Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Triquetral Fractures

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Triquetral Fractures · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Welcome to Deep Dive Ortho. Today, we're getting
0:02
to grips with a really common yet, well, often
0:06
quite frustrating wrist injury, the trichetral
0:09
fracture. That's right. It might actually surprise
0:12
you just how prevalent these are. We're talking
0:14
the second most common carpal bone fracture.
0:18
Indeed. About 15 % to 18 % of all carpal fractures,
0:21
give or take. Which is significant. But despite
0:24
that, they're Let's face it, notoriously tricky
0:27
to diagnose, often just labeled a wrist sprain.
0:30
Exactly. Or if they're simply radiographically
0:32
occult, just don't show up on the initial x -rays.
0:35
So our aim today is to really give you a deep
0:38
understanding of these elusive injuries. We want
0:41
to look at the subtle diagnostic clues, the,
0:44
well, the surprisingly complex ways they happen.
0:47
Mechanisms, yes. Yeah. Which have evolved quite
0:49
a bit. And the latest thinking on management,
0:51
both conservative and surgical. We've got our
0:54
expert here to guide us through all this. Thank
0:56
you. It's great to be here. We're talking about
0:57
a small bone, the trichobrum, but one that plays
1:00
a really pivotal role in how the wrist works.
1:02
Can you just remind us where it sits anatomically?
1:05
Of course. So if you picture the wrist, the trichotrum
1:07
is this sort of wedge -shaped bone. It's in the
1:10
proximal carpal row over on the ulnar side, the
1:13
little finger side. OK. And its position is key.
1:16
It connects with several neighbors. The lunid
1:18
bone next to it, the pisiform sits right on top.
1:21
and the hamate is distal to it. Right. And it's
1:25
connection to the ulna. Ah, well that's interesting.
1:27
It doesn't directly touch the ulna. Instead,
1:30
it connects via the TFCC, the triangular fibrocartilage
1:32
complex. Disc. Precisely. Which acts as a crucial
1:37
shock absorber and stabilizer for that medial
1:39
side of the wrist. And another really important
1:42
point, its dorsum medial surface, the back, has
1:45
these two significant areas where ligaments attach.
1:48
strong ligaments. Ah okay so not just bone -on
1:51
-bone articulation but critical ligament anchor
1:53
points too. Exactly and that's why when the tricotrum
1:56
gets injured it's well it's really just the bone
1:59
itself the surrounding structures especially
2:01
those ligaments are often involved. It sort of
2:03
sets the scene for why these injuries can be
2:05
complex. That's a perfect setup. It immediately
2:08
tells us, we're not just dealing with a simple
2:10
chip. So let's dive into that complexity. How
2:13
do these fractures actually happen? There's been
2:15
quite a debate over the years, hasn't there?
2:17
Oh, absolutely. A real sort of historical back
2:21
and forth. It mainly centered around two competing
2:23
ideas, ligament avulsion versus impaction. Pull
2:26
versus push, essentially. You could put it like
2:28
that, yes. The traditional views were fairly
2:31
distinct. First, you had the ligament avulsion
2:33
theory. Right. This suggested that these fractures
2:36
particularly the common dorsal ones, happened
2:38
when a ligament attaching to the trichotrum was
2:41
pulled so hard, perhaps during a fall with the
2:44
wrist bent sharply forward and inwards, palmar
2:47
flexion and radial deviation, that the ligament
2:50
just pulled a fragment of bone off with it. Simple
2:53
tensile failure at the insertion site. Okay,
2:55
so a pulling mechanism. What was the alternative?
2:57
The alternative was the endocarpal impaction
3:00
theory. Garcia Elias, a well -known hand surgeon,
3:03
really detailed this. He proposed a chisel action.
