Manual of Fracture Management

Je sse B Jupite r | Douglas A Cam pbe ll | Fie sky Nuñe z
Manual of Fracture Management

Wrist
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Wrist
Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z

Wrist
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IV Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
Fore word
Foreword
Thomas J Fischer, MD, FAOA, ASSH, AAOS, AOTK In th e spirit an d in n ovation th at ch aracterized th e ou n ders
Hand Expert Group o th e AO, th ese skilled su rgeon s h ave approach ed th is task
Clinical Associate Professor with a passion to per orm better an d to teach better in a world
Indiana University School of Medicine wh ere on lin e edu cation is th e n orm . Th ey h ave u sed th e
Department of OrthopedicSurgery written text as an an ch or an d plat orm to work rom an d go
Section Chief Hand Surgery back to in order to u n derstan d th e com plex repairs o th is
Ascension St Vincent, Indianapolis w on der u lly m ade join t. In reality, th e w rist is a series o
Indiana Hand to Shoulder Center m u ltiple join ts workin g in h arm on y to place ou r h an d in space.
8501 Harcourt Rd Th ey h ave broken down th e workin g com pon en ts an d th e
Indianapolis, IN 46260 com m on in ju ries to sh ow u s th e operative an d n on operative
USA treatm en t th at covers th e m u ltitu de o in tern al deran gem en ts
th at can occu r.
We are n ow in ou r 60th year o celebratin g th e su rgeon s th at Th ese su rgeon s are m y valu ed colleagu es an d I am h on ored
cam e be ore u s an d started a u n iqu e organ ization or “workin g th at th ey asked m e to set th e stage or th is Manual of Fracture
grou p” th e Arbeitsgem ein sch a t ü r Osteosyn th ese ragen , th e Management— Wrist. It is th e logical ou tgrowth o all th e learn in g
AO. Th e AO h ad at its core an organ ization al stru ctu re th at an d developm en t th at h as taken place sin ce th e rst develop-
worked to develop edu cation al program s, docu m en tation o m en t o volar platin g or sh earin g ractu res an d extern al
ractu re care, research , an d in stru m en tation to m ake th eir xation with pin xation or wildly m u lti ragm en ted ractu res.
prin ciples applicable to th e variety o ractu res. It covers th e “lay o th e lan d” qu ite well an d gives u s th e m ap
we n eed or li elon g learn in g in wrist trau m a care.
It was ou t o th is grou p a text was created, som e 30 years ago,
called th e Manual of Internal Fixation. Th is was th e con sen su s
an d widely con sidered tech n ical m an u al o its tim e in devel-
opin g tech n iqu es or ractu re xation . It provided a ram ework
or su rgeon s to approach broken bon es an d disru pted join ts.
It provided th e in tegration o th ou gh t to per orm th e docu -
m en tation , in stru m en tation , an d edu cation o su rgeon s arou n d
th e world, th u s u l llin g th e aim s o th e organ ization .
Now several decades an d th ou san ds o operation s later we

n d ou rselves im m ersed in a m ou n tain o im plan ts with
h igh ly adapted tech n iqu es th at ocu s n ely on a u n iqu e piece
o h u m an real estate, th e wrist.
Drs Cam pbell, Ju piter, an d Nu n ez, th ree li elon g su rgeon

edu cators, h ave tackled th is n ely ocu sed application o th e
prin ciples o ractu re care an d h ave given u s a well-docu m en ted
an d organ ized text. Th e text lin ks electron ic m edia with th e
written word to organ ize th e su rgical approach es to prim ary
ractu re m an agem en t an d clearly docu m en ts th e eviden ce
th at h elps u s ch oose ou r su rgical m eth ods an d ou r su rgical
im plan ts. Bu t th eir work does n ot stop with th e prim ary care
o th e ractu re. Th e book’s h ybrid approach to diagram s, case
presen tation s, an d eviden ce-based decision m akin g can also
be applied to th e described com plication s an d posttrau m atic
con dition s th at plagu e ou r patien ts.
V
Pre face
Preface
A con siderably greater u n derstan din g o trau m atic an d som e ascin atin g clin ical cases in volvin g severe m u lti rag-
recon stru ctive problem s abou t th e wrist led u s to th e decision m en tation an d de orm ity. Th e n al section provides th e
to revise th e in itial AO Manual of Hand and Wrist in to two reader w ith illu strated cases o variou s recon stru ctive prob-
distin ct texts. Followin g com pletion an d pu blication o th e 2 n d lem s in clu din g n on u n ion an d m alu n ion s o th e distal radiu s
edition o th e h an d ractu res volu m e (n ow titled Manual of as w ell as posttrau m atic con dition s o th e radiocarpal an d
Fracture Management— Hand) in 2016, we n ow o er you th e in tercarpal join ts.
n ew an d expan ded Manual of Fracture Management— Wrist.
Th is w rist m an u al also ref ects th e experien ce an d expertise
Th e orm at o th e m an u al is en tirely case based, w h ich h as o m an y teach in g acu lty th at h ave tau gh t in AO Fou n dation
proven to be so su ccess u l or both train ees as w ell as season ed h an d an d w rist cou rses, over m an y years, an d th rou gh ou t
su rgeon s in h elpin g to approach an d treat both sim ple an d th e w orld. Th eir con cepts as w ell as clin ical exam ples h ave
com plex in ju ries. As w ith th e recen t h an d m an u al, w e h ave assisted an d in f u en ced th e editors th rou gh ou t its produ ction .
en h an ced ou r clin ical case presen tation s w ith illu stration s We w ish to especially ackn ow ledge th e ollow in g su rgeon s
taken rom th e expan sive library o th e AO Fou n dation on - or th eir con tribu tion s: Drs Diego Fern an dez, Ren ato Fricker,
lin e edu cation site, AO Su rgery Re eren ce, or u sed th e ex- Fiesky Nu ñ ez Jr, Zh on g yu Li, Th om as Fisch er, an d Ju an Del
ception al skills an d resou rces o th e m edical illu stration an d Pin o, all o w h om con tribu ted u n iqu e treatm en ts o speci c
graph ic design team s at AO Su rgery Re eren ce an d th e problem s th at are illu strated w ith in th e m an u al.
AO Edu cation In stitu te.
As w e rst iden ti ed in ou r origin ally pu blish ed AO Manual
Recogn izin g th e su bstan tial advan cem en ts in th e u n derstan d- of Hand and Wrist, an d again em ph asized w ith th e recen t
in g o th e com plex an atom y o th e w rist, expan ded su rgical Manual of Fracture Management— Hand, th is w rist pu blication
approach es, an d tech n ological im provem en ts in im plan ts prim arily en com passes several exam ples o operative treat-
speci c to a variety o an atom ical sh apes an d in ju ry pattern s, m en t. It sh ou ld n ot be con stru ed to be th e on ly w ay n or
th is volu m e covers a wide ran ge o in orm ation an d is divided even n ecessarily th e best w ay to approach th e in dividu al
in to ve speci c section s. Section on e o ers th e reader ten problem s presen ted. Likew ise it is n ot in ten ded to be an
di eren t su rgical approach es to th e distal radiu s, carpu s, an d exh au stive text on th e su bject. Still, w e h ope you w ill n d
distal u ln a. Section tw o exam in es ractu res an d ractu re m an y h ou rs o learn in g an d pleasu re in th is text in retu rn
dislocation s o th e carpu s in clu din g sim ple an d m u lti rag- or th e m an y h ou rs w e an d oth ers h ave dedicated in provid-
m en tary ractu res o th e scaph oid, n on u n ion s, an d even th e in g th is book to you .
u se o vascu lar pedicle gra tin g. Th e th ird section ocu ses on
problem s o th e distal u ln a an d distal radiou ln ar join t w h ile Jesse B Ju piter
th e ou rth section covers a w ide variety o ractu re pattern s Dou glas A Cam pbell
an d m eth ods o in tern al xation o th e distal radiu s, w ith Fiesky Nu ñ ez
VI Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
Acknowle dgme nts
Acknowledgments
We are w ell aw are th at it w ou ld n ot be possible to produ ce • Ren ato Fricker, or h is con tribu tion s both as an editor o
an d pu blish th e Manual of Fracture Management— Wrist, n or th e Manual of Fracture Management— Hand an d as an au th or
an y o th e n e AO Fou n dation book pu blication s you see o th is w ork
today, w ith ou t th e dedication an d assistan ce o a large n u m - • Diego Fern an dez an d Ladislav Nagy or th eir previou s con -
ber o con tribu tors. Th e com radery sh ow n by ellow AO tribu tion s to h an d an d wrist edu cation at AO Fou n dation
m em bers to sh are resou rces, im ages, an d cases, an d th e an d con tribu tion s an d assistan ce with th is pu blication
h ou rs o edu cation w ork previou sly u n dertaken by w rist • Pro Tom Fisch er or kin dly providin g h is Forew ord
su rgeon colleagu es, plu s ad h oc in volvem en t o ou r ow n • Carl Lau , Man ager Pu blish in g, an d Mich ael Gleeson ,
clin ical sta m ean s th at th ere tru ly is a lon g list o people Project Man ager or both h an d an d w rist pu blication s,
to th an k. plu s th e en tire team o graph ic design an d m edical
illu stration sta an d con su ltan ts th at h elped brin g h an d
Bu t w h ile th ere h ave been cou n tless people in volved in draw n sketch es an d verbal ideas in to reality
som e w ay in th e developm en t o th is book, w e w ou ld like • Lars Veu m , Man ager AO Su rgery Re eren ce, an d th e team s
to especially m en tion th e ollow in g in dividu als, com m ittees, o cu rren t an d orm er project m an agers, su rgeon au th ors
an d grou ps: an d editors, an d illu strators or th eir editorial an d
illu stration w ork developin g th e AO Su rgery Re eren ce
• Mem bers o th e AOTrau m a Edu cation Com m ission , or carpal an d distal radiu s m odu les
providin g th e opportu n ity to develop both th is w ork an d • Fion a Hen derson an d An dreas Sch abert rom AO
th e partn er pu blication th e Manual of Fracture Management— Fou n dation ’s pu blish in g partn er Th iem e
Hand • An d last bu t n ot least to ou r partn ers an d am ily or th eir
• Urs Rü etsch i an d Robin Green e, rom th e AO Edu cation con tin u in g an d n ever-en din g su pport or ou r in volvem en t
In stitu te, or providin g access to th e resou rces an d AOEI w ith th e AO Fou n dation ’s w orld-class books, cou rses,
sta requ ired to brin g th is pu blication to ru ition an d on lin e edu cation activities an d even ts.
VII
Contributors
Contributors
Ed it o rs
Jesse B Jupiter, MD Douglas A Campbell, ChM, FRCS Ed, FRCS(Orth), Fiesky A Nuñez Sr, MD
Hansjorg Wyss/AO Professor of Orthopaedic Surgery FFSEM(UK) Associate Professor
Harvard Medical School Consultant Hand and Wrist Surgeon Department of Orthopaedic Surgery
Massachusetts General Hospital Leeds General Infirmary Wake Forest School of Medicine
Yawkey Center, Suite 2100 Great George St Medical Center Boulevard
55 Fruit Street Leeds LS1 3EX Winston-Salem NC 27157-1010
Boston MA02114 United Kingdom USA
USA
Au t h o rs
Douglas A Campbell, ChM, FRCS Ed, FRCS(Orth), Diego L Fernández, MD Thomas J Fischer, MD, FAOA, ASSH, AAOS, AOTK
FFSEM(UK) Professor of Orthopaedic Surgery Hand Expert Group
Consultant Hand and Wrist Surgeon University of Bern Clinical Associate Professor
Leeds General Infirmary Orthopedic Surgeon Indiana University School of Medicine
Great George St Consultant, Hand and Upper Extremity Surgery Department of Orthopedic Surgery
Leeds LS1 3EX Ch. de la Côte du Bas 12 Section Chief Hand Surgery
United Kingdom CH-1588 Cudrefin Ascension St Vincent, Indianapolis
Switzerland Indiana Hand to Shoulder Center
8501 Harcourt Rd
Indianapolis, IN 46260
USA
VIII Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
Contributors
Renato Fricker, MD Jesse B Jupiter, MD Fiesky A Nuñez Jr, MD, PhD

