Giant Cell Tumor of the Triquetrum: Clinical Case and Literature Review.

Giant cell tumor (GCT) is a benign, locally aggressive neoplasm with little incidence at the carpal bone level. We present a case of pyramidal bone GCT that required open biopsy for diagnosis. As a definitive treatment, en bloc resection of the pyramidal bone and luno-capitate arthrodesis were performed to avoid frequent relapses of these neoplasms and ensure proper functionality of the anatomical segment.

The Intercalated Segment: Does the Triquetrum Move in Synchrony With the Lunate?

PURPOSE: To quantify the relative motion between the lunate and triquetrum during functional wrist movements and to examine the impact of wrist laxity on triquetral motion. METHODS: A digital database of wrist bone anatomy and carpal kinematics for 10 healthy volunteers in 10 different positions was used to study triquetral kinematics. The orientation of radiotriquetral (RT) and radiolunate rotation axes was compared during a variety of functional wrist movements, including radioulnar deviation (RUD) and flexion-extension (FE), and during a hammering task. The motion of the triquetrum relative to the radius during wrist RUD was compared with passive FE range of motion measurements (used as a surrogate measure for wrist laxity). RESULTS: The difference in the orientation of the radiolunate and RT rotation axes was less than 20° during most of the motions studied, except for radial deviation and for the first stage of the hammering task. During wrist RUD, the orientation of the RT rotation axis varied as a function of passive FE wrist range of motion. CONCLUSIONS: The suggestion that the lunate and triquetrum move together as an intercalated segment may be an oversimplification. We observed synchronous movement during some motions, but as the wrist entered RUD, the lunate and triquetrum no longer moved synchronously. These findings challenge the assumptions behind models describing the mechanical function of the carpals. CLINICAL RELEVANCE: Individual-specific differences in the amount of relative motion between the triquetrum and lunate may contribute to the variability in outcomes following lunotriquetral arthrodesis. Variation in triquetral motion patterns may also have an impact on the ability of the triquetrum to extend the lunate, affecting the development of carpal instability.

Posttraumatic Arthrosis and Triquetral Nonunion Associated With Pisotriquetral Subluxation in Adolescent Female Softball Players.

Impaction fracture subluxation of the pisotriquetral joint producing arthrosis and ulnar triquetral osteochondral nonunion is a cause for ulnar wrist pain in batting athletes. Two cases of adolescent female softball players managed successfully with pisiform and triquetral fragment excision are reported.

Surgical Management of Triquetral Osteoid Osteoma with Adjunct Tetracycline for Intraoperative Visualization: A Case Report.

CASE: We report the case of a 15-year-old male patient presenting with persistent wrist pain after surgical treatment of a triquetral osteoid osteoma. The patient was found to have a persistent nidus. These tumors are difficult to observe intraoperatively or through fluoroscopy, limiting adequate resection and resulting in continued pain. CONCLUSION: The nidus was excised successfully through an unusual technique using tetracycline for intraoperative identification. The patient remains asymptomatic without recurrence at 31 months postoperative. Difficulties visualizing and removing carpal lesions leading to recurrence are described.

Three-dimensional kinematics of the lunate, hamate, capitate and triquetrum with type 1 or 2 lunate morphology.

The purpose of this study was to investigate the differences in three-dimensional carpal kinematics between type 1 and 2 lunates. We studied 15 instances of wrist flexion to extension (nine type 1, six type 2), 13 of radial to ulnar deviation (seven type 1, six type 2), and 12 of dart-throwing motion (six each of type 1 and 2) in 25 normal participants based on imaging with computerized tomography. Mean proximal translation of the distal articular midpoint of the triquetrum relative to type 2 lunates during wrist radioulnar deviation was 2.9 mm (standard deviation (SD) 0.7), which was significantly greater than for type 1 lunates, 1.6 mm (SD 0.6). The hamate contacted the lunate in ulnar deviation and ulnar flexion of wrists with type 2 lunates but not with type 1. We conclude that the four-corner kinematics of the wrist joint are different between type 1 and 2 lunates.

Management of Pisotriquetral Instability.

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Joint Space Narrowing in Patients With Pisotriquetral Osteoarthritis.

