Lunotriquetral Ligament Injury

Other Names

• Lunotriquetral instability
• LT ligament injury
• LT ligament tear
• Lunotriquetral ligament tear
• Lunotriquetral sprain
• Lunotriquetral dissociation
• LT dissociation
• Lunotriquetral interosseous ligament injury
• LTIL injury
• Ulnar-sided carpal instability

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Background

• This page refers to injuries to the the Lunotriquetral Ligament, which secures the relationship between the Lunate and Triquetral

History

• The earliest reported case of a lunotriquetral injury was documented in the medical literature in 1903
• Reagan published first formal clinical description of lunotriquetral pathology in 1984

Epidemiology

• Epidemiology is very limited, mostly to case reports and case series
• Between 2.2 and 9.9% of distal radius fractures have LTIL injuries
• The average patient is young, male

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Introduction

Lunotriquetral Instability

Plain radiograph of acute lunotriquetral (LT) tear with disruption of Gillula arcs (arrow).

Illustration of the Lunotriquetral Ligament

A 14-year-old boy fell off a skateboard and complained of wrist pain and numbness in his radial fingers. He was diagnosed with a displaced scaphoid fracture. (A) PA radiograph shows scaphoid fracture (black arrow), loss of alignment at the capitolunate joint (black dots) with radial translation of the capitate, a triquetral fracture (horizontal white arrow) with widening of the LT joint (vertical white arrow) compared with the SL joint, and a widening of the triquetrohamate joint (∗). This transscaphoid, transtriquetral greater arc perilunate dislocation was not appreciated by the referring physician. (B) On the lateral radiograph, note that the lunate is located in its radial fossa (black arrows) with dorsal dislocation of the capitate (white arrow) and a triquetral fracture fragment (black dot). (C) The patient underwent carpal tunnel release followed by dorsal approach. Operative photograph showing dorsal carpus exposed between the dorsal intercarpal ligament and dorsal radiotriquetral ligaments. Capitate head should not be visible if it is reduced in the lunate distal articular surface. (D) Postoperative PA radiograph showing reduction of the carpal bones, fixation of scaphoid using a cannulated headless bone screw and pinning of the LT joint. E. Lateral radiograph with restoration of radius, lunate, capitate, and third metacarpal alignment (black dots).

General

• Lunotriquetral ligament injury represents a spectrum of pathology ranging from partial ligament tears to complete dissociation
• Patients present with ulnar sided wrist pain, weakness, limited ROM and "click"
• Diagnosis can be challenging as more subtle injuries are often occult
• Treatment is variable depending on severity, chronicity and degree of instability

Mechanism of Injury

• Typically involves a fall on a hyperextended wrist that is radially deviated, flexed, and pronated
• Forced wrist extension
  • Most commonly reported mechanism in clinical series
  • Reflects the biomechanical stress placed on the ulnar side of the carpus
  • Frequently occur during sports activities in young patients
• Alternative mechanisms
  • Chronic attenuation related to ulnar impaction syndrome
  • Part of perilunate or reverse perilunate trauma patterns

Terminology

• Lunotriquetral Ligament Injury: describes damage to the lunotriquetral interosseous ligament, including sprains and tears
• Lunotriquetral Sprain: stretch injury of the lunotriquetral ligament
• Lunotriquetral Ligament Tear: partial/complete rupture of the lunotriquetral ligament
• Lunotriquetral Instability: abnormal motion between the lunate and triquetrum caused by ligament insufficiency
• Dynamic Lunotriquetral Instability: Instability present only during wrist motion or stress but not visible on resting imaging
• Static Lunotriquetral Instability: Persistent malalignment between the lunate and triquetrum visible on standard radiographs
• Lunotriquetral Dissociation: Severe separation of the lunate and triquetrum due to complete ligament disruption
• Lunotriquetral Interosseous Ligament Injury (LTIL): specific term for injury to the intrinsic ligament connecting the lunate and triquetrum
• Volar Intercalated Segment Instability (VISI): carpal alignment deformity in which the lunate flexes volarly due to lunotriquetral ligament incompetence
• Ulnar-Sided Carpal Instability: General term for instability involving structures on the ulnar side of the wrist, including but not limited to the lunotriquetral joint