Member AOTauma Europe, Swiss and American Hansjorg Wyss/AO Professor of Orthopaedic Surgery Hand Surgeon
Societies for Hand Surgery, German speaking Working Harvard Medical School Bon Secours Mercy Health
Group for Surgery of the Hand Massachusetts General Hospital Piedmont Orthopedic Associates
Specialist in Hand Surgery FMH Yawkey Center, Suite 2100 35 International Drive
Senior Consultant Hand, Wrist, Elbow Surgery 55 Fruit Street Greenville, SC 29615
Orthopedic and Trauma Surgeons Boston MA02114 USA
Hirslanden Clinic Birshof USA
Reinacherstrasse 28 Fiesky A Nuñez Sr, MD
CH4142 Münchenstein Zhongyu Li, MD, PhD, FAOA, FAAOS, ASSH, ASPN Associate Professor
Switzerland ABOS Board Certified in Orthopaedic Surgery and Department of Orthopaedic Surgery
Hand Surgery Wake Forest School of Medicine
Juan González del Pino, MD, PhD Professor Medical Center Boulevard
Member Spanish Society for Hand Surgery Department of Orthopaedic Surgery Winston-Salem NC 27157-1010
Member Spanish Society for Orthopaedic Surgery Department of Vascular and Endovascular Surgery USA
Former member AOTKHand Expert Group Wake Forest School of Medicine
Former Editor-in-Chief Spanish Journal of Medical Center Boulevard
Orthopaedic Surgery Winston-Salem NC 27157-1070
Former President Spanish Society for Microsurgery USA
Founder and Head
The Institute of the Hand
Nuestra Señora del Rosario Hospital
80 Castelló St
28006 Madrid
Spain
IX
Abbre viations
Abbreviations
A PL abdu ctor pollicis lon gu s

CH capitate h ead
CMC carpom etacarpal
D CP dyn am ic com pression plate
D RUJ distal radiou ln ar join t
ECRB exten sor carpi radialis brevis
ECRL exten sor carpi radialis lon gu s
ECU exten sor carpi u ln aris
ED C exten sor digitoru m com m u n is
ED M exten sor digiti m in im i
EIP exten sor in dicis propriu s
EPB exten sor pollicis brevis
EPL exten sor pollicis lon gu s
FCR f exor carpi radialis
FCU f exor carpi u ln aris
FPL f exor pollicis lon gu s
LC-D CP lim ited con tact dyn am ic com pression plate
LCP lockin g com pression plate
PIP proxim al in terph alan geal
SL scaph olu n ate
SLA C scaph olu n ate advan ced collapse
SN A C scaph oid n on u n ion advan ced collapse
TFCC trian gu lar brocartilage com plex
TFC trian gu lar brocartilage disc
VA variable an gle
VCP volar colu m n plate
X Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
Online book content
Online book content
Usin g a QR code scan n er on a m obile device, readers w ill

be able to access th e approach an d dem on stration videos
featu red in th is book. Th e QR code on th is page w ill also
brin g you to addition al on lin e edu cation al con ten t related
to th is book.
ht t ps://wrist .aoeducation.org/asset s.ht m l
XI
Table of conte nts
Pa rt I
Front matter Surgical approach
1 Approache s 3
Fore word V 1.1 Palm ar approach to the scaphoid 5
Pre face VI 1.2 Dorsal approach to the scaphoid 13
Acknowle dgm e nts VII 1.3 Com bine d approach to the lunate and pe rilunate injurie s 21
Contributors VIII 1.4 Radiopalm ar approach to the thum b base 31
Abbre viations X 1.5 Dorsoradial approach to the distal radius 37
Online book conte nt XI 1.6 Modifie d He nry palm ar approach to the distal radius 41
1.7 Ulnar palm ar approach to the distal radius 49
1.8 Dorsal approach to the distal radius 55
1.9 Exte nde d dorsal approach to the distal radius 65
1.10 Ulnar approach to the distal ulna 77
XII Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
Table of conte nts
Pa rt II
Case s
2 Carpals 83 4 Radius 239
2 .1 Scaphoid—nondisplace d fracture tre ate d pe rcutane ously 85 4 .1 Radial styloid—fracture tre ate d with a radial colum n plate 241
with a he adle ss com pre ssion scre w
4 .2 Distal radius—dorsally displaced e xtraarticular fracture 257
2 .2 Scaphoid—displace d fracture tre ate d with a he adle ss 95 treated with a palmar plate
com pre ssion scre w
4 .3 Distal radius—lunate facet fracture treated with a 265
2 .3 Scaphoid—m ultifragm e ntary fracture tre ate d with a 103 buttress plate
he adle ss com pre ssion scre w and lag scre w
4 .4 Distal radius—shearing fracture treated with a buttress plate 273
2 .4 Scaphoid, proxim al pole —fracture tre ate d with a 111
4 .5 Distal radius—dorsally displaced intraarticular fracture 287
he adle ss com pre ssion scre w
treated with double plating
2 .5 Scaphoid, proxim al pole —nonunion tre ate d with a 123
4.6 Distal radius—multifragmentary intraarticular fracture 29 9
he adle ss com pre ssion scre w and bone graft
treate d with a palmar plate
2 .6 Scaphoid, waist—nonunion with de form ity tre ate d with a 131
4 .7 Distal radius—m ultifragm e ntary intraarticular fracture 30 9
he adle ss com pre ssion scre w and bone graft
with de fe ct tre ate d with a palm ar plate
2 .7 Scaphoid, proxim al pole —nonunion tre ate d with a 141
4 .8 Distal radius—m ultifragm e ntary intraarticular fracture 319
vascularize d bone graft
tre ate d with triple plating
2 .8 Pe rilunate dislocation tre ate d with K-wire s 157
4 .9 Distal radius—m ultifragm e ntary intraarticular fracture 329
2 .9 Transscaphoid pe rilunate fracture dislocation tre ate d 173 with associate d scaphoid fracture tre ate d with triple
with K-wire s and a he adle ss scre w plating and scre w
2 .10 Transtrique tral transscaphoid pe rilunate fracture 193 4.10 Distal radius—displace d intraarticular fracture treate d with 339
dislocation tre ate d with scre ws a bridge plate
2 .11 Multiple carpal pe rilunate fracture dislocation and 203 4.11 Distal radius—radiocarpal fracture dislocation treate d with 355
scaphocapitate syndrom e tre ate d with scre ws double plating
2 .12 Trape zium —displace d fracture tre ate d with lag scre ws 213
3 Ulna 219
3 .1 Ulnar styloid—fracture tre ate d with te nsion band wiring 221
3 .2 Ulna, he ad and ne ck—m ultifragm e ntary fracture tre ate d 231

with a hook plate
XIII
Table of conte nts
Appendix
5 Reconstructions and treatment of 369
complications
5 .1 Distal radius—dorsal e xtraarticular malunion treate d with 371 Furthe r re ading 4 93

oste otomy and double plating
AO/ OTA Fracture and Dislocation Classification 4 99
5 .2 Distal radius—palmar e xtraarticular malunion treated with 387
oste otomy and plate
5 .3 Distal radius—intraarticular malunion treate d with 39 9

oste otomy and palmar plate
5 .4 Distal radius—e xtraarticular and intraarticular m alunion 417

tre ate d with oste otom y and dorsal double plating
5 .5 Rheumatoid arthritis treate d with radiolunate arthrodesis 429
5 .6 Kienbock’s disease treate d with total wrist arthrode sis 439
5 .7 Malunite d fracture with associate d ulnar abutm e nt 44 9

syndrom e tre ate d with an ulnar shorte ning oste otom y
5 .8 Long-standing nonunion tre ate d with re se ction of 467

the distal ulna and double plating of the radius
5 .9 Chronic inte rcarpal arthritis tre ate d with scaphoid 475

re se ction and 4 -corne r fusion
XIV Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
Pa rt I
Surgical approach
Pa rt II Case s
2 Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d Je sse B Jupite r