3:05
Yes, the idea was that the ulnar styloid process,
3:09
that bony bump on the end of your ulna, acted
3:11
like a chisel. During forceful dorsiflexion,
3:14
bending the wrist back hard combined with ulnar
3:17
deviation towards the little finger. That classic
3:19
fall mechanism. Exactly. The styloid would supposedly
3:22
strike the dorsal aspect of the trichatrum and
3:25
chip a piece off. And this theory gained some
3:28
traction because some studies noted a slightly
3:30
longer ulnar styloid in these patients. They
3:33
measured the ulnar styloid process index, the
3:35
USPI. Right, I remember reading about that. I
3:37
mean USPI of about .29 was reported. That's the
3:42
figure often cited, suggesting a longer styloid
3:44
might predispose to this impaction. Then later,
3:48
Hucker and Menchik sort of expanded on this impaction
3:51
idea. How so? They suggested it wasn't maybe
3:53
just the ulnar styloid. They argued that the
3:56
edge of the hamat bone, the dorsoproximal edge,
3:58
could also act as a chisel against the trichatrum
4:01
in that same extended ulnar deviated position.
4:04
OK, so a similar impact mechanism, but potentially
4:07
from a different bony structure. So historically
4:09
it was pull versus impact, either from the ulna
4:11
or the hermit. That was the basic picture, yes.
4:14
But as often happens in medicine, things aren't
4:16
usually that simple, are they? What have newer
4:19
techniques, especially MRI, shown us? Has it
4:23
clarified things or, dare I say, made it even
4:26
muddier? Huh. Well, complex might be a better
4:28
word than muddy. But yes, you're absolutely right.
4:31
Modern MRI studies, like the one by Bess and
4:34
colleagues, have really peeled back the layers
4:37
here. OK. And their findings don't just tweak
4:40
the old theories. They, well, they challenge
4:42
some of the fundamental assumptions and show
4:44
it's often a much more mixed, multifactorial
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picture. How so? Let's take the ulnar styloid
4:49
impaction theory first. What did the MRI data
4:51
show there? Well, firstly, the average USPI they
4:54
found in their patients was 0 .21. Which is normal.
4:57
Exactly. Within the normal range. Yeah. Not consistently
5:00
high like the theory predicted. But here's the
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really interesting bit. The median USPI was actually
5:05
higher in patients whose injury story sounded
5:08
more like an avulsion 0 .27. Higher in the avulsion
5:10
group. Yes. Compared to those whose story suggested
5:14
impaction. where it was .20. So that directly
5:18
contradicts the simple idea that a long styloid
5:21
equals impaction fracture. It's clearly not that
5:23
straightforward. Okay, that's definitely counterintuitive.
5:26
What else did the MRI reveal about the ulnar
5:28
styloid's role? This is perhaps the most damning
5:32
evidence against the direct ulnar styloid chisel
5:34
idea. at least in the cases they studied. They
5:37
found no fracture or even bone marrow edema bone
5:40
bruising in the ulnar styloid process itself
5:43
in any of their patients with trichotral fractures.
5:46
None at all. None. And you'd really expect to
5:49
see some sign of trauma on the styloid if it
5:52
was directly hitting the trichotrum hard enough
5:54
to break it. That seems pretty conclusive for
5:56
those cases, doesn't it? It makes direct impaction
5:58
from the ulna seem unlikely as the sole cause.
6:01
It certainly makes it much less likely in those
6:02
instances, yes. However, The heme impaction theory
6:06
did get some support. Oh, OK. How? They did find
6:09
bone marodema in the hamat bone in nearly a quarter
6:12
of the patients, 23 .8%, which does suggest that
6:16
the hemo hitting the trichotrum, as Hucker and
6:18
Menchik proposed, could well be a contributing
6:21
factor in that extended ulnar deviated position.
6:24
So maybe the heme is the more common impactor
6:27
than the ulna. Okay, so the picture is shifting.
6:30
Less ulna, maybe more heme involvement in impaction.
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What else complicated the simple avulsion versus
6:35
impaction story? Well, they looked at specific
6:38
fracture patterns using the Gersi -Alias classification
6:41
we'll discuss later. He'd suggested type III
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fractures partially displaced at the distal end
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were likely evulsions. And Besse's group did
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find a lower mean USPI for these, .17, which
6:51
sort of fits. But crucially, they found this
6:54
type III pattern was significantly more common
6:56
in the group whose history suggested impaction.
6:59
Oh, right. So the pattern associated with a lower
7:01
USPI thought to be evulsion was actually more
7:04
common in the impaction group. Precisely. Yeah.
7:06
doesn't fit neatly into either box. It suggests
7:09
a real overlap, maybe a combination of forces
7:11
rather than one single mechanism defining the
7:14
fracture type. Okay, it sounds truly multifactorial.