Associated Conditions

• Distal Radius Fractures
  • Major LTIL injuries (2.2%), minor (9.9%) of cases
  • More broadly, intercarpal ligament injuries occur in 1/3 of distal radius fractures
• Periluante Injuries
• Ulnar impaction Syndrome
  • Fequently associated with lunotriquetral pathology, with positive ulnar variance contributing to both conditions
  • Can exist as part of the ulnar impaction syndrome or independently
• TFCC Injury
• Other fractures
  • Carpometacarpal Fractures
  • Hamate Fracture
  • Volar Triquetral Avulsion Fractures
  • Scapholunate Ligament Tear

Anatomy of the Lunotriquetral Ligament

• Joins the lunate and triquetrum, stabilizing the lunotriquetral joint
• Along with the scapholunate ligament, stabilizes the proximal carpal row
• Composed of volar, dorsal and proximal components

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Risk Factors

• Unknown

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Differential Diagnosis

Differential Diagnosis Wrist Pain

• Fractures
  • Distal Radius Fracture
    • Bartons Fracture
    • Chauffers Fracture
    • Colles Fracture
    • Die-Punch Fracture
    • Radial Styloid Fracture
    • Smiths Fracture
  • Distal Ulna Fracture
  • Carpal Fractures
    • Scaphoid Fracture
    • Lunate Fracture
    • Triquetrum Fracture
    • Pisiform Fracture
    • Trapezium Fracture
    • Trapezoid Fracture
    • Capitate Fracture
    • Hamate Fracture
  • Essex Lopresti Fracture
• Dislocations
  • Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
  • Carpometacarpal Joint Dislocation
  • Distal Radioulnar Joint Dislocation
  • Lunate Dislocation
  • Perilunate Dislocation
• Instability & Degenerative
  • Scapholunate Instability
  • Lunotriquetral Instability
  • Scaphoid Nonunion Advanced Collapse
  • Distal Radial Ulnar Joint Instability
  • Kienbocks Disease
  • Dorsal Wrist Impingement
  • Carpal Instability
• Tendinopathies & Ligaments
  • De Quervain's Tenosynovitis
  • Intersection Syndrome
  • TFCC Injury
  • Wrist Tendinopathies
  • Extensor Carpi Ulnaris Tendinopathy
• Neuropathies
  • Carpal Tunnel Syndrome
  • Pronator Teres Syndrome
  • Anterior Interosseus Nerve Syndrome
  • Posterior Interosseus Nerve Syndrome
  • Guyon Canal Syndrome
  • Wartenbergs Syndrome
• Pediatric Considerations
  • Distal Radial Epiphysitis (Gymnast's Wrist)
  • Torus Fracture
• Arthropathies
  • Wrist Osteoarthritis
  • Scaphotrapeziotrapezoidal Joint Arthritis (STT Arthritis)
  • Rheumatoid Arthritis
  • Gout
• Cartilage
  • Osteochondral Defect
• Vascular
  • Hypothenar Hammer Syndrome
• Other
  • Ganglion Cyst of Wrist
  • Ulnar Impingement Syndrome
  • Infectious Tenosynovitis

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Clinical Features

Lunotriquetral Ballottement Test

History

• Most commonly involves forced wrist extension,
• Frequently occurring during falls while playing sports in young men
• specific position is often a radially deviated, flexed, and pronated wrist
• Pain localized to the ulnar side of the wrist
• Weakness and limitation in range of motion may also be present
• Many patients report a "click" or snap sensation with lateral wrist movements

Physical Exam: Physical Exam Wrist

• Point tenderness over the lunotriquetral joint is a consistent finding
• palpable snap over the lunotriquetral joint
• Joint laxity may be present
• Some patients may have associated dorsal subluxation of the ulnar head and supination of the carpus
• Grip strength can be reduced