1
Approaches
Pa rt II Case s

1.1 Palmar approach to the scaphoid
1 Su rgica l a p p ro a ch
Fig 1.1 -1 In ju ries in volvin g th e scaph oid can be treated

u sin g a palm ar approach .
2 In d ica t io n s
Fig 1.1-2 a – b Fractu res o th e scaph oid are typically

described by th e location o th e ractu re, as proxim al pole
(in th e proxim al th ird), scaph oid w aist (in th e cen tral
th ird), or distal pole (in th e distal th ird). Th e palm ar
approach to th e scaph oid is in dicated or displaced
ractu res in th e cen tral or distal th irds ( a ). It is also
in dicated or th e treatm en t o scaph oid ractu re n on -
u n ion s ( b ).
a b
5
Pa rt I Surgical approache s
2 In d ica t io n s (co n t )
Fig 1.1-3 Th e palm ar approach also gives access to

th ose irredu cible displaced scaph oid w aist (cen tral
th ird) ractu res th at can n ot be redu ced an d xed by
percu tan eou s tech n iqu es.
Fra ct u re p a t t e rn
Fig 1.1-4 a – c Most scaph oid w aist ractu res are tran sverse
( a ); h ow ever, som e can be obliqu e eith er in th e h orizon tal
( b ) or vertical plan e ( c ).
a b c
6 Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse B Jupite r, Douglas A Cam pbe ll, Fie sky Nuñe z
1 Approache s
3 Su rgica l a n a t o m y
Ca rp a l b o n e s
Capitate Trapezoid
Fig 1.1-5 Th e bon es o th e w rist com prise th e carpu s or
carpal bon es at th e proxim al en d o th e h an d, an d th e
radial an d u ln ar bon es at th e distal en d o th e arm . Th e
carpu s is m ade u p o eigh t carpal bon es, w h ich in clu de
th e h am ate, capitate, trapezoid, an d trapeziu m in th e
Hamate
distal carpal row , an d th e pisi orm , triqu etru m , lu n ate,
Trapezium
an d scaph oid in th e proxim al carpal row .
Pisiform
Scaphoid
A com plex series o so t-tissu e stru ctu res stabilize th e
carpal bon es an d th eir con n ection to each oth er an d to Triquetrum Lunate
th e radiu s an d u ln a. Th e scaph oid, h ow ever, is by ar th e
m ost com m on ly in ju red carpal bon e.
So ft t is s u e s
Fig 1.1-6 a – b On th e palm ar side o th e w rist, th e

ollow in g stru ctu res can also be ou n d:
1. Motor bran ch o th e m edian n erve
2. Palm ar cu tan eou s bran ch o th e m edian n erve
3. Median n erve 1
4. Pron ator qu adratu s m u scle
5. Flexor digitoru m pro u n du s ten don s 2
6. Flexor digitoru m su per cialis ten don s
7. Flexor carpi radialis (FCR) ten don
8. Radial artery.
3
5 4
8
a
6 5 3 2 4 7 8
7
4 Sk in in cis io n
An gle d s k in in cis io n
Fig 1.1-7 Im portan t an atom ical lan dm arks or th e an gled

palm ar skin in cision are:
• Th e scaph oid tu bercle
• Th e FCR ten don .
Scaphoid tubercle
Median nerve
Palmar cutaneous branch Flexor carpi

radialis tendon
Fig 1.1-8 Th e in cision lin e can be m arked on th e skin in lin e

w ith th e FCR ten don , startin g at th e scaph oid tu bercle an d
ru n n in g proxim ally or abou t 2 cm . Distal to th e scaph oid
tu bercle, th e in cision an gles tow ard th e base o th e th u m b
over th e scaph otrapezial join t. Be aw are o th e proxim ity o
th is in cision to th e palm ar cu tan eou s bran ch o th e m edian
n erve (as sh ow n in Fig 1.1-7 ) an d be su re to avoid in ju rin g it.
1 Approache s
4 Sk in in cis io n (co n t )
Zigza g in cis io n
Fig 1.1-9 Altern atively, a zigzag palm ar in cision can be

con stru cted u sin g th e sam e lan dm arks.
Scaphoid tubercle
Median nerve
Palmar cutaneous branch Flexor carpi

radialis tendon
Liga t e t h e s u p e r ficia l p a lm a r b ra n ch o f t h e ra d ia l a r t e r y
Fig 1.1-1 0 Th e su per cial palm ar bran ch o th e radial

artery passes tow ard th e palm , ru n n in g close to th e
scaph oid tu bercle. I n ecessary, it can be ligated an d
divided.
Superficial palmar branch
Scaphoid tubercle
Flexor carpi
Palmar cutaneous branch of the radialis tendon
median nerve Radial artery
Op e n t h e fle xo r ca rp i ra d ia lis s h e a t h
Fig 1.1-1 1 Th e FCR sh eath is open ed as ar distally as

possible an d th e ten don retracted tow ard th e u ln ar side.
Superficial palmar branch

Flexor carpi radialis tendon
Radial artery
Palmar cutaneous branch
of the median nerve
9
Exp o s e t h e w ris t ca p s u le
Fig 1.1-1 2 Th e capsu le is th en in cised obliqu ely rom

th e tu bercle distally tow ard th e palm ar rim o th e
radiu s proxim ally. Th is in cision also in volves th e
radioscaph ocapitate an d lon g radiolu n ate ligam en ts.
As determ in ed by th e ractu re con gu ration , preserve
as m u ch o th e palm ar ligam en t com plex as possible
Scaphoid tubercle
as it h elps to con tain th e proxim al pole an d preven ts
Radioscaphocapitate ligament
palm ar tilt o th e scaph oid.
Long radiolunate ligament
Z-s h a p e d ca p s u la r in cis io n
Fig 1.1-1 3 Altern atively, to preserve th e palm ar liga-

m en ts, a Z-sh aped in cision can be m ade in th e join t
capsu le.
Scaphoid tubercle
Exp o s e t h e s ca p h o id
Fig 1.1-1 4 Retract th e divided radioscaph ocapitate

ligam en t to expose th e scaph oid.
Thenar muscles
1 Approache s
Fig 1.1-1 5 I it is n ecessary to expose th e proxim al part o

th e scaph oid, divide th e lon g radiolu n ate ligam en t
proxim ally as ar as th e palm ar rim o th e radiu s.
Exp o s e t h e s ca p h o t ra p e zia l jo in t
Fig 1.1-1 6 Th e scaph otrapezial join t m u st be exposed to

allow optim al position in g o a screw . Th e in cision is
deepen ed distally, dividin g th e origin o th e th en ar
m u scles in lin e w ith th eir bers. Thenar muscles
Fig 1.1-1 7 Th e scaph otrapezial join t is iden ti ed, th e

scaph otrapezial ligam en t divided in th e lin e o its bers,
an d th e join t capsu le open ed. Scaphotrapezial ligament
11
5 Wo u n d clo s u re
Fig 1.1-18 Th e divided palm ar ligam en ts (radioscaph ocapitate

an d lon g radiolu n ate) m u st be repaired with n e in terru pted
su tu res to preven t secon dary carpal in stability. Approxim ate th e
so t tissu es over th e scaph otrapezial join t. Test th e in tegrity o
th e so t-tissu e repair by passive wrist m otion . Fin ally, th e FCR
ten don sh eath is repaired an d covered with su bcu tan eou s tissu e.
Vid e o
Th is video dem on strates th e

Vid e o 1 .1 -1
palm ar approach to th e carpals.
1.2 Dorsal approach to the scaphoid
Fig 1.2 -1 In ju ries in volvin g th e scaph oid can be treated

u sin g a dorsal approach .
2 In d ica t io n s
Fig 1.2-2 a – b Th e dorsal approach to th e scaph oid is

in dicated or all acu te displaced an d n on displaced
ractu res o th e proxim al pole (proxim al th ird) ( a ). It is
also in dicated or th e bon e gra tin g o proxim al pole
n on u n ion s ( b ).
a b
13
Ext e n s o r co m p a r t m e n t s
Fig 1.2-3 Th ere are ve exten sor com partm en ts on th e

dorsu m o th e radiocarpal region an d on e exten sor
com partm en t at th e u ln ocarpal region . Th ese com part-
m en ts or tu n n els con tain th e exten sor ten don s.
Th e rst com partm en t con tain s th e abdu ctor pollicis

lon gu s (APL) an d exten sor pollicis brevis (EPB) ten don s.
Th e secon d com partm en t con tain s th e exten sors carpi
radialis lon gu s (ECRL) an d brevis (ECRB). Th e th ird
com partm en t con tain s th e exten sor pollicis lon gu s (EPL)
ten don . Th e ou rth com partm en t con tain s th e exten sor
in dicis propriu s (EIP) an d th e exten sor digitoru m com m u -
I II III IV V VI
n is (EDC). Th e th com partm en t con tain s th e exten sor
digiti m in im i (EDM). Fin ally, th e sixth com partm en t
h osts th e exten sor carpi u ln aris (ECU).
Fig 1.2-4 Th e su per cial radial n erve (1) an d th e dorsal

bran ch o th e u ln ar n erve (2) lie in th e su bcu tan eou s
tissu es su per cial to th e exten sor com partm en ts an d are
vu ln erable to in ju ry du rin g su rgical approach .
VI
I V
II IV
III
1 Approache s
4 Sk in in cis io n
Make a straigh t dorsal skin in cision startin g

Fig 1.2-5 a – b
over Lister tu bercle (th e bon y prom in en ce located at th e
distal en d o th e radiu s) an d exten d th e in cision or abou t
4 cm distally.
15
Id e n t ify t h e ra d ia l n e r ve
Fig 1.2-6 En su re to preserve an y parts o th e su per cial

bran ch o th e radial n erve, w h ich ru n s in th e radial skin
f ap o th e w ou n d.
Superficial branch of
the radial nerve
In cis e t h e re t in a cu lu m
Fig 1.2-7 In cise th e distal part o th e exten sor retin acu lu m

over th e EPL ten don , leavin g th e proxim al part in tact.
Superficial branch of Extensor retinaculum

the radial nerve
Extensor pollicis longus
1 Approache s
Fig 1.2-8Open th e distal part o th e th ird exten sor

com partm en t.
Re t ra ct io n o f t h e t e n d o n s
Fig 1.2-9 Th e EPL ten don is th en retracted radially

togeth er w ith th e ten don s o th e secon d exten sor
com partm en t (th e ECRB an d th e ECRL). Extensor carpi radialis brevis
Th e ten don s o th e ou rth exten sor com partm en t are Dorsal intercarpal ligament
retracted in an u ln ar direction .
17
Op e n in g t h e ca p s u le
Fig 1.2-1 0 Make a lon gitu din al or in verted T-sh aped

in cision , startin g at th e dorsal rim o th e distal radiu s, an d
exten din g to th e dorsal radiocarpal ligam en t. Extensor carpi radialis brevis
Dorsal intercarpal ligament
Dorsal radiocarpal ligament
Fig 1.2-1 1 Take care to preserve th e vessels to th e dorsal

ridge o th e scaph oid. Th e capsu le sh ou ld n ot be stripped
rom th is area.
Capitate
Scapholunate ligament
Lunate
Scaphoid
Dorsal radiocarpal ligament
1 Approache s
Exp o s e t h e s ca p h o id
Fig 1.2-12 To expose th e proxim al pole o th e scaph oid, it is

n ecessary to f ex th e wrist. Th e scaph oid n ow com es in to
view. An d th e scaph olu n ate ligam en t can be iden ti ed.
Fig 1.2-1 3 Close th e capsu le w ith in terru pted su tu res.
It is n ot n ecessary to repair th e th ird exten sor com partm en t

becau se th e proxim al part rem ain s in tact.
19
5 Wo u n d clo s u re (co n t )
Vid e o