7:17
And what about the ligaments in all this? Did
7:19
they find differences between the evulsion and
7:22
impaction groups there? This is probably the
7:24
most critical finding. Clinically speaking, they
7:27
found no significant difference in how often
7:29
associated ligaments were torn between the supposed
7:33
avulsion and impaction groups. Really? So regardless
7:36
of whether it looked more like a pull or a push
7:38
fracture? The surrounding ligaments were just
7:40
as likely to be injured. It strongly points towards
7:43
a complex combined injury mechanism where the
7:47
soft tissues nearly always take a hit, whatever
7:49
the primary force on the bone appears to be.
7:51
Wow. So the key takeaway is forget simple either.
7:55
It's a complex interplay and assume ligaments
7:57
are involved. That sums it up perfectly. It's
7:59
a dynamic event affecting the whole complex.
8:02
So if the mechanism is this complex, does that
8:05
translate into different types of tricatural
8:07
fractures? And more importantly, given what we've
8:09
just heard about ligaments, what associated injuries
8:12
should we really be looking for? Absolutely.
8:15
Yeah. Understanding the different fracture types
8:17
is key for management. For the common dorsal
8:19
cortical fractures, the Garcia -Elias system
8:21
is useful. It goes from type 1 Undisplaced. Just
8:25
a crack. Essentially, yes. Types 2 and 3 are
8:28
partially displaced, either proximally or distally.
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Type 4 is completely displaced. Type 5 means
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multiple fragments, more committed. And type
8:36
6 is a more significant vertical frontal fracture
8:39
involving the whole dorsal surface. Right. But
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beyond those dorsal ones, what are the main anatomical
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types? Broadly, we think of three main types.
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First, the dorsal cortical fractures we've been
8:49
discussing, they make up the vast majority, 93
8:52
to 95%. And also called benign. Historically,
8:55
yes, but maybe that's misleading given the ligament
8:58
issue. They typically happen from falls onto
9:01
an extended ulnar deviated wrist, the impaction
9:04
scenario. But they can also result from avulsion
9:07
of the dorsal radiotricotrol or scaphotricotrol
9:10
ligaments, particularly in wrist flexion with
9:12
radial deviation. So same fracture appearance.
9:16
Potentially different initiating force. Understood.
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What's the second type? Second are trichotral
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body fractures. These are less common, but generally
9:23
indicate higher energy trauma. More serious,
9:26
then? Definitely. Because they involve the main
9:28
structural part of the bone. You often see these
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alongside really significant wrist injuries,
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like peri -lunar fracture dislocations. Ah, right.
9:36
Part of a bigger picture. Exactly. A trichotral
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body fracture is found in something like 12 to
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25 percent of peri -lunar injuries. It's a red
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flag for major carpal disruption. The mechanism
9:46
is usually direct compression, axial loading,
9:49
or crush injuries. OK. And because they're central
9:52
in high energy, they're often associated with
9:54
a whole host of other problems. Lunar trichotrial
9:56
ligament tears, scaphoid fractures, distal radius
9:59
fractures. You have to look carefully for these
10:02
associated injuries. Missing them is bad news.
10:05
Absolutely. And the third type. The least common,
10:08
but potentially the most problematic for stability
10:10
are volar cortical fractures. On the palm side?
10:13
Yes. Usually caused by avulsion of the volar
10:16
ligaments, like the ulnotrichotrol or lunotrichotrol
10:19
ligament. Why are they more problematic? Because
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those volar ligaments are absolutely critical
10:24
for maintaining the alignments of the carpal
10:26
bones. Injuring them carries a much higher risk
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of leading to carpal instability, which can cause
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long -term pain and dysfunction if it's not picked
10:35
up and managed correctly. They need a high index
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of suspicion. So it really hammers home that
10:40
point about associated injuries. It's not just
10:42
the bone. And that best study you mentioned really
10:45
quantified this ligament issue, didn't it? It
10:47
really did. And the figures are, well, quite
10:50
sobering. They found that an incredible 95 .2
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% of patients with dorsal trichatrial fractures
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had at least one associated dorsal carpal ligament
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injury. 95%. 20 out of 21 patients. It essentially
11:03
means if you diagnose a dorsal trichatral fracture,
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you should assume there's significant ligament
11:08
damage until proven otherwise. That completely
11:10
changes the perspective from a simple fracture
11:12
or sprain? It absolutely should. The specific
11:15
breakdown is also revealing. Dorsal ulnortrichatral
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ligament tears were seen in 81%. Dorsal intercarpal
11:21
ligament tears in 76%. And dorsal radiocarpal
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ligament tears in about 67%. These ligaments
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are almost routinely injured alongside the bone.
