Lunotriquetral
Ligament Tear
Jacksonville, FL
Ulnar-sided wrist pain that worsens with gripping, twisting, or weight-bearing — and doesn't resolve with rest — is often a lunotriquetral ligament tear. Unlike scapholunate tears where waiting is an option, Dr. R. David Graham at JOI repairs LT ligament injuries early, before the carpus destabilizes further.
- LT ligament connects the lunate and triquetrum — ulnar carpal stabilizer
- Tear produces VISI deformity if untreated — progressive instability
- Dr. Graham repairs early — does not watch and wait
- Technique: direct repair + K-wire stabilization
- TFCC tear frequently coexists — assessed and addressed at same setting
- MRI arthrogram preferred for diagnosis confirmation
The LT ligament is the wrist's less-publicized partner to the scapholunate — tears here cause ulnar-sided pain and instability that is frequently misattributed to TFCC injury or ulnar styloid pathology until the ligament is specifically evaluated.
Understanding the Condition
The LT Ligament —
Ulnar Carpal Stability
The lunotriquetral (LT) ligament connects the lunate and triquetrum — the two ulnar-sided carpal bones that work together as a unit during wrist motion. When intact, the LT ligament keeps the lunate and triquetrum moving synchronously and prevents the lunate from flexing into a palmar-tilted position (VISI — volar intercalated segment instability).
LT tears most commonly occur from falls on an outstretched hand with the wrist extended and radially deviated, or from forced ulnar deviation injuries. They are frequently missed initially — the ulnar wrist is complex, and LT tears produce a symptom pattern that overlaps with TFCC tears, ECU tendinitis, and ulnar styloid pathology. The distinction matters because the treatment is different.
LT ligament tears are unstable injuries. Unlike some partial TFCC tears where a trial of injection and bracing is appropriate, an LT tear that is producing wrist instability warrants early surgical repair — before the carpus develops progressive malalignment that makes reconstruction more complex than primary repair would have been.
TFCC tears coexist with LT tears in a meaningful proportion of cases and are assessed and addressed at the same arthroscopic setting when present.
The LT ligament (gap between lunate and triquetrum) is torn — red. When disrupted, the lunate loses its ulnar support and can flex palmarly into VISI deformity (orange arrow). The scapholunate ligament on the radial side remains intact in isolated LT tears.
Ulnar Wrist Pain
Deep ulnar-sided wrist pain — at or just distal to the ulnar head, over the LT joint. Reproduced with palpation directly over the LT interval. Distinguished from ECU tendinitis (more dorsal, along the groove) and TFCC pain (more distal ulna/fovea).
Pain with Grip & Twisting
Gripping, twisting, and ulnar deviation load the LT joint and reproduce pain. Activities like opening jars, wringing a towel, or using a screwdriver are characteristically provocative. Weight-bearing through the wrist — pushups, rising from a chair — also loads the ulnar carpus.
LT Ballottement Test
The LT ballottement test — stabilizing the lunate while translating the triquetrum — reproduces pain and demonstrates abnormal laxity when positive. The Reagan test (shear stress across the LT joint) is similarly diagnostic. A positive test directs imaging to confirm the tear.
MRI Arthrogram for Diagnosis
Standard MRI misses LT tears — the ligament is small and the standard sequences are insufficient. MRI arthrogram, with contrast injected into the wrist joint, demonstrates dye extravasation through the LT tear. This is the preferred imaging study for suspected LT pathology.
Coexisting TFCC Tear
TFCC tears and LT tears frequently coexist — both are injured by the same ulnar-loading mechanisms. Patients with LT instability should have TFCC integrity specifically assessed on MRI arthrogram and arthroscopically. When both are present, both are addressed at the same surgical setting.
VISI on X-Ray (Advanced)
In established LT instability, lateral wrist radiographs may show VISI (volar intercalated segment instability) — the lunate flexed palmarly relative to the capitate and radius. The presence of VISI on plain X-ray indicates significant ligamentous disruption and makes early repair even more urgent.