Vid e o 1 .2 -1
dorsal approach to th e carpals.
1.3 Combined approach to the lunate and
perilunate injuries
Fig 1.3 -1 In ju ries in volvin g th e lu n ate or its

su rrou n din g stru ctu res can be treated u sin g a
com bin ed dorsal an d palm ar approach .
2 In d ica t io n s
Fig 1.3-2 a – c Th e com bin ed approach (u sin g both dorsal

an d palm ar in cision s) is o ten in dicated or lu n ate an d
perilu n ate in ju ries.
A lu n ate dislocation exists w h en th e lu n ate ( a ) loses

con tact w ith th e lu n ate ossa o th e distal radiu s ( b ).
How ever, a perilu n ate in ju ry exists w h en an adjoin in g

carpal bon e is dam aged or dislocated bu t th e lu n ate itsel
rem ain s in con tact w ith th e lu n ate ossa o th e distal
radiu s ( c ).
In m ost cases in volvin g th e com bin ed approach , th e

Normal Lunate Perilunate
dorsal approach is m ade rst. How ever, start w ith a dislocation dislocation
palm ar approach in cases o palm ar dislocation o th e
a b c
lu n ate or in th e rarer palm ar lu xation o oth er carpal
bon es.
Note th at a com bin ed approach or th ese in ju ries is n ot

alw ays n ecessary. Th e dorsal aspect o th e scaph olu n ate
ligam en t is th e stron ger, so th e dorsal approach is
in dicated to repair it an d to redu ce an y scaph olu n ate
dissociation (ligam en t in ju ries). It is also in dicated to
redu ce an d stabilize oth er perilu n ate ractu re dislocation s.
21
Fig 1.3-3 Th ere are ve exten sor com partm en ts in th e

dorsoradial region an d on e exten sor com partm en t at th e
dorsou ln ar region .
Th e secon d com partm en t con tain s th e exten sor carpi

radialis lon gu s an d brevis. Th e th ird com partm en t
con tain s th e exten sor pollicis lon gu s (EPL) ten don . Th e
ou rth com partm en t con tain s th e exten sor in dicis
propriu s an d th e exten sor digitoru m com m u n is. Perilu -
n ate in ju ries can be approach ed th rou gh th e secon d,
th ird, an d ou rth com partm en ts. I II III IV V VI
So ft t is s u e s

ollow in g stru ctu res can also be ou n d:
1. Motor bran ch o th e m edian n erve
3. Median n erve 1
5. Flexor digitoru m pro u n du s ten don s 2
6. Flexor digitoru m su per cialis ten don s
7. Flexor carpi radialis (FCR) ten don
8. Radial artery.
3
5 4
8
a
6 5 3 2 4 7 8
1 Approache s
1.3 Combine d approach to the lunate and pe rilunate injurie s
4 Do rs a l s k in in cis io n
St ra igh t s k in in cis io n
Fig 1.3-5 Make a straigh t skin in cision begin n in g

proxim ally an d u ln ar to Lister tu bercle an d en din g
distally at th e level o th e th ird carpom etacarpal join t.
Th e in cision sh ou ld be abou t 8 cm lon g. Th e in cision can
be exten ded proxim ally or distally i n ecessary.
Ele va t e t h e s k in fla p
Fig 1.3-6 Preserve th e large lon gitu din al vein s an d ligate

an d divide th e crossin g bran ch es to ach ieve exposu re.
Extensor retinaculum
radial nerve
23
4 Do rs a l s k in in cis io n (co n t )
Fig 1.3-7 Elevate th e skin f aps, com plete w ith su bcu tan eou s Superficial branch of the radial nerve
tissu e, rom th e exten sor retin acu lu m . Th e su per cial bran ch
o th e radial n erve sh ou ld be iden ti ed an d elevated w ith th e
skin f ap.
Op e n t h e t h ird co m p a r t m e n t
Fig 1.3-8 In cise th e exten sor retin acu lu m over th e EPL

ten don , open in g th e th ird exten sor com partm en t.
Fourth compartment
Second compartment Extensor

retinaculum
Extensor pollicis Superficial

longus tendon cutaneous branch
Superficial branch of of the ulnar nerve
radial nerve
Fig 1.3-9 Th e EPL ten don is released an d retracted

radially, togeth er w ith th e exten sor ten don s o th e secon d
com partm en t.
1 Approache s
Op e n t h e fo u r t h co m p a r t m e n t
Fig 1.3-1 0Retract th e exten sor ten don s o th e ou rth

com partm en t in an u ln ar direction to expose th e w rist Fourth compartment
capsu le.
Second compartment
Extensor pollicis Superficial cutaneous

longus tendon branch of the ulnar nerve
radial nerve
Ra d ia lly b a s e d ca p s u la r in cis io n
Fig 1.3-1 1 To gain a com plete view o th e carpu s, a

radially based capsu lar ligam en tou s f ap is elevated. Th e
capsu lotom y in cision starts radially deep to th e f oor o
th e secon d exten sor com partm en t.
Leave a rin ge o 2–3 m m o th e capsu lar attach m en t at

th e dorsal rim o th e radiu s or su bsequ en t su tu re repair. Dorsal intercarpal 3
ligament
Th e in cision occu rs as ollow s: Radiolunotriquetral
1 2 ligament
1. Th e in cision con tin u es in an u ln ar direction alon g th e
dorsal rim o th e radiu s
2. It th en tu rn s distally in lin e w ith th e bers o th e
radiolu n otriqu etral (dorsal radiocarpal) ligam en t
3. At th e triqu etru m it tu rn s radially in lin e w ith th e
bers o th e dorsal in tercarpal ligam en t.
25
Pro t e ct t h e d is t a l ra d io u ln a r jo in t
Fig 1.3-1 2 Be care u l n ot to cu t th e dorsal radiou ln ar

ligam en t or th e trian gu lar brocartilage o th e distal
radiou ln ar join t, w h ich m u st be protected.
Radiolunotriquetral ligament
Triangular fibrocartilage
Dorsal intercarpal ligament Dorsal radioulnar ligament
Ele va t e t h e ca p s u la r fla p
Fig 1.3-1 3 Th e capsu lar f ap is elevated by sh arp dissection

in an u ln ar to radial direction .
Dorsal intercarpal ligament
C H
S T
L
Radiolunotriquetral ligament
Fig 1.3-1 4 Th e proxim al carpal row w ith its in trin sic

ligam en ts an d th e m idcarpal join t are exposed.
1 Approache s
5 Pa lm a r s k in in cis io n
Fig 1.3-1 5A ter th e dorsal approach , w ith tem porary

xation on th e dorsal side, th e palm ar approach is
per orm ed i n ecessary.
Ext e n d e d ca rp a l t u n n e l in cis io n
Fig 1.3-1 6 Th e in cision begin s in th e palm , at th e level o

th e distal edge o th e f exor retin acu lu m , in lin e w ith th e
th ird m etacarpal. It con tin u es proxim ally in th e in terem i-
n en ce crease to th e level o th e tran sverse f exor crease o
th e w rist.
At th is poin t, th e in cision an gles 90 degrees in an u ln ar

direction or 2 cm in th e lin e o th e w rist f exor crease. It
th en tu rn s proxim ally as a sligh tly cu rved lon gitu din al
exten sion as ar as n ecessary.
27
5 Pa lm a r s k in in cis io n (co n t )
Ele va t e t h e s k in fla p s
Fig 1.3-1 7 Elevate th e skin f aps by sh arp dissection ,

rstly rom th e su r ace o th e palm ar apon eu rosis distally,
th en rom th e an tebrach ial ascia proxim ally, on th e u ln ar
side o th e palm aris lon gu s ten don . Th is protects th e
palm ar cu tan eou s bran ch o th e m edian n erve, w h ich Palmar aponeurosis
passes to th e radial side o th e palm aris lon gu s ten don .
Palmaris longus
Ulnar artery tendon
and nerve
Median nerve
Antebrachial fascia

of the median nerve
Op e n t h e ca rp a l t u n n e l
Fig 1.3-1 8 Iden ti y th e m edian n erve, w h ich lies radial

an d deep to th e palm aris lon gu s ten don . In sert a blu n t
in stru m en t in to th e carpal tu n n el betw een th e m edian
n erve an d th e f exor retin acu lu m . Now divide th e f exor
Motor branch of
retin acu lu m lon gitu din ally over th e blu n t in stru m en t, Flexor the thenar muscles
w h ich protects th e m edian n erve. Th e retin acu lu m sh ou ld retinaculum
be divided to th e u ln ar side o th e m edian n erve to
protect its m otor bran ch to th e th en ar m u scles.
Median nerve
Palmaris longus tendon

Ulnar artery
of the medial nerve
and nerve
1 Approache s
Re t ra ct t h e fle xo r t e n d o n s
Fig 1.3-1 9 To expose th e palm ar carpal ligam en ts, retract

all th e f exor ten don s radially.
Ulnotriquetral ligament
Flexor tendons
Pronator quadratus muscle
Fig 1.3-2 0 On ly th e u ln ar n erve an d artery rem ain on th e

u ln ar side.
29
Op t io n : a p p ro a ch t o t h e ra d ia l p a lm a r ca p s u le
Fig 1.3-2 1 Som etim es th e m edian n erve m u st be

care u lly retracted radially togeth er w ith th e ten don o
th e f exor pollicis lon gu s. Th e f exor ten don s o th e
n gers are retracted in an u ln ar direction , th ereby
exposin g th e radial side o th e palm ar capsu le.
Finger flexor tendons