11:31
Is there any correlation between where the bone
11:34
bruising is on MRI and which ligament is torn?
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Interestingly, no. They looked for that but found
11:40
no statistically significant link. Where the
11:43
bone marrow oedema was located didn't reliably
11:45
predict which specific ligament was injured.
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So you can't rely on the bone oedema pattern
11:49
to guide you on the ligaments? Not reliably,
11:51
no. The implication is clear. High suspicion
11:54
of ligament injury is warranted in nearly all
11:56
cases, irrespective of the precise edema pattern
11:59
on the MRI. Okay, that 95 % figure is the one
12:01
I'll take away. Assume ligament injury. Now,
12:04
if we need to assess these ligaments, especially
12:06
with MRI, how well can we actually see them?
12:09
Are there imaging pitfalls we need to be aware
12:11
of? That's a very practical question. Generally,
12:13
3D gadolinium enhanced MRI using sequences like
12:16
VBE is pretty good. The best study identified
12:18
over 92 % of these ligaments in healthy controls.
12:21
So MRI is the tool. It's definitely our best
12:24
tool for soft tissues, yes. But, and it's important,
12:28
but visibility isn't perfect for all the ligaments.
12:31
Which ones are tricky? Well, the dorsal intercarpal
12:34
ligaments showed up very well. completely visible
12:36
in almost 97 % of cases. The dorsal radiocarpal
12:39
was also good, 80 % complete visibility. But
12:42
the dorsal ulno -tree control ligament was much
12:45
more challenging. It was only completely visible
12:47
in about 53 % of cases. And worryingly, it wasn't
12:51
seen at all in nearly a quarter. 23 .3 % of the
12:55
healthy controls. Not seen at all, even when
12:57
presumably intact. Exactly. So if you don't see
13:00
it clearly on the scan, you can't automatically
13:02
assume it's torn or absent. There might be technical
13:05
limitations. Why is that one harder to see? It's
13:08
likely due, at least in part, to something called
13:10
the magic angle artifact. Right, I've heard of
13:12
that. Because ligaments are ordered collagen
13:15
fibers, If they lie at roughly 55 degrees to
13:18
the main magnetic field of the MRI scanner, they
13:21
can produce an artificially high signal. Making
13:23
it look like a tear. Precisely. Or just making
13:26
it blurry. The dorsal ulnitricular ligament has
13:29
a curved path, and combined with the short echo
13:31
time, TE, used in some sequences, it's particularly
13:35
susceptible. So you have to interpret findings
13:38
relating to that specific ligament with a degree
13:41
of caution. Reported tear rates might be slightly
13:44
inflated due to this artifact. That's a really
13:46
crucial point for interpreting MRI reports. Combine
13:50
the imaging with the clinical picture and be
13:52
aware of potential artifacts. Absolutely. Clinical
13:54
correlation is paramount. Know the limitations
13:57
of the test. Which leads us perfectly into evaluation
14:00
and diagnosis. Given these challenges, occult
14:03
fractures, tricky ligaments. What should alert
14:05
us clinically? What's the typical presentation?
14:08
Well, the starting point is always that high
14:10
index of suspicion, especially with the right
14:12
history. Clinically, patients usually complain
14:14
of quite specific ulnar -sided wrist pain. Often,
14:17
yes. They might say it's worth with bending the
14:20
wrist, flexion, or extension. You often find
14:23
some swelling on the dorsal side. And the key
14:25
sign is usually localized tenderness right over
14:28
the dorsal aspect of the trichotrum. If you press
14:31
there, they'll likely jump. OK. And the history?
14:34
Typically, it involves excessive load or the
14:36
classic fall onto an outstretched hand injury,
14:39
often with the wrist extended and pushed towards
14:41
the little finger side, that ulnar deviation.