Treatment
Early Repair — Not Watchful Waiting
LT ligament tears are unstable injuries. Early repair before carpal malalignment develops is more reliable than reconstruction after it has.
Why Dr. Graham Repairs LT Tears Early
Some wrist ligament injuries allow a trial of conservative management — splinting, injection, and observation to see if the ligament heals sufficiently. The LT ligament, in Dr. Graham's experience, is not reliably one of them when instability is present. The lunotriquetral joint is a pivot point for ulnar carpal mechanics; when the LT ligament is disrupted and the triquetrum is unsupported, the carpus tends to progress toward VISI rather than stabilize spontaneously.
The practical implication: a patient who presents with an acute LT tear and positive ballottement test is offered early surgical repair — not a 3-month splinting trial followed by repeat imaging to see if it got worse. Repairing a fresh tear with good tissue is technically straightforward. Reconstructing a carpus that has been in VISI for six months is significantly more demanding and produces less predictable results.
When TFCC pathology coexists — found at the time of wrist arthroscopy — it is addressed at the same setting. Both injuries are treated in a single operation.
Wrist Arthroscopy — Diagnostic & Therapeutic
Performed at Baptist Beaches Hospital or Horizon Surgery Center as a same-day outpatient procedure under regional block. Wrist arthroscopy is performed first — the LT tear is visualized and graded, and any coexisting TFCC pathology is identified and treated before proceeding to open repair.
Open LT Ligament Repair
Through a small ulnar dorsal incision, the LT joint is exposed and the torn ligament is freshened. The LT ligament is repaired using suture anchors placed in the lunate and triquetrum, reapproximating the torn ends to their anatomic footprints. The goal is restoration of the native ligament rather than reconstruction with a graft.
K-Wire Stabilization
After repair, the LT joint is held in its reduced position with percutaneous K-wires placed across the lunotriquetral interval. The K-wires protect the repair from the shear forces of wrist motion during the critical early healing period — allowing the repaired ligament to heal in proper anatomic alignment rather than under load. Wires are removed at 8–10 weeks in the office.
Cast & Immobilization
A short-arm cast is applied postoperatively, maintaining the wrist in neutral position. The cast protects both the ligament repair and the K-wire fixation. Cast immobilization continues until K-wire removal at 8–10 weeks, at which point a removable splint and formal hand therapy begin.
Recovery
After LT Ligament Repair
Cast & K-Wires
Short-arm cast protecting repair and K-wire fixation. Finger motion encouraged throughout. K-wires removed in office at 8–10 weeks under local anesthesia — no OR needed.
Motion & Early Therapy
Removable splint replaces cast. Formal hand therapy begins — progressive wrist range of motion and forearm rotation. Strengthening deferred until motion goals are achieved.
Strengthening
Progressive grip and wrist strengthening through formal therapy. Return to light manual work. Activities that load the ulnar wrist are advanced gradually as strength returns.
Full Return
Return to heavy manual labor and full activity at 6–9 months. Wrist radiographs confirm LT alignment maintained. In Dr. Graham's experience, patients who repair early have significantly better outcomes than those with established VISI.
“Very personable, makes you feel very comfortable and addresses all concerns or questions. Highly recommend DR Graham.”
Common Questions
Frequently Asked Questions
Related Conditions
Also Treated by Dr. Graham
Next Steps
Ulnar wrist pain after a
fall deserves early evaluation.
In Dr. Graham's experience, LT tears are frequently dismissed as sprains — and the window for straightforward repair narrows as carpal malalignment develops. Ulnar wrist pain with instability, clicking, or weakness of grip after a twisting or fall injury should be specifically evaluated for LT pathology. The MRI arthrogram is the key imaging study; a standard MRI is insufficient.
Jacksonville Beach, FL 32250
No imaging required to be seen. Walk-ins welcome via JOI Now, Monday–Friday.