Special Tests

• Kleinmans Shear Test: shearing force across LT joint
• Reagans Test: Applying opposing forces to lunate and triquetrum
• Lunotriquetral Compression Test: Apply ulnar sided compression to the triqeutrum

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Evaluation

Radiographic signs of lunotriquetral injury. (A) Left hand lateral radiograph of volar intercalated segmental instability (VISI) deformity secondary to chronic lunotriquetral insufficiency showing volar rotation of the lunate (red arrow). (B) Left hand frontal radiograph of VISI deformity secondary to chronic lunotriquetral insufficiency showing severe disruption of the carpal Gilula arcs (green arrows).

Normal appearances of the proximal/interosseous component of the lunotriquetral ligament (LTL) in the coronal plane. a Illustration and (b, c) (moving volar) coronal plane T2-weighted 3-T MR images in a 17-year-old girl demonstrate the normal LTL. Note the spectrum of normal intrinsic “clefts” of high T2 signal intensity depicted in the inset of the illustration, and demonstrated on MRI (arrowheads). This normal anatomical variation should not be confused with a partial tear

Radiographs

• Standard Radiographs Wrist
  • May be normal on initial evaluation
• Potential findings
  • Lateral view: Scapholunate angle < 30°, VISI deformity
  • AP: break in Gilulas Lines or the carpal alignment

MRI

• Most commonly used for diagnosing LTIL tears
  • Sensitivity is limited compared to scapholunate ligament evaluation
• 3T improves diagnostic performance compared to 1.5T MRI
  • Sensitivty reaches 860-82%, specificity 100%
• Negative predictive value is 75-95%

CT Arthrography

• Superior to MRI for LTIL evaluation
• Approximately 100% sensitivity, 80% specificity and overall 90% accuracy
• Outperforms MR and MR arthrography

MR Arthrography

• Reported sensitivity of 50-60% across studies
• Can produce false-positive results due to microperforations without true anatomic tears

Arthroscopy

• May be required if suspicion is high as radiographs can be normal

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Classification

• N/A

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Management

Illustration of lunotriquetral ligament reconstruction

General

• Guided by injury severity, chronicity, degree of instability, patient factors
• Ranges from conservative management to various surgical interventions
• Most injuries can be treated nonoperatively; surgery reserved for persistent symptoms or more severe injuries

Nonoperative

• Indications
  • Mild lunotriquetral instability
• Immobilization is useful for acute injuries when diagnosed early
  • Consider Cock Up Wrist Brace, Forearm Volar Splint
  • Typically 4-6 weeks for acute injury
• Corticosteroid Injection
• Activity modification
• Physical Therapy following the period of immobilization

Operative

• Indications
  • Acute instability
  • Chronic instability
  • Failure of conservative management
• Technique
  • Arthroscopic debridement
  • Capsulodesis
  • Repair or reconstruction of lunotriquetral ligament
  • Ulnar shortening osteotomy
  • Lunotriquetral arthrodesis

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Rehab and Return to Play

Lunotriquetral instability exercises

Lunotriquetral Ligament Injury Rehab

Rehabilitation: Conservative Management or Arthroscopic Debridement

• Phase 1: Protection (Weeks 0-2)
  • Immobilization in forearm-based wrist splint in neutral position
  • Edema control with elevation and compression
  • Active finger ROM exercises
  • Shoulder and elbow ROM exercises
• Phase 2: Early Mobilization (Weeks 2-4)
  • Discontinue immobilization
  • Begin active wrist ROM exercises (flexion, extension, radial/ulnar deviation)
  • Gentle passive ROM as tolerated
  • Light ADL activities avoiding heavy loading
  • Continue edema management
• Phase 3: Strengthening (Weeks 4-8)
  • Progressive grip strengthening exercises
  • Wrist isometric exercises in all planes
  • Proprioceptive retraining exercises
  • Gradual return to functional activities
  • Dart-throwing motion exercises for neuromuscular control
• Phase 4: Return to Activity (Weeks 8-12)
  • Progressive resistance training
  • Sport-specific or work-specific training
  • Unrestricted activities as tolerated