14:44
Right. Think of someone falling backwards. But
14:46
remember, the flexion radial deviation mechanism
14:49
can also occur. So keep an open mind. Some also
14:52
say wrist flexion can be more painful if it displaces
14:55
a dorsal fragment. Good tip. Now, the radiographic
14:58
challenges. You mentioned occult fractures. How
15:01
often are we talking? It's surprisingly often.
15:03
Some older studies suggested up to 80 % might
15:06
be missed on initial plane x -rays. 80%. That's
15:09
huge. It is. Even the best MRI study found 19
15:13
% were occult on the initial radiographs they
15:15
reviewed. It just highlights how insensitive
15:18
standard x -rays can be for these small, complexly
15:22
located bones. Compared to, say, a scaphoid fracture,
15:26
The combined sensitivity of clinical exam and
15:29
x -ray is often lower for the trichotrum. So
15:31
what x -ray views should we be ordering to maximize
15:34
our chances? You definitely need more than just
15:37
the standard PA and lateral, although the lateral
15:39
is often the most useful for seeing dorsal fragments
15:42
displaced posteriorly. Okay. You should also
15:44
get a 45 -degree pronated oblique view. This
15:48
can sometimes rotate the trichoderm out from
15:50
overlapping bones, and a radial deviation view
15:53
might help highlight volar fractures by tensioning
15:56
those ligaments. Any specific signs to look for?
15:58
There's the slightly amusingly named pooping
16:01
duck sign. The what now? The pooping duck. On
16:04
the lateral view, sometimes the trigger profile
16:06
looks a bit like a duck's head, and a dorsal
16:08
cortical fragment can look like it's, well, exiting
16:11
posteriorly. It's quite memorable. if you see
16:13
it. I'll definitely remember that one. But even
16:15
with these views, many are still missed. Yes,
16:18
a significant number. So the rule has to be,
16:21
if you strongly suspect a trichetral fracture
16:24
based on the clinical picture, but the x -rays
16:27
are normal or equivocal, you must pursue further
16:30
imaging. Which brings us to CT and MRI. If x
16:35
-rays aren't enough, what's the specific role
16:37
for each of these? When do you choose one over
16:39
the other? Excellent question. They both have
16:42
critical but slightly different roles. CT is
16:46
brilliant for bone detail. It's really the next
16:48
step if you suspect an occult fracture that X
16:51
-ray missed. better at seeing the fracture line.
16:53
Much better. The cross -sectional views cut through
16:56
the overlap issues. CT is also more accurate
16:59
for measuring the exact size and volume of any
17:01
fragments, which can be really important if you're
17:03
considering surgery deciding if a piece is big
17:05
enough to fix, for example. So high clinical
17:08
suspicion, negative x -ray CT for bone. That's
17:10
a very common and logical pathway, yes. But MRI
17:13
comes into its own, crucially, when you're worried
17:15
about instability or, as we've discussed extensively,
17:18
associated ligament injury. Which is almost always.
17:20
Which is in over 95 % of cases, according to
17:23
that best study. So MRI is often essential. It's
17:27
also useful if CT is negative, but you still
17:30
suspect an occult fracture, as MRI can pick up
17:33
bone marrow edema. the bruising, even before
17:36
a clear fractal line forms. And it shows the
17:38
soft tissues. Exactly. Ligaments, the TFCC, cartilage.
17:42
Given the high rate of ligament tears, you could
17:44
argue MRI is needed in most cases to get the
17:47
full picture and planned treatment probably to
17:50
avoid long -term problems like instability. So
17:52
it's not really an either with CT and MRI sometimes?
17:55
Often not. You might need both, depending on
17:57
the clinical question. CT for the bone detail,
18:00
MRI for the soft tissues, and subtle bone injury.
18:02
And don't forget to look at the other carpal
18:04
bones too. Best found edema in the hemat in nearly
18:07
24 % of cases and in other wrist bones in 19%.
18:11
It's often a wider injury pattern. Right, a comprehensive
18:14
assessment is key. Okay, let's say we've navigated
18:17
the diagnosis, we got the imaging, we know the
18:19
fracture type and any associated injuries. How
18:21
do we manage these? What's the first line approach
18:23
usually? For the majority, especially those undisplaced
18:26
or minimally displaced dorsal cortical fractures
18:29
without instability. non -displaced body fractures,
18:33
and stable volar fractures, non -operative management
18:36
is definitely the way to go. Good news for the
18:38
patient. Absolutely. The trichotrum generally
18:41
heals well thanks to a decent blood supply. The
18:44
mainstay is immobilization, usually for about
18:47
four to six weeks. How is that typically done?