Flexor pollicis longus
tendon
Median nerve
Pronator quadratus muscle
Clo s e t h e ca p s u la r in cis io n
Fig 1.3-2 2 On th e dorsal side, repair th e radially based

f ap w ith in terru pted su tu res.
To avoid th e risk o isch em ic ru ptu re o th e EPL, it is

recom m en ded th at it be le t above th e exten sor retin acu -
lu m in th e su bcu tan eou s tissu e.
I an in cision is also m ade on th e palm ar side, th e skin is

closed in th e stan dard ash ion .
1.4 Radiopalmar approach to the thumb base
Fig 1.4-1 In ju ries in volvin g th e base o th e th u m b can

be treated u sin g a radiopalm ar approach .
2 In d ica t io n s
Fig 1.4-2 Th is approach is in dicated or ractu res o th e

trapeziu m as w ell as or in traarticu lar ractu res o th e rst
carpom etacarpal join t, su ch as Ben n ett or Rolan do
ractu res. It is also in dicated or basal m etacarpal ractu res.
Trapezoid
Trapezium
Scaphoid
31
Th e join t su r aces o th e trapeziu m an d

Fig 1.4-3 a – b
th u m b m etacarpal resem ble tw o reciprocally in terlockin g
saddles. Th is articu lar geom etry, th e ligam en tou s su pport
system , an d th e th u m b m u scles all w ork in syn ergy to
en able opposition o th e th u m b to th e n gers.
a b
Fig 1.4-4 Th e stron g palm ar obliqu e ligam en t is essen tial

as a stabilizin g u n it o th e base o th e th u m b m etacarpal;
it in serts in to th e articu lar m argin o th e palm ar beak on
th e u ln ar aspect o th e rst m etacarpal base. On th e radial
Adductor pollicis
side o th e m etacarpal base is th e in sertion o th e abdu c-
tor pollicis lon gu s (APL) ten don . Th e addu ctor pollicis
exerts a orce th at pu lls th e th u m b in a palm ar an d u ln ar
direction . Palmar oblique
ligament
Abductor pollicis
longus tendon
4 Sk in in cis io n
Tw o di eren t skin in cision s can be u sed: Superficial branch of the

radial nerve
• Th e straigh t radiopalm ar in cision
• Th e cu rved in cision , described by Wagn er.
Fig 1.4-5 Th e straigh t in cision is m ade in th e dorsoradial

aspect o th e th en ar em in en ce at th e tran sition betw een
th e dorsal an d palm ar skin . It starts abou t 1 cm distal to
th e tip o th e radial styloid an d exten ds distally or 4–5 cm .
Th e su per cial bran ch o th e radial n erve divides in to Radial artery

several bran ch es in th is area. Iden ti y an d protect th ese
bran ch es to avoid trou blesom e n eu rom a orm ation . Th e
radial artery crosses th e proxim al lim it o th e in cision in
an obliqu e direction an d m u st also be iden ti ed, protect-
ed, an d preserved.
1 Approache s
Fig 1.4-6 Th e Wagn er in cision ollow s th e th en ar em i- Superficial branch of the

radial nerve
n en ce in a gen tle cu rve tow ard its palm ar aspect. Th e
disadvan tage o th is in cision is th e risk o scar orm ation
across th e w rist crease an d lesion s o n erve bran ch es.
Radial artery
Ele va t e t h e fla p
Fig 1.4-7 Elevate th e f aps o skin an d su bcu tan eou s tissu e

by blu n t dissection , iden ti yin g an d protectin g th e
division s o th e su per cial bran ch o th e radial n erve an d Abductor pollicis longus
th e APL ten don . Gen tle retraction w ith elastic vessel tendon
loops aids th e exposu re.
Superficial branch of the

radial nerve
Abductor pollicis longus

tendon
Fig 1.4-8 How ever, th e excessive retraction o th e f aps
can im pair vascu larity o th e tissu es.
Superficial branch of the

radial nerve
33
De t a ch t h e t h e n a r m u s cle s
Fig 1.4-9 A ter retractin g th ese stru ctu res, th e th en ar

m u scles com e in to view . Th ey are th en detach ed rom
th eir origin s at th e base o th e rst m etacarpal an d
ref ected in a palm ar direction . Abductor pollicis
longus tendon
Thenar muscles
Abductor pollicis
longus tendon
Fig 1.4-1 0 Preservin g a sm all part o th e in sertion w ill
later h elp w ith reattach m en t o th e th en ar m u scles.
Thenar muscles
Ca p s u lo t o m y
Fig 1.4-1 1Per orm a tran sverse or lon gitu din al

capsu lotom y to expose th e join t.
Abductor pollicis
longus tendon
Thenar muscles
1 Approache s
In s p e ct t h e jo in t
Fig 1.4-1 2 In spect th e join t by rotatin g th e th u m b in to

pron ation an d su pin ation , w h ile exertin g lon gitu din al
traction . Th is m an eu ver also h elps to assess th e ractu re
geom etry an d to redu ce Ben n ett ractu res.
Fig 1.4-1 3Close th e capsu le w ith in terru pted su tu res.

Reattach th e th en ar m u scles to th e base o th e rst
m etacarpal u sin g in terru pted su tu res.
35
5 Wo u n d clo s u re (co n t )
Vid e o

Vid e o 1 .4 -1
radiopalm ar approach to th e th u m b base.
1.5 Dorsoradial approach to the distal radius
Fig 1.5 -1 In ju ries in volvin g th e radial styloid can be

treated u sin g a dorsoradial approach .
2 In d ica t io n s
Fig 1.5-2 Depen din g on th e speci c ractu re pattern , a IV

III
dorsal approach betw een th e variou s exten sor V
com partm en ts I-VI is ch osen .
II
VI
In in ju ries in volvin g th e radial styloid, an approach A
betw een th e rst an d secon d exten sor com partm en ts (A)
is in dicated.
I
Radius Ulna
37
An a t o m ica l s n u ffb o x
Fig 1.5-3 Th e exten sor pollicis lon gu s an d th e exten sor Anatomical snuffbox Extensor pollicis longus
pollicis brevis are th e lan dm arks or th e an atom ical
sn u box, with th e tip o th e radial styloid orm in g th e f oor.
Radial styloid
Extensor pollicis brevis
Fig 1.5-4 Im portan t stru ctu res arou n d th e an atom ical

sn u box in clu de th e su per cial bran ch es o th e radial
n erve, wh ich sh ou ld be care u lly protected du rin g an y
xation procedu re. Th e radial artery crosses th e f oor o
th e an atom ical sn u box an d sh ou ld also be protected.
Radial artery Superficial branch

of radial nerve
1 Approache s
1.5 Dorsoradial approach to the distal radius
4 Sk in in cis io n
Fig 1.5-5 A straigh t in cision is m ade over th e an atom ical

sn u box an d exten ded distally an d proxim ally, to th e
n ecessary exten t, as illu strated. Th e tw o resu ltan t skin /
su bcu tan eou s f aps are raised by blu n t dissection rom
th e u n derlyin g exten sor retin acu lu m .
Exp o s u re
Fig 1.5-6 Th e su per cial cu tan eou s bran ch es o th e radial

n erve are iden ti ed an d protected. Th e radial styloid is
approach ed betw een th e rst an d secon d com partm en ts
an d th en exposed by sh arp dissection .
Superficial branch of radial nerve
39
Fig 1.5-7 Th e rst an d secon d com partm en ts can be

elevated as n ecessary.
Superficial branch of radial nerve
Th e skin is closed in a stan dard ash ion .
1.6 Modi ed Henry palmar approach to the
distal radius
Fig 1.6 -1 In ju ries in volvin g th e distal radiu s can be

treated u sin g a m odi ed Hen ry palm ar approach .
2 In d ica t io n s
Fig 1.6-2 Th e m odi ed Hen ry approach is su itable or

m ost ractu res o th e distal radiu s.
41
So ft t is s u e s

ollow in g stru ctu res can be ou n d:
1. Motor bran ch o th e m edian n erve 1

2
3. Median n erve
5. Flexor digitoru m pro u n du s ten don s
6. Flexor digitoru m su per cialis ten don s 3
7. Flexor carpi radialis (FCR) ten don 4
5
8. Radial artery.
6
6 5 3 2 4 7 8
1 Approache s
1.6 Modif e d Henry palmar approach to the distal radius
3 Su rgica l a n a t o m y (co n t )
Bo n y a n a t o m y
Fig 1.6-4 a – bIn addition to th e su rrou n din g so t tissu es, 3 4 6 7 1 2 3 8 7

th e distal radiu s con tain s a n u m ber o bon y protru sion s:
1. Uln ar styloid
2. Uln ar h ead
3. Sigm oid n otch
4. Lu n ate acet
5. Lister tu bercle
6. Scaph oid acet
7. Radial styloid
8. Watersh ed lin e.
1 2 5
a b
Wa t e rs h e d lin e
Fig 1.6-5 Th e w atersh ed lin e represen ts th e m argin

betw een th e stru ctu res th at m ay be elevated proxim ally
an d th e capsu le o th e w rist join t, w h ich sh ou ld be
respected.
43
4 Pla n n in g t h e in cis io n
Fig 1.6-6 Th e m odi ed Hen ry approach u ses th e plan e Palmar cutaneous branch of median nerve Flexor pollicis longus
betw een th e FCR ten don an d th e radial artery. Th e classic
Hen ry approach goes betw een th e brach ioradialis an d th e Median nerve Flexor carpi radialis
radial artery, th at is, radial to th e radial artery; h ow ever, Modified Henry approach
th e m odi ed Hen ry approach is u ln ar to th e radial artery. Pronator quadratus Classic Henry approach
Th e FCR ten don is palpated be ore m akin g th e skin
in cision to th e radial side.
Radial artery
Fig 1.6-7 A distal exten sion o th e in cision in a zigzag

ash ion across th e w rist f exion crease w ill allow m obiliza-
tion o th e FCR ten don or a m ore exten sile approach .
Pit fa ll
Th e radial artery an d th e palm ar cu tan eou s bran ch o th e

m edian n erve are at risk du rin g th is approach .
1 Approache s
5 Sk in in cis io n
Fig 1.6-8 Make th e skin in cision alon g th e radial border