Rehabilitation: Arthroscopic Repair and Ligament Reconstruction

• Phase 1: Immobilization (Weeks 0-6)
  • Forearm-based thumb-spica splint or cast immobilization
  • K-wire fixation typically maintained for 6-8 weeks
  • Active finger, elbow, and shoulder ROM
  • Edema control
• Phase 2: Protected Mobilization (Weeks 6-10)
  • K-wire removal at 6-8 weeks
  • Transition to removable wrist splint
  • Begin gentle active ROM exercises
  • Avoid passive stretching
  • Light ADL activities with splint protection between exercises
• Phase 3: Active Mobilization (Weeks 10-14)
  • Discontinue splint use
  • Progress active ROM exercises
  • Begin gentle strengthening with putty, therapy bands
  • Proprioceptive training
  • Functional activity simulation
• Phase 4: Strengthening (Weeks 14-20)
  • Progressive resistance exercises
  • Grip strengthening to achieve >80% contralateral side
  • Wrist stabilization exercises
  • Sport-specific or work-specific training
• Phase 5: Return to Full Activity (Weeks 20-24)
  • Unrestricted activities as tolerated
  • Continue strengthening program
  • Gradual return to high-demand activities

Lunotriquetral Ligament Injury Rehab PDF

• Lunotriquetral Ligament Injury Wrist Exercises PDF

Return to Play

• Timeline by Treatment Type
  • Arthroscopic debridement: 8-12 weeks
  • Ligament repair/reconstruction: 20-24 weeks
  • Ulnar shortening osteotomy: 16-24 weeks
  • Lunotriquetral arthrodesis: 20-24 weeks
• Functional Criteria for Return
  • Strength: Grip strength ≥80% of contralateral side, target ≥90% for high-demand sports
  • Range of Motion: flexion-extension ≥80% of contralateral side, radial-ulnar deviation ≥80% of contralateral side
• Pain: Rest: 0/10, activities of daily living: ≤2/10, sport simulation: ≤3/10
• Function: no mechanical symptoms, sport-specific movements without compensation
• Sport-Specific Progression (4-6 weeks total)
  • Week 1-2: Individual skills at 50% intensity, no contact
  • Week 3-4: Advanced skills at 75% intensity, simulated game situations
  • Week 5: Full practice with limited contact at 100% intensity
  • Week 6: Unrestricted practice and competition
• Return-to-Work Timeline:
  • Light duty (desk work): 2-4 weeks (debridement); 8-12 weeks (repair)
  • Moderate duty (repetitive use): 6-8 weeks (debridement); 12-16 weeks (repair)
  • Heavy duty (manual labor): 8-12 weeks (debridement); 16-24 weeks (repair)

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Prognosis and Complications

VISI

Prognosis

• General
  • Varies significantly by injury severity and treatment approach
  • Outcomes generally improving over the past two decades due to advances in diagnostic and surgical techniques
  • Spectrum of injury can cause disabling pain and wrist dysfunction if not appropriately managed
• Surgical outcomes
  • Arthroscopic debridement demonstrates favorable outcomes with 85% of patients reporting symptom improvement at mean follow-up
  • Arthroscopic dorsal capsulodesis shows excellent functional recovery with 90% of patients returning to their original jobs
• Predictors of outcome
  • Chronicity: acute injuries respond better to conservative treatment when diagnosed early
  • Degree of instability: partial tears have better outcomes than complete dissociative injuries
  • Presence of ulnar impaction syndrome: responds well to ulnar shortening
  • Patient physical demands

Complications

• Arthrodesis specific complications
  • Nonunion occurs in up to 57% of cases
• Volar intercalated segmental instability (VISI)
• Reconstruction complications
  • Persistent postoperative pain (38%)
  • Residual disability
  • Need for salvage procedures (13%)

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See Also

• Forearm Pain (Main)
• Wrist Pain (Main)
• Hand and Wrist Anatomy (Main)
• Physical Exam Wrist

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