18:49
Just a cast? It's usually phased. Yeah. Initially,
18:52
say for the first few weeks while things are
18:54
swollen and sore, a volar splint is often preferred.
18:57
wrist in slight extension. Oh, movable. Yes,
19:00
which allows for gentle range of motion exercises,
19:03
just wiggling fingers and thumb, and for hygiene.
19:06
Cold packs are also really helpful in this early
19:08
phase, especially the first 72 hours, to manage
19:10
that swelling and pain. Okay, split first, then
19:13
what? Once the initial swelling settles, maybe
19:15
around the 2 -4 week mark, depending on the case,
19:18
you might transition to a proper short arm cast
19:20
for more rigid support as healing progresses.
19:22
And after the cast comes off, usually around
19:24
four weeks, maybe slightly longer, you'd move
19:27
to a removable wrist splinter brace. This allows
19:30
for gradual increases in movement and starting
19:32
gentle strengthening exercises. The goal is regaining
19:36
mobility without stressing the healing site too
19:38
much. When can patients expect to get back to
19:41
normal activities? Weight -bearing activities
19:43
can usually be gradually resumed around eight
19:46
weeks post -injury, assuming things are progressing
19:48
well and pain allows. Full unrestricted activity
19:52
might take a bit longer. And the outcomes with
19:54
this conservative approach? Generally very good.
19:57
Most fractures manage this way heal well, often
20:00
with what's called a fibrous union. Not solid
20:03
bone. Not always solid bone, but strong fibrous
20:05
tissue connecting the fragments. And crucially,
20:07
this is usually completely asymptomatic. Patients
20:10
typically get significant pain relief and recover
20:13
good wrist motion, often within six to eight
20:15
weeks of starting treatment. So for most, surgery
20:18
isn't needed. That's very reassuring. But inevitably,
20:21
some cases do require surgery. What are the main
20:23
indications for going down the operative route?
20:26
Yes, surgery definitely has its place. The main
20:29
triggers are significant displacement of the
20:31
fracture fragments, clear evidence of carpal
20:34
instability, associated fracture dislocations
20:36
involving the trichotrum, or those relatively
20:40
rare cases of symptomatic non -union where conservative
20:43
treatment has failed and the patient still has
20:45
pain or mechanical issues. So instability and
20:49
significant displacement are key flags. Absolutely.
20:52
The goal of surgery is to put things back where
20:54
they belong, make the wrists stable, and optimize
20:57
long -term function. What surgical techniques
21:00
are typically used? It depends on the specifics,
21:03
of course. Open reduction internal fixation,
21:05
or ORAC -A, is common for displaced body fractures
21:08
or instability. So opening it up and fixing it.
21:11
Exactly. You make an incision, carefully reduce
21:13
the fragments back into place, and then fix them
21:15
internally. You might use small interfragmentary
21:17
screws to compress the fragments, or perhaps
21:20
K -wires, which are temporary pins. If ligaments
21:23
need repairing, you might use suture anchors
21:25
drilled into the bone. Right, like Herbert screws
21:27
for fracture dislocations. Herbert screws were
21:30
often used, yes, sometimes combined with K -wire
21:33
stabilization across the lunatric ritual joint
21:36
if needed. Okay, so... RIF is one option. Are
21:40
there others? Yes. Particularly for those problematic,
21:42
symptomatic non -unions. Especially if it's a
21:45
small fragment and not involving the joint surface.
21:47
Not articular. Precisely. In those cases, fragment
21:51
excision, just removing the troublesome little
21:53
piece, can be a very effective option. Just take
21:55
it out. Yes. Sometimes trying to fix a tiny chip
21:58
is more trouble than it's worth. There was a
22:00
case report of a young man with a tiny, painful
22:03
non -union, only about five millimeter. They
22:06
excised it. brief immobilization, and he became
22:09
pain -free. Others have reported success excising
22:12
slightly larger fragments, too. It's a good option
22:15
for selected cases. That makes sense for small,
22:17
non -articular, persistently painful fragments.
