal fractures.

Fracture Pattern

Q: What percentage of triquetral fractures are dorsal chip fractures? A: Over 90% of triquetral fractures are dorsal chip (cortical avulsion) fractures. Body fractures account for less than 10%.

Radiographic Diagnosis

Q: Which radiographic view is most important for diagnosing triquetral dorsal chip fractures? A: The lateral radiograph is essential. Dorsal chip fractures are frequently missed on PA views but clearly visible as a small osseous fragment dorsal to the carpus on the lateral.

Mechanism of Injury

Q: What is the primary mechanism causing triquetral dorsal chip fractures? A: Hamate impaction - when the wrist falls into extension and ulnar deviation, the hamate dorsal pole impacts the triquetral dorsum, avulsing a fragment of dorsal cortex.

Treatment Approach

Q: What is the standard treatment for an isolated triquetral dorsal chip fracture? A: Conservative management with short arm cast for 4-6 weeks. Over 95% heal with immobilization, and the prognosis is excellent.

Non-Union Management

Q: How should symptomatic non-union of a triquetral dorsal chip be treated? A: Surgical fragment excision through a dorsal approach. This is a straightforward procedure with excellent outcomes in over 95% of patients.

Understanding these key concepts will help with exam success.

Australian Context

Triquetral fractures are commonly encountered across Australian emergency departments and orthopaedic practices. The typical mechanism of a fall onto an outstretched hand occurs frequently in outdoor activities, sports, and occupational settings common in Australia.

The Australian orthopaedic community follows international evidence supporting conservative management for the vast majority of triquetral fractures. Short arm casting for 4-6 weeks is standard practice, with excellent outcomes expected.

Radiology departments throughout Australia are familiar with the importance of lateral radiographs for diagnosis. Digital imaging has improved detection of subtle dorsal chip fractures, though clinical awareness remains essential for appropriate imaging requests.

Surgical intervention for symptomatic non-union or displaced body fractures is available in both public and private settings. Hand surgery subspecialists manage complex cases, while general orthopaedic surgeons commonly perform fragment excision for symptomatic non-union.

Workers compensation pathways support appropriate treatment for occupationally-acquired triquetral injuries. The excellent prognosis and straightforward treatment mean most patients return to work within weeks of injury.