o th e FCR ten don . Th e sh eath is open ed an d th e ten don
retracted tow ard th e u ln ar side. Deepen th e in cision
betw een th e f exor pollicis lon gu s (FPL) ten don an d th e
radial artery.
Palmar cutaneous
Care m u st be taken to avoid dam agin g th e radial artery branch of
on th e radial side an d th e palm ar cu tan eou s bran ch o th e median nerve
m edian n erve on th e u ln ar side.
Flexor carpi radialis
tendon Radial artery
Flexor pollicis
longus tendon
Fig 1.6-9 Th e FPL m u scle belly is sw ept aw ay tow ard th e

u ln a. Th is in creases th e space an d exposes th e pron ator
qu adratu s m u scle.
Pronator quadratus
Flexor pollicis
longus tendon
45
Pe a rl
Fig 1.6-1 0 Th e pron ator qu adratu s m u scle sh ou ld be

elevated u sin g an L-sh aped in cision . Th e h orizon tal
lim b is placed at th e w atersh ed lin e. Th is lies a ew
m illim eters proxim al to th e join t lin e; th e position o
th e join t lin e can be determ in ed by a h ypoderm ic
n eedle placed in th e join t.
Pronator quadratus
Exp o s in g t h e d is t a l ra d iu s
Fig 1.6-1 1 Th e pron ator qu adratu s m u scle is in cised on

its radial border, exposin g th e distal radiu s. It is stripped
o th e distal radiu s togeth er w ith th e periosteu m .
1 Approache s
Fig 1.6-1 2 Th e pron ator qu adratu s sh ou ld be placed over

th e plate. Every attem pt sh ou ld be m ade to reattach th e
h orizon tal lim b o th e pron ator qu adratu s elevation to
th e capsu le. I possible, it sh ou ld be reattach ed to its
radial in sertion .
Th e ten don sh eath m ay be closed, bu t care m u st be taken

to avoid catch in g th e cu tan eou s bran ch o th e m edian
n erve. Th e skin is th en closed.
Vid e o

Vid e o 1 .6 -1
palm ar approach to th e distal radiu s.
47
1.7 Ulnar palmar approach to the distal radius

treated u sin g an u ln ar palm ar approach .
2 In d ica t io n s
Fig 1.7-2 a – b An u ln ar palm ar approach is pre erred to

expose th e palm ar lu n ate acet. Th e u ln ar palm ar approach
also acilitates exposu re o th e sigm oid n otch , th e palm ar
w rist capsu le, th e distal radiou ln ar join t, an d th e distal
u ln a ( a ). It is less su itable or th e radial part o th e distal
radiu s.
For m ore com plex ractu res, an u ln ar palm ar exten sile

approach m ay be u sed.
I it is desired to decom press th e carpal tu n n el, th is can

be per orm ed eith er th rou gh an u ln ar palm ar exten sile
approach or tw o separate approach es ( b ). a b
49
Details on th e an atom y in volved in th is approach can be

ou n d in th e su rgical an atom y topic in ch apter 1.6
Modi ed Hen ry palm ar approach to th e distal radiu s.
Fig 1.7-3 Th e u ln ar palm ar approach u ses th e plan e

betw een th e u ln ar artery an d n erve on on e side an d th e
f exor ten don s on th e oth er side. Ulnar nerve
Ulnar artery
Flexor
digitorum
superficialis
tendon
Flexor carpi
ulnaris
tendon
1 Approache s
5 Sk in in cis io n
Fig 1.7-4 a – bTh e in cision starts at th e w rist crease an d

ru n s proxim ally parallel to th e u ln a ( a ). It can be exten d-
ed alon g th e w rist crease an d distally in to th e palm . Th e
in terval is developed betw een th e u ln ar artery an d th e
f exor ten don s ( b ).
Ulnar artery
Flexor digitorum
superficialis
tendon
Dis s e ct io n
Fig 1.7-5 Th e f exor ten don s an d m edian n erve are

retracted tow ard th e radial side to provide excellen t
exposu re o th e pron ator qu adratu s.
Pronator quadratus
Ulnar artery
Flexor tendons
51
Fig 1.7-6 Th e pron ator qu adratu s is in cised as m u ch as

n ecessary.
Pronator quadratus
Ulnar artery
Flexor tendons
Fig 1.7-7 Expose th e u ln ar side o th e distal radiu s by

elevatin g th e in cised portion o th e pron ator qu adratu s.
Radius
Ulna
1 Approache s
Ext e n s io n o f u ln a r p a lm a r a p p ro a ch
Fig 1.7-8 Th e u ln ar palm ar approach can be exten ded dis-

tally. Th is allow s decom pression o th e carpal tu n n el an d
gives good access to th e radiocarpal stru ctu res in h igh -
en ergy in ju ries.
Th e skin is closed in th e stan dard ash ion .
53
1.8 Dorsal approach to the distal radius
Fig 1.8 -1 In ju ries in volvin g m u lti ragm en tary articu lar

ractu res, or both th e radial an d in term ediate colu m n s o
th e distal orearm , can be approach ed th rou gh a sin gle
dorsal skin in cision w ith m u ltiple approach es th rou gh
th e exten sor com partm en ts.
2 In d ica t io n s
Prin cip le o f co lu m n s
Fig 1.8-2 Th e distal orearm can be th ou gh t o in term s o

th ree colu m n s. Th e u ln a orm s on e colu m n (th e u ln ar
colu m n ) w h ile th e radiu s can be separated in to tw o (th e
in term ediate colu m n an d th e radial colu m n ).
Th e radial colu m n in clu des th e radial styloid an d scaph oid

ossa w h ile th e in term ediate colu m n in clu des th e lu n ate
ossa an d th e sigm oid n otch , w h ich is part o th e distal
radiou ln ar join t (DRUJ). Th e u ln ar colu m n com prises th e
distal u ln a w ith th e trian gu lar brocartilage com plex
(TFCC).
n
m
u
l
o
c
n
n
m
e
Distally at th e w rist join t, th e radial colu m n articu lates
m
t
u
a
u
i
l
d
o
l
o
w ith th e scaph oid w h ile th e in term ediate colu m n
c
e
c
m
l
a
r
r
a
i
articu lates w ith th e lu n ate. Th e u ln ar colu m n term in ates
e
d
n
t
a
l
U
n
R
I
distally at th e TFCC.
55
Th is 3-colu m n con cept h elps in describin g th e location o

w rist in ju ries an d is a h elp u l biom ech an ical m odel or
u n derstan din g th e path om ech an ics o w rist ractu res.
Fig 1.8-3 Depen din g on th e speci c ractu re pattern , a B C

III IV
dorsal approach betw een th e variou s exten sor V
com partm en ts I-VI is ch osen .
II
VI
In in ju ries requ irin g a dorsal approach to th e distal radiu s,
approach es (m arked as A, B, or C) betw een th e variou s A
exten sor com partm en ts are in dicated:
A: Approach to th e radial colu m n
B: Approach to th e in term ediate colu m n I
C: Approach to th e in term ediate colu m n or th e dorsal
lu n ate acet an d distal radiou ln ar join t.
Radius Ulna

dorsoradial region (I-V) an d on e exten sor com partm en t
in th e dorsou ln ar region (VI).
In a dorsal approach to th e distal radiu s, n u m erou s

com partm en ts m ay be in volved.
I II III IV V VI
1 Approache s
4 Sk in in cis io n
Fig 1.8-5 Th e radial an d in term ediate colu m n s can be

approach ed separately u sin g a sin gle dorsal skin in cision .
5 Ap p ro a ch t o t h e ra d ia l co lu m n
Tw o in cis io n o p t io n s
Fig 1.8-6 Depen din g on th e ractu re con gu ration , IV

III
variou s retin acu lar in cision s are possible to deal w ith 2 V
radial colu m n ractu res. Eith er o th e ollow in g option s
II
can be ch osen : VI
1. Approach to th e radial colu m n betw een th e rst an d
secon d exten sor com partm en ts 1
2. Approach to th e radial colu m n u n der th e secon d

exten sor com partm en t.
I
Radius Ulna
57
5 Ap p ro a ch t o t h e ra d ia l co lu m n (co n t )
Op t io n 1 : b e t w e e n firs t a n d s e co n d co m p a r t m e n t s
Fig 1.8-7 Th e approach in option 1 allow s plate position in g

on th e radial side o th e radial colu m n w h en it is n ot
n ecessary to expose th e articu lar su r ace. Th e radial
colu m n is approach ed w ith a su bcu tan eou s dissection
tow ard th e radial side.
Extensor
A ter exposin g th e exten sor pollicis lon gu s (EPL), a pollicis longus
secon d approach is m ade th rou gh th e retin acu lu m
betw een th e rst an d secon d exten sor com partm en ts.
Iden ti y th e sen sory bran ch o th e radial n erve, w h ich lies

in th e su bcu tan eou s f ap above th e rst com partm en t an d
m u st be protected. Sensory branch
of radial nerve
I it is di cu lt to obtain satis actory redu ction o a radial

styloid ractu re, it can be h elp u l to release th e brach iora-
dialis ten don .
In cis io n t h ro u gh firs t co m p a r t m e n t
Fig 1.8-8 Th e rst exten sor com partm en t is in cised at th e

level o th e m u scu loten din ou s tran sition an d is released
u p to th e tip o th e radial styloid. Th e ten don s o th e rst
com partm en t are released an d m obilized.
Extensor
Extensor carpi pollicis longus
radialis brevis
1 Approache s
Su b p e rio s t e a l e le va t io n o f s e co n d co m p a r t m e n t
Fig 1.8-9 Th e secon d com partm en t is elevated su bperios-

teally, leavin g th e com partm en t itsel in tact. Th e radial
colu m n is n ow exposed.
Op t io n 2 : e le va t io n u n d e r t h e s e co n d e xt e n s o r co m p a r t m e n t
Fig 1.8-1 0 In th is approach , Lister tu bercle is iden ti ed on

th e radial side an d th e secon d com partm en t is partially
elevated. Th e EPL ten don can be retracted to th e u ln ar side.
Extensor
pollicis longus
59
Ele va t io n o f s e co n d co m p a r t m e n t
Th e secon d com partm en t an d its con ten ts are