22:19
What about post -op? Still needs immobilization,
22:22
of course. Maybe six weeks in a cast, then a
22:24
brace, followed by rehab. Outcomes are generally
22:27
good. Maybe some slight loss of flexion or extension
22:30
compared to the other side. But usually satisfactory
22:32
function and pain relief. And crucially, You
22:35
have to address the associated injuries found
22:38
earlier. Absolutely vital. If the pisiform is
22:41
subloxed, you might need to excise it or fix
22:44
the trichotrum. If the lunotrichotral ligament
22:47
is unstable, it needs pinning or repair. Surgery
22:50
has to address the whole problem, not just the
22:53
trichotral fragment in isolation. It really highlights
22:56
that holistic diagnostic approach again. Okay,
22:59
so... After treatment, whether conservative or
23:02
surgical, what's the general outlook and what
23:04
potential complications should we be keeping
23:06
an eye out for long term? The overall outlook
23:08
is generally positive. As we said, functional
23:11
recovery is typically good to excellent for most
23:13
patients, even those with some associated ligament
23:16
issues provided they're managed correctly. People
23:18
often get back to good function relatively quickly.
23:20
That's good to hear. What about non -union? You
23:22
mentioned it's rare but can be symptomatic. Yes.
23:25
True non -union is uncommon, especially in body
23:28
fractures. Fibrous union is more frequent and
23:31
usually fine. But if a true non -union does occur
23:34
and becomes symptomatic, causing persistent pain
23:36
or clicking, that's when it can cause significant
23:39
disability and might need that surgical excision
23:42
or fixation we discussed. Okay. What other long
23:45
-term issues can crop up? Well, related to the
23:47
associated injuries mostly. TFCC injury is common,
23:50
especially with dorsal fractures. If it remains
23:53
symptomatic despite initial treatment, it might
23:55
need arthroscopic debridement or repair later
23:57
on. Right. Pizzotrich or periosaurosis arthritis
24:01
in the joint between the pisiform and trichotrum
24:03
can develop if the fracture went into that joint
24:05
or sometimes related to a nonunion there. If
24:08
that becomes painful, excising the pisiform can
24:10
be a good solution. Makes sense. And the big
24:13
one, though thankfully less common if things
24:15
are managed well initially, is persistent carpal
24:19
instability. This usually results from missed
24:22
or undertreated ligament injuries, especially
24:24
involving the lunotrichotrial ligament. It really
24:27
underlines why that initial thorough assessment
24:30
with advanced imaging is so incredibly important
24:33
to catch these instability patterns early. Absolutely.
24:36
Preventing that long -term instability seems
24:38
key. Well, this has been an incredibly thorough
24:42
exploration. We've really covered the ground
24:44
from presentation to long -term follow -up. We
24:46
have. It's clear that these fractures, despite
24:49
being common, are anything but simple. From understanding
24:52
the shift in thinking about mechanisms away from
24:54
simple, either to this complex, multifactorial
24:58
picture revealed by MRI, to appreciating that
25:02
staggering 95 % rate of associated ligament injuries,
25:05
it really changes the game. It really does. It
25:07
mandates that high index of suspicion and the
25:10
readiness to use advanced imaging like CT and
25:12
MRI, not just for the bone, but critically for
25:14
those soft tissues. It's about seeing the whole
25:17
wrist complex. Precisely. and then tailoring
25:20
the management, knowing that most do well with
25:22
straightforward immobilization, but also recognizing
25:25
the clear indications for surgery, like ORIF,
25:29
or even fragment excision when needed. This deep
25:32
dive has certainly illuminated a corner of wrist
25:34
trauma that deserves careful attention. It might
25:37
look like a small chip, but the implications
25:39
can be significant. Indeed. If you, listening,
25:42
found this deep dive valuable, please do consider
25:44
leaving us a rating or perhaps sharing it with
25:46
a colleague. And finally, a thought to take away
25:49
and perhaps ponder. Given everything we've discussed
25:51
about the extensive soft tissue attachments and
25:54
that near -universal ligament involvement, how
25:57
might future advances perhaps in dynamic imaging
25:59
techniques or maybe even intraoperative assessment
26:02
tools further refine our understanding of wrist
26:04
kinematics after these trick - How could that
26:08
ultimately help us improve long -term stability
26:10
and function for our patients even more?