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Three Part Question

In [patients with a dorsal chip fracture of the triquetrum] is a plaster cast, removeable splint or a bandage] better at providing [pain relief and functional recovery]?

Clinical Scenario

A 25 year old man attends the Emergency department having injured his right wrist by falling on his outstetched hand. Following clinical assessment X-Rays reveal an isolated dorsal chip fracture of the triquetrum. He is unwilling to be treated in a plaster cast and you wonder whether treatment in a removeable splint will be sufficient?

Search Strategy

Medline 1950 to present using OVID interface. (triquetrum.mp. AND fracture$.mp.) OR (exp triquetrum bone). The references cited by relevant papers were also checked and retrieved where they appeared to be releavant.

Search Outcome

The search revealed a total of 97 results. 2 papers were found to be relevant and a further 4 identified as a result of examining the citations of these papers

Comment(s)

The triquetrum is the second commonest carpal fracture after the scaphoid, and dorsal chip fractures are the commonest type of triquetral fracture (Hocker and Menshik, 1994). The fracture is thought to occur as a result of the chisel-like action of the ulnar styloid process in forceful wrist extension (Levy M, Fischel RE, Stern GM and Goldberg I. Chip fractures of the os triquetrum. Journal of Bone and Joint Surgery 61-B, 355-357. 1979). The largest study (Hocker and Menshik, 1994) primarily studied radiological outcomes, and whilst other studies have mentioned clinical outcomes these have been based upon the authors' preferred methods of treatment and have not compared various treatment options. Further the assessment of clinical outcomes has been varied such that extrapolation between studies is not possible. Various treatment options such as plaster casts, elastic and leather splints, and crepe bandages are described. Bartone and Grieco (1956) suggested that the clinically more severe cases should be treated in plaster casts followed by splints and physiotherapy, whereas milder cases should be treated in supports, but this advice appears to represent the authors' preferences rather than being evidence based. Thompson (1933) implied a poor outcome as a result of insufficient splintage, Bonnin and Greening (1944) suggested that the outcome of those fractures initially mis-diagnosed as sprains is occasionally poor, but there have been no studies to investigate the effect of treatment, or type of treatment, on clinical outcome or complications. It would seem reasonable to conclude that the isolated dorsal chip fracture of the triquetrum can be treated symptomatically with a plaster cast being used for those patients with significant symptoms, and bandages / splints used in those individual cases where such treatments provide adequate support and pain relief. However further studies are required to both compare treatment types and also to investigate the effects of treatment on outcomes and future complications.

Clinical Bottom Line

The literature suggests that dorsal chip fractures of the triquetrum can probably be treated symptomatically with either a plaster cast or splint / bandage depending upon the individual patient's level of discomfort. However further studies are required to determine whether the method of treatment affects outcomes and complications.