Fig 1.8-1 1
elevated rom th e distal radiu s by sh arp dissection .
Fig 1.8-1 2 Th e ECRB ten don is retracted rom th e f oor o

th e com partm en t. Th is allow s access to th e radiocarpal
articu lar su r ace on th e radial colu m n .
Extensor carpi Extensor

radialis brevis pollicis longus
1 Approache s
6 Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n
In cis io n o f t h e re t in a cu lu m
Fig 1.8-1 3 In th e approach to th e in term ediate colu m n B

III IV
(B), th e th ird com partm en t is open ed in lin e w ith th e EPL V
ten don . Wh en open in g th e exten sor com partm en t, be
care u l n ot to cu t th e ten don . II
VI
Radius Ulna
Fig 1.8-1 4 Th e in cision is exten ded proxim ally in lin e

w ith th e EPL. Distally, open th e exten sor retin acu lu m as
ar as n eeded. It is recom m en ded to preserve th e distal
part so th at th e ten don still glides tow ard th e th u m b.
Altern atively, th e com partm en t can be open ed distally
an d th e ten don elevated an d retracted radially. Extensor
pollicis longus
61
6 Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n (co n t )
Mo b iliza t io n o f e xt e n s o r p o llicis lo n gu s t e n d o n
Fig 1.8-1 5Th e EPL ten don is reed an d a vessel loop is

passed arou n d it.
Su b p e rio s t e a l e le va t io n o f t h e fo u r t h co m p a r t m e n t
Fig 1.8-1 6 Th e ou rth com partm en t is elevated su bperios-

teally, leavin g th e com partm en t itsel in tact. Th e in term e-
diate colu m n is n ow exposed.
1 Approache s
6 Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n (co n t )
Op t io n : a r t h ro t o m y
Fig 1.8-1 7 On ce th e com partm en ts h ave been elevated

an d th e distal radiu s exposed, th e capsu le can be open ed
to expose th e articu lar su r ace. A plate can be applied to
th e radial colu m n th rou gh th is approach . Th e EPL an d
ECRB ten don s can be retracted in eith er direction , as Extensor
pollicis longus
dictated by th e ractu re con gu ration .
Extensor carpi
Th e capsu lar in cision sh ou ld be big en ou gh to see th e radialis brevis
lu n ate acet an d a part o th e scaph oid acet in cases o
distal radial articu lar com pression or carpal bon e in ju ry.
7 Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n fo r t h e d o rs a l lu n a t e fa ce t a n d d is t a l ra d io u ln a r jo in t
Fig 1.8-1 8 An approach betw een th e ou rth an d th C

III IV
exten sor com partm en ts (C) is also possible. V
II
VI
Radius Ulna
63
7 Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n fo r t h e d o rs a l lu n a t e fa ce t a n d d is t a l ra d io u ln a r jo in t (co n t )
Fig 1.8-1 9 Th is w ill allow clear access to th e u ln ar side o

th e in term ediate colu m n to treat lu n ate acet an d DRUJ
in ju ries.
A ran ge o w ou n d closu res exist or th e variou s dorsal Vid e o

approach es to th e distal radiu s. Th ese are described in
u rth er detail in Part II Cases.

Vid e o 1 .8 -1
dorsal approach to th e distal radiu s.
1.9 Extended dorsal approach to the
distal radius

treated u sin g an exten ded dorsal approach .
2 In d ica t io n s
Fig 1.9-2 Th e exten ded dorsal approach can be u sed or

w rist u sion s or or join t bridgin g (span n in g) plate
xation o m u lti ragm en tary in traarticu lar distal radial
ractu res.
65

dorsoradial region (I-V) an d on e exten sor com partm en t
in th e dorsou ln ar region (VI).
In an exten ded dorsal approach to th e distal radiu s,

n u m erou s com partm en ts m ay be in volved.
I II III IV V VI
Fig 1.9-4 Wh en m obilizin g th e skin f aps, m ake su re n ot

to in ju re th e su per cial radial n erve.
1 Approache s
1.9 Extende d dorsal approach to the distal radius
5 Sk in in cis io n
In cis io n o p t io n s
Distal extension Distal incision
Dorsal approach
Proximal extension Proximal incision
a b c
Depen din g on th e ractu re con gu ration or disorder, variou s in cision s are possible. Th e ollow in g option s
Fig 1.9-5 a – c
can be ch osen :
1. Lon gitu din al skin in cision ( a )
2. Stan dard dorsal in cision w ith an addition al exten ded proxim al or exten ded distal in cision or both ( b )
3. Proxim al an d distal in cision s on ly ( c ).
Op t io n 1 : lo n git u d in a l s k in in cis io n
Fig 1.9-6 A lon gitu din al skin in cision is m ade alon g a lin e
over Lister tu bercle to th e in terspace betw een th e
secon d an d th ird m etacarpal.
67
In cis io n o f re t in a cu lu m
Fig 1.9-7 Th e th ird com partm en t is open ed in lin e with th e

exten sor pollicis lon gu s (EPL). Wh en open in g th e exten sor
com partm en t, be care u l n ot to cu t th e ten don .
Th e in cision is exten ded proxim ally in lin e with th e EPL
ten don . Distally, th e exten sor retin acu lu m is u lly open ed.
Extensor
pollicis longus
Mo b ilize t h e e xt e n s o r p o llicis lo n gu s
Fig 1.9-8 Th e EPL ten don is reed an d a vessel loop is

passed arou n d it. Th e ten don is retracted tow ard th e
radial side.
1 Approache s
Su b p e rio s t e a l e le va t io n o f t h e fo u r t h co m p a r t m e n t
Fig 1.9-9 Th e ou rth com partm en t is elevated

su bperiosteally, leavin g th e com partm en t itsel in tact. Th e
in term ediate colu m n is n ow exposed. Th e ten don s o th e
ou rth exten sor com partm en t are retracted to th e u ln ar
side. I n ecessary, th e ten don s o th e secon d exten sor
com partm en t are m obilized to th e radial side.
Fig 1.9-1 0 Th e periosteu m is in cised on th e dorsal side o

th e th ird m etacarpal an d th e in terosseou s m u scles
elevated su bperiostally, i n ecessary.
69
Op t io n 2 : d o rs a l in cis io n w it h a d d it io n a l p ro xim a l o r d is t a l in cis io n s
Distal Distal
extension extension
Dorsal Dorsal
approach approach
Proximal Proximal
extension extension
a b
Fig 1.9-1 1a –b In option 2, a stan dard dorsal in cision can be m ade w ith eith er an addition al exten ded proxim al or
exten ded distal in cision or both . How ever, it is rst n ecessary to determ in e w h ich m etacarpal align s best w h en th e
ractu re is redu ced. Note th at a m in im u m o th ree screw s sh ou ld be placed in th e m etacarpal. Th e m eth od or
determ in in g w h ich m etacarpal to u se is as ollow s:
1. Provision ally redu ce th e ractu re
2. Place th e plate on to th e dorsal su r ace o th e w rist
3. Use th e im age in ten si er, to m ake sm all adju stm en ts in radiou ln ar deviation allow in g th e optim al plate location to
be determ in ed over eith er th e secon d or th ird m etacarpal
4. Make th e in cision s.
1 Approache s
Ma rk in cis io n lin e s t h ro u gh t h e p la t e h o le s
Fig 1.9-1 2 Usin g th is approach , it is h elp u l to m ark all

in cision s at th e begin n in g th rou gh th e plate h oles. Draw a
3 cm straigh t rst skin in cision lin e over th e ch osen
m etacarpal. A secon d in cision lin e o 2 cm is draw n over
Lister tu bercle. Th e th ird an d n al straigh t in cision lin e o
3 cm is draw n over th e radial sh a t h oles.
Ma ke t h e d is t a l in cis io n
Fig 1.9-1 3A 3 cm in cision is m ade at th e base o th e

selected m etacarpal an d con tin u ed over th e sh a t. Th e
m etacarpal is exposed w h ile th e exten sor ten don s are
retracted an d protected.

Extensor carpi radialis longus
Extensor carpi radialis brevis
71
Ma ke t h e d o rs a l in cis io n a n d m o b ilize t h e e xt e n s o r p o llicis lo n gu s
Fig 1.9-1 4a –b Th e m iddle in cision is recom m en ded to

avoid an y dam age to th e EPL ( a ). Palpate Lister tu bercle
an d m ake a 2 cm lon gitu din al in cision directly over th e
bon y lan dm ark. Fu lly release th e EPL an d retract it
tow ard eith er th e radial or u ln ar side depen din g on th e
ractu re con gu ration ( b ). Mobilizin g th e EPL acilitates
plate in sertion , ractu re redu ction , an d stabilization o th e
articu lar su r ace, as w ell as th e application o bon e gra t Extensor pollicis longus
or llin g voids (i n ecessary). Th is in cision also allow s Extensor carpi radialis longus
slidin g o th e plate u n der th e secon d com partm en t Extensor carpi radialis brevis
ten don s to avoid im pin gin g th em u n der th e plate.