BACKGROUND: Patients with suspected pisotriquetral osteoarthritis may show joint space narrowing. However, the extent of joint space narrowing and its deviation from the joint space width (JSW) in normal anatomy is unknown. In this pathoanatomic study, we therefore compared the JSW in the pisotriquetral joint between osteoarthritic patient wrists and healthy wrists. METHODS: We reviewed preoperative computed tomography (CT) scans of 8 wrists of patients with ulnar-sided wrist pain who underwent a pisiformectomy with confirmed pisotriquetral osteoarthritis at surgery. We also reviewed CT scans of 20 normal wrists from healthy volunteers serving as control group. Three-dimensional CT models of the pisiform and triquetrum were obtained from both affected and normal wrists, after which the minimum JSW was calculated in an automated fashion. RESULTS: In the patient group, the median (interquartile range) of the minimum JSW was 0.1 mm (0.0-0.2), and in the control group, 0.8 mm (0.3-0.9) ( P = .007). CONCLUSIONS: We showed that the pisotriquetral joint space in osteoarthritic patient wrists was significantly narrowed compared with healthy wrists. These results suggest that JSW evaluation has a potential diagnostic value in the work-up of patients with suspected pisotriquetral osteoarthritis. This is an interesting area for future clinical research, especially because no gold standard for diagnosing pisotriquetral osteoarthritis has been established yet.

Triquetrohamate Impaction Syndrome: An Unrecognized Cause of Ulnar-Sided Wrist Pain; Its Presentation Further Defined.

BACKGROUND: The aim of this review was to further define the clinical condition triquetrohamate (TH) impaction syndrome (THIS), an entity underreported and missed often. Its presentation, physical findings, and treatment are presented. METHODS: Between 2009 and 2014, 18 patients were diagnosed with THIS. The age, sex, hand involved, activity responsible for symptoms, and defining characteristics were recorded. The physical findings, along with ancillary studies, were reviewed. Delay in diagnosis and misdiagnoses were assessed. Treatment, either conservative or surgical, is presented. Follow-up outcomes are presented. RESULTS: There were 15 male and 3 females, average age of 42 years. Two-handed sports such as golf and baseball accounted for more than 60% of the cases, and these cases were the only ones that involved the lead nondominant hand, pain predominantly at impact. Delay in diagnosis averaged greater than 7 months, with triangular fibrocartilage (TFCC) and extensor carpi ulnaris (ECU) accounting for more than 50% of misdiagnoses. Physical findings of note included pain over the TH joint, worse with passive dorsiflexion and ulnar deviation. Radiographic findings are described. Instillation of lidocaine with the wrist in radial deviation under fluoroscopic imaging with relief of pain helped to confirm the diagnosis. Conservative treatment was successful in 9 of 18 patients (50%), whereas in the remaining, surgical intervention allowed approximately 80% return to full activities without limitation. CONCLUSION: Triquetrohamate impaction syndrome remains an underreported and often unrecognized cause of ulnar-sided wrist pain. In this report, the largest series to date, its presentation, defining characteristics, and treatment options are further elucidated.

Idiopathic bilateral lunate and triquetrum avascular necrosis: A case report.

We report on the case of bilateral avascular osteonecrosis (AVN) of the lunate and triquetrum in a 45-year-old woman without any relevant medical history for which the cause could not be established. She was treated conservatively with splinting and analgesics. The patient was able to pursue her work and hobbies with subnormal range of motion at 1-year follow-up. AVN of the triquetrum is very rare, as it is a richly vascularized bone. The presence of AVN in multiple carpal bones has only been described in patients receiving high doses of corticosteroids. To our knowledge, there are no other cases of idiopathic AVN of multiple carpal bones in the literature.

Isolated or predominant capitolunate osteoarthritis is the consequence of lunotriquetral dissociation. X-ray analysis of 22 consecutive cases.

