David Nelson , MD Private Practice, San Francisco Webmaster, eRadius Associate Editor, J Hand Surgery Director, San Francisco Bay Area Hand Club

There were two issues.

The first issue is the size of the gap. The radiologist was hesitant to state a size of the gap and claimed that he had no basis for measuring the gap. He stated that the manufacturer did not claim any specific level of accuracy of the scans, there were no phantoms that could indicate the accuracy of the scans, and that he had no experimental basis for claiming any accuracy of the scans. (So much for relying on radiologists!)

Figure 5 a-c CT scans, coronal dorsal image on left, sagittal images on the ulnar side in the middle and right.

It appeared that the gap was probably on the order of 3 to 4 mm in size, based on the two selected views, above left. The image on the far right is through the ulnar cortex of the radius and probably represents a tangential view of the gap, and therefore overrepresents the true gap size. The dorsal fragment probably is at risk of further subsidence.

The angles on the plane films, both PA and lateral, as well as the radial length, are normal. There are no stepoffs seen in any views, either plain films or CT.

The gap size and risk of subsidence of the dorsal fragment, which would further increase the size of the gap, suggested that ORIF was appropriate.

The second issue was the patient's desire to return to work as soon as possible. She did not feel she could do her job in a cast. She asked about other options. One option would be an ORIF with a fixed angle volar plate, which would allow splinting for comfort for three days and then no immobilization at all. Light use of the arm would start as soon as pain would allow. Moderately forceful use would be allowed in three months and unlimited forceful use or traumatic use (contact sports) would be allowed in four months.

(8) Is there any indication for ORIF based on her desire to return to work early? Has the advent of the fixed angle volar plates changed your treatment of fractures that otherwise could be well treated in just a case? Does it vary by age?

(9) What would you recommend for treatment for this woman?

The case continues on the next page >>>

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