Prof. Dr. med. Ueli Beuchler Inselspital, Universitatsspital, Bern, Switzerland (case submitted June 22, 1999)

A 40 year-old merchant, otherwise healty and without prveious complaints regarding his upper extremities, sustained a distal radius fracture of his non-dominant left wrist in October 1997 while playing soccer. The fracture was of the A type of the AO classification and involved disruption of the DRUJ and an ulnar styloid avulsion. Initial non-operative treatment at an outside institution resulted in malunion with foreshortening of 4 mm, a dorsal tilting of 40°and a radial tilting of 12° of the radius plateau and nun-union of the ulnar styloid. In January 1998, an other hand surgeon performed a corrective osteotomy utilizing a bone graft and a T-plate which was removed in November 1998.

Figure 1a and 1b Symptomatic left wrist

Figure 2a and 2b Normal right wrist for comparison

The patient presents with a very painful snapping at the DRUJ and frank palmar dislocation of the ulna versus the radius when the forearm is supinated past 30° of supination. There is tenderness over the ulnar styloid process. The DRUJ is tender and moderately unstable, both passively and actively. Pronation/supination encompass 80°/70°. Radioulnocarpal functions are reasonable, but the ranges of motion are shifted to 50° of flexion and 105° of extension with normal radial/ulnar deviation values. Grip strehngth measures 60 pounds. Other clinical findings are normal.

Figure 3 axial CT scan

. Figure 3 depicts axial cuts through both DRUJ in pronation (top), neutral forearm rotation (middle) and supination (bottom). Radiographs of the elbow and the diaphyses are normal and not shown.

(1) What are your diagnoses?

(2) Can you help the patient with non-operative means?

(3) In case surgery was indicated, do you need additional information? Which one?

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