Secondary osteoarthritis due to a scapholunate malalignment is well known, but is debatable in cases of lunotriquetral malalignment. It has been shown that lunotriquetral malalignment can lead to midcarpal osteoarthritis. The hypothesis of this retrospective study was that a relationship exists between the presence of midcarpal osteoarthritis and the presence of lunotriquetral malalignment. All patients with midcarpal osteoarthritis, isolated or predominant, treated between 1981 and 2013 were reviewed. Intracarpal angles were measured and the relative position of the carpal bones was analyzed by two examiners. Osteoarthritis of the wrist's joints was quantified in three stages. Diagnosis of static dissociative ligament lesion was made and correlated with the location of osteoarthritis. Twenty-two wrists in 20 patients (13 men and 7 women; mean age of 59 years) were included. The lunocapitate osteoarthritis was moderate in 6 cases and severe in 16 cases. The radioscaphoid osteoarthritis was moderate in 5 cases and severe in 1 case. Lunotriquetral malalignment was present in all cases; it was isolated in 8 cases and associated with scapholunate malalignment in 14 cases. In isolated lunotriquetral malalignment cases, midcarpal osteoarthritis was isolated or associated with degenerative lesions of lunotriquetral interval. Cases of perilunate instability in which the osteoarthritis is more severe in the midcarpal joint than in the radioscaphoid joint likely resulted from an injurying mechanism with ulnar beginning (ulnar-sided perilunate instability).

Three-Corner Arthrodesis With Scaphoid and Triquetrum Excision for Wrist Arthritis.

PURPOSE: To report the clinical and radiographic results of a consecutive series of patients who underwent the 3-corner arthrodesis (3CA) (arthrodesis of capitate, hamate, and lunate with scaphoid and triquetrum excision) procedure for wrist arthritis. METHODS: This was a retrospective study of 30 consecutive patients who underwent a 3CA between 1994 and 2008. The indications were painful wrist osteoarthritis due to stage 2 or 3 scapholunate advanced collapse, scaphoid nonunion advanced collapse, or scaphoid chondrocalcinosis advanced collapse wrists. The clinical assessment consisted of range of motion, grip strength, and the Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores. The radiographic assessment parameters consisted of bone fusion, carpal height and translation, lunate tilt, and appearance of the radiolunate joint space. RESULTS: The average follow-up was 6 years (± 4 years). The arthrodesis was performed with staples, 2 screws, or a plate and screws. Grip strength was 72% of the contralateral side. The mean range of motion in flexion-extension arc and ulnar-radial deviation arc was 70° and 36°, respectively. The mean Disabilities of the Arm, Shoulder, and Hand and the Patient-Rated Wrist Evaluation scores were 17 (± 11) and 22 (± 24), respectively. The fusion incidence was 90% (27 of 30). The mean difference of radiolunate angle on preoperative and postoperative radiographs was 8° (16°-8° in dorsal direction). The radiolunate joint space had narrowed in 1 patient. Six surgical revisions (20%) were necessary owing to dorsal pain in patients operated using plates, staples, or excessively long screws. CONCLUSIONS: Three-corner arthrodesis results are comparable with 4-corner arthrodesis and proximal row carpectomy. We feel that it is simpler technically than 4-corner arthrodesis. Although 3CA is more complex than proximal row carpectomy, it preserves the native radiolunate joint. Complications that can be attributed to the dorsal fixation hardware (particularly staples and plates) were noteworthy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluation for fracture patterns around the wrist on three-dimensional extremity computed tomography, especially focused on the triquetrum.

INTRODUCTION: To describe fracture patterns of triquetrum and analyse them according to fracture classifications, anatomy of intrinsic carpal ligaments and comparison with other wrist fractures. METHODS: We retrospectively reviewed 297 three-dimensional extremity computed tomographies (CTs) on wrist fractures from October 2007 to January 2012. We initially classified the fractures according to the involved bones and analyzed them according to the patterns of triquetrum fractures, associated carpal bone fractures and presence of combined distal radius fractures. We also correlated the fracture patterns with the patient's injury patterns. RESULTS: A total of 297 CTs and 291 patients were included (162 males and 129 females; mean age, 47.8 years). There were a total of 131 carpal bone fractures in 102 patients of 102 CTs. Triquetrum fractures were the most commonly observed cases (36 cases/27.5%). For the triquetrum fractures, the following types were observed: 26 dorsal, five volar, two comminuted fractures are observed in triquetrum. Three other triquetrum fractures show combined forms of other carpal bone fractures. For the combined distal radius fractures, 10 dorsal and two volar fractures were shown. Out of 187 distal radius fractures, 20 showed carpal bone fractures (10.7%). There were no differences in injury patterns according to the fracture patterns. The most common pattern of injury was falling on the outstretched hand, followed by fall from height. CONCLUSION: The dorsum of triquetrum is more frequently fractured than the volar aspect. The number of carpal bone fractures among the patients who have distal radius fractures is higher than usual expectation.

