Guest Professor David Nelson Case 6

This is an intra-operative view of the radius. The volar comminution was much less than anticipated, and the rotated fragment seen on the xray was the small fragment seen at the bottom of the photograph.

The fracture was reduced by releasing the brachioradialis and the first extensor compartment, then pronating the radius out of the way. This allowed a direct reduction of the intraarticular component.

Fluoroscopic views showed that the reduction was actually fairly good. A volar plate* was placed. The two most proximal shaft screws were replaced with longer screws, for bicortical purchase. Note that the distal screws are a bit proximal, but a more distal plate placement would be a problem due to the under-reduction of the lunate facet. The screws are intentionally 2 to 4 mm short of the dorsal cortex. See notes on this site.)

The fracture reduced fairly easily, somewhat to my surprise. The reduction was not perfect, but was improved with pronating the radial shaft out of position and reducing the fragments against the carpus, using it as a template. Although the final reduction was not perfect (there is a mild step-off between the scaphoid and the lunate facets, and the lunate facet has a slight slope), it was felt that the reduction was adequate. Further manipulation might displace the fragments further, and if they could not be reduced, would necessitate the use of an external fixator. The current alignment was felt to be adequate for an 88 year old patient and would allow her to ambulate. An external fixator would probably not. This should not be considered age discrimination, but rather that "the enemy of good is better" and that one should keep the goals of treatment in mind. This patient just wants to walk, be independent, and get back to her assisted living facility. She is not playing active sports.

* The plate was an Orthofix Contours II. See disclaimer

Jump to Page: 1 2 3 4 5 6 7