Carpal fractures.

Carpal fractures are exceedingly rare clinical entities and are often associated with concomitant injuries. In this review, we focus on fractures of the carpus, excluding the scaphoid, and provide an update on the current consensus as to mechanism, diagnosis, management, outcomes, and complications after such injuries.

A rare case of an isolated triquetrum body fracture in a 14-year-old boy.

Isolated carpal fractures are uncommon injuries usually caused by a fall on the outstretched hand. The patient might present with non-specific clinical signs and X-ray diagnosis might be difficult due to bone overlay. An isolated triquetrum body fracture is an absolute rarity. The treatment is easy and the outcome excellent but if missed, degenerative changes with chronic pain and impaired movement might be the consequence.

In vivo triquetrum-hamate kinematics through a simulated hammering task wrist motion.

BACKGROUND: The shape and kinematics of the triquetrum-hamate joint have been the subject of continued research, as its articulation provides wrist stability and motion. The purpose of this study was to measure the in vivo articulation of the triquetrum-hamate joint as the wrist moves along an important functional wrist motion, the dart thrower's path. METHODS: The right wrist of six male and six female volunteers (average age [and standard deviation], 24.8 ± 3.8 years) were imaged with computed tomography in five positions along a simulated hammering task. Three-dimensional kinematics of the third metacarpal, triquetrum, hamate, and radius were analyzed with use of the rotation axis and the path of contact areas. RESULTS: As the wrist ulnar-flexed with respect to the radius, the triquetrum translated 3.7 ± 1.7 mm distally on the hamate. Approximately midway through this distal course, when the triquetrum appeared to engage the distal ridge of the hamate, the triquetrum began translating volarly. Total volar translation was 2.6 ± 1.1 mm. As the wrist ulnar-flexed, there was also a decrease in the distance and variability in the location of the triquetrum-hamate rotation axis from the hamate centroid: it decreased from 11.7 ± 4.1 mm to 3.3 ± 1.4 mm (p < 0.0001). CONCLUSIONS: Our findings support the concept that the triquetrum rotates on the convex ellipsoid surface of the hamate and that the helicoidal description of the triquetrum's motion on the hamate may be an oversimplification.

Clinical outcomes of scaphoid and triquetral excision with capitolunate arthrodesis versus scaphoid excision and four-corner arthrodesis.

PURPOSE: To compare the clinical outcomes of scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) intercarpal arthrodesis. METHODS: We retrospectively identified 50 patients with scapholunate advanced collapse wrist changes who had 4-corner arthrodesis. Thirty-four patients were able to return and complete all follow-up evaluations. Patient demographics were similar between the 2 groups. Follow-up evaluation included radiographs, wrist range of motion (flexion-extension, radial-ulnar deviation, and pronation-supination); grip strength; visual analog scale (VAS); and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Complications of nonunion, hardware migration, conversion to wrist arthrodesis or arthroplasty, and pisotriquetral arthritis were recorded. RESULTS: Sixteen patients had capitolunate arthrodesis, and 18 patients had a 4-corner arthrodesis. There was no statistical difference in radial-ulnar deviation, pronation-supination, grip strength, VAS, or DASH scores between groups. There was a slight increase in flexion-extension in the 4-corner group. There were 2 nonunions in the 4-corner group and none in the capitolunate group. Five patients in the capitolunate group required screw removal secondary to migration. Three patients in the 4-corner group required a subsequent pisiform excision. CONCLUSIONS: Capitolunate arthrodesis compares favorably to 4-corner arthrodesis at an average 3-year follow-up in this series with respect to range of motion, grip strength, DASH scores, and VAS. Advantages of capitolunate arthrodesis include a lessened need for bone graft harvesting while maintaining a similarly low nonunion rate, easier reduction of the lunate following triquetral excision, and avoiding subsequent symptomatic pisotriquetral arthritis. Screw migration, however, remains a concern with this technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.