Abductor pollicis longus
Extensor carpi radialis longus
Extensor carpi radialis brevis

b
1 Approache s
Ma ke t h e p ro xim a l in cis io n
Extensor pollicis brevis Extensor pollicis brevis

Abductor pollicis longus Abductor pollicis longus
Extensor carpi radialis longus Extensor carpi radialis longus
Extensor carpi radialis brevis Extensor carpi radialis brevis
a b
Fig 1.9-1 5a –b Usin g th e im age in ten si er or gu idan ce, an in cision m easu rin g approxim ately 3 cm is m ade over th e
dorsal aspect o th e radiu s ju st proxim al to th e m u scle bellies o th e abdu ctor pollicis lon gu s (APL) an d th e exten sor
pollicis brevis (EPB) ten don s, in lin e w ith th e exten sor carpi radialis lon gu s (ECRL) an d brevis (ECRB) ten don s.
Th e exact location o th e in cision m ay depen d on w h eth er th e plate w ill attach distally at th e secon d or th ird m etacarpal.
For a secon d-m etacarpal xation by blu n t dissection , th e in terval betw een th e ECRL an d ECRB is developed an d th e
diaph ysis o th e radiu s is exposed ( a ).
For a th ird-m etacarpal xation by blu n t dissection , th e in terval betw een th e rst com partm en t (con tain in g th e APL an d
EPB ten don s) an d secon d com partm en t (ECRL an d ECRB ten don s) is developed an d th e diaph ysis o th e radiu s is
exposed ( b ). Retract th e rst com partm en t m u scles u ln arly an d th e secon d com partm en t radially.
73
Op t io n 3 : p ro xim a l a n d d is t a l in cis io n s
Fig 1.9-1 6 As an altern ative, th e approach can be m ade

u sin g ju st proxim al an d distal in cision s.
Distal incision
Proximal incision
Fig 1.9-1 7Th is is don e by m arkin g th e skin at th e level o

th e proxim al an d distal screw h oles o th e plate an d
m akin g 3–4 cm in cision s.
1 Approache s
Th e skin is closed in a stan dard ash ion .
75
1.10 Ulnar approach to the distal ulna
Fig 1.1 0-1 In ju ries in volvin g th e distal u ln a can be

treated u sin g an u ln ar approach .
2 In d ica t io n s
Fig 1.10 -2 Th e u ln ar approach is in dicated or all ractu res

o th e distal u ln a.
Radius Ulna
77
3 Sk in in cis io n
Fig 1.10 -3 Th e u ln ar sh a t an d th e ractu re gap betw een

th e u ln ar styloid an d th e distal m etaph ysis are u su ally
easily palpated.
A straigh t lon gitu din al in cision is m ade over th e distal

u ln a between th e ten don s o th e exten sor an d f exor carpi
u ln aris.
Extensor carpi
ulnaris Flexor carpi
ulnaris
Dis s e ct io n
Fig 1.10 -4 Th e dorsal bran ch o th e u ln ar n erve sh ou ld be

able to be seen . Care sh ou ld be taken to avoid in ju ry to
th is n erve. Th e ractu re site is th en exposed, i n ecessary,
releasin g th e u ln ar attach m en t o th e exten sor retin acu lu m .
Dorsal branch
of ulnar nerve
1 Approache s
1.10 Ulnar approach to the distal ulna
Fig 1.10 -5a –b Su pin ation o th e orearm resu lts in th e Flexor carpi ulnaris
u ln ar styloid lyin g dorsally. Th is exposes th e distal u ln a
w ith ou t in ter eren ce rom th e exten sor carpi u ln aris ( a ).
Pron ation o th e orearm exposes th e u ln ar styloid in th e
cen ter o th e approach ( b ).
Extensor carpi ulnaris

a
Extensor carpi ulnaris
b Flexor carpi ulnaris
Th e exten sor retin acu lu m is repaired as n ecessary, an d Vid e o

th e w ou n d is closed in layers.
Vid e o 1 .1 0-1Th is video dem on strates th e u ln ar approach

to th e distal u ln a.
79
Pa rt II Proximal interphalangeal
Cases (PIP) joint
Pa rt II Case s

2 Carpals
Pa rt II Case s

2.1 Scaphoid—nondisplace d fracture
treate d percutane ously with a headle ss
compre ssion screw
1 Ca s e d e s crip t io n
Fig 2.1-1 a –b A 26-year-old m an ell on to h is

ou tstretch ed righ t h an d du rin g a clu b soccer gam e
n otin g im m ediate acu te pain . An exam in ation
revealed pain in th e an atom ical sn u box o h is
w rist. Th e AP an d lateral x-rays revealed a ractu re
lin e across th e w aist o th e scaph oid, h ow ever, carpal
a b align m en t appeared n orm al.
a b c
Fig 2.1-2a – cTh e 2-D an d 3-D CT scan s iden ti ed th e ractu re as h avin g m in im al displacem en t bu t goin g
th rou gh both cortices o th e scaph oid in th e ron tal an d sagittal plan es (arrow s).
2 In d ica t io n s
No n d is p la ce d s ca p h o id fra ct u re s
Fig 2 .1-3 Percu tan eou s (m in im ally in vasive) xation is largely in dicated or
n on displaced or m in im ally displaced ractu res o th e w aist o th e scaph oid.
85
Pa rt II Case s
In t e rn a l fixa t io n vs n o n o p e ra t ive t re a t m e n t Im a gin g
In gen eral, in tern al xation o ractu res is th ou gh t to With n on displaced an d m in im ally displaced scaph oid
provide e ective bon e h ealin g in at least th e sam e i n ot ractu res, con ven tion al x-rays o ten do n ot adequ ately
less tim e th an n on operative treatm en t, bu t th at th e dem on strate th e com plete ractu re con gu ration . As
period o im m obilization is sh orten ed. Percu tan eou s sh ow n in th e case description o th is patien t, CT scan s
treatm en t brin gs th e advan tages o avoidin g a w ide w ere th ere ore per orm ed an d are stron gly recom m en ded
su rgical approach , preservin g th e palm ar ligam en t i a percu tan eou s procedu re is plan n ed.
com plex an d local vascu larity, an d avoidin g th e exten ded
im m obilization requ ired or h ealin g a ter a w ider open
exposu re.
Readers o th is pu blication are im m ediately rem in ded th at

in som e in stan ces o w rist in ju ry, n on operative treatm en t
is a viable altern ative. How ever, th e detailed cases
provided th rou gh ou t th is book ou tlin e situ ation s w h ere,
or th ose patien ts, su rgical tech n iqu es w ere deem ed th e
m ore appropriate treatm en t option .
An a t o m ica l co n s id e ra t io n s Va s cu la rit y
Dorsal l l Palmar
a b c d e
Fig 2.1-4 a – eWith all scaph oid ractu res, th e an atom y an d

vascu larity o th e scaph oid n eed to be con sidered. Close
to 80% o th e su r ace o th e scaph oid is covered w ith
articu lar cartilage, w h ich greatly lim its th e poin ts o en try a b
or xation devices. An addition al con strain t is th e cu rved
m orph ology o th e scaph oid. Th is m ean s th at it can be Fig 2.1-5 a – b Th e blood su pply o th e scaph oid is derived
di cu lt to pass a w ire or xation device alon g th e tru e rom tw o sou rces. Th e m ain sou rce is a grou p o blood
lon g axis o th e bon e, yet th is is th e im plan t location th at vessels en terin g th e dorsal su r ace o th e distal pole ( a ).
provides th e greatest stability an d com pression . Occasion - Th is is th e largest con tribu tion to th e vascu larity o th e
ally, access to th e correct distal en try poin t or a device scaph oid as th e dorsal grou p su pplies th e proxim al tw o
can on ly be gain ed by a lim ited excision o th e overh an g- th irds o th e bon e. How ever, th e proxim al pole relies on a
in g edge o th e trapeziu m . retrograde blood f ow , a act th at m akes th is part o th e
scaph oid m ore pron e to su er avascu lar bon e n ecrosis
an d a con sequ en t n on u n ion .
A secon d grou p o vessels en ters th e palm ar aspect o th e

distal pole ( b ). Th ese vessels con tribu te largely to th e
vascu larity o th e distal th ird.
2 Carpal bone s
2.1 Scaphoid—nondisplace d fracture tre ate d percutane ously with a he adle ss compre ssion scre w
3 Pre o p e ra t ive p la n n in g
Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• Headless com pression screw set 2.4 or 3.0

• 1.1 m m K-w ires, 150 m m len gth
• Hypoderm ic n eedle
• Osteotom e
• Im age in ten si er
Fig 2.1-6 Be ore startin g th e procedu re, re-exam in e th e

ractu re pattern u n der an im age in ten si er. Be su re th at
th e ractu re is su itable or a percu tan eou s tech n iqu e an d
th at n o secon dary displacem en t h as occu rred. Position th e
patien t su pin e an d place th e orearm on th e h an d table.
By abdu ctin g th e patien t’s sh ou lder it is possible or th e
su rgeon an d th e assistan t to sit on eith er side o th e h an d
table. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph y-
lactic an tibiotics are option al.
Ap p ro a ch
a b
Fig 2.1-7 a – b Tw o approach es exist or percu tan eou s screw xation , en terin g eith er palm arly
( a ) or dorsally ( b ) to reach th e scaph oid rom eith er th e distal or proxim al pole. For th e
patien t in th is ch apter, th e palm ar approach w as u sed, en terin g th rou gh th e distal pole o th e
scaph oid.
87
Pa rt II Case s
4 Su rgica l a p p ro a ch (co n t )
Hyp e re xt e n d t h e w ris t Ma rk t h e s k in
Fig 2.1-8 To assist in th e approach , place a Fig 2.1-9 It can be h elp u l to m ark on
rolled tow el or bolster u n der th e w rist an d th e skin th e position o th e scaph oid,
h yperexten d it. Th e u se o th e su pport h elps th e palm ar rim o th e distal radiu s, an d
access th e correct en try poin t or a gu ide w ire. th e level o th e scaph otrapezial join t.
Sk in in cis io n
A stab in cision o 5–10 m m is m ade distally to th e scaph otrapezial join t. Deepen th e in cision th rou gh th e su bcu tan eou s
tissu es by blu n t dissection th en in cise th e capsu le o th e scaph otrapezial join t. Th e distal pole o th e scaph oid is n ow
accessible or in sertion o a K-w ire, w h ich w ill be u sed as a gu ide w ire.
5 Re d u ct io n
De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire
Palmar ridge
of trapezium
a b a b
Fig 2.1-10a –b Th e correct en try poin t or th e gu ide wire is Fig 2.1-1 1a –b Use a h ypoderm ic n eedle to determ in e th e
th e cen ter o th e distal pole o th e scaph oid. However, to in sertion poin t radiologically be ore in sertin g th e gu ide
get proper access, it m ay be n ecessary to rem ove th e palm ar w ire.
ridge o th e trapeziu m with an osteotom e or a bon e n ibbler/
ron geu r. Th is reveals th e distal pole o th e scaph oid an d
allows th e path o th e gu ide wire to be m ade m ore cen trally
with in th e bon e.
2 Carpal bone s
5 Re d u ct io n (co n t )
In s e r t t h e gu id e w ire
Fig 2 .1 -12 a – cTh e gu ide w ire sh ou ld be

in serted th rou gh a drill gu ide ( a ). I n o
drill gu ide is available, u se a protective
sleeve. Th e position o th e w ire sh ou ld
be as perpen dicu lar as possible to th e
ractu re lin e ( b – c ). In obliqu e ractu res,
th is prin ciple m ay h ave to be com pro-
m ised. Do n ot pen etrate beyon d th e
a b c proxim al cortex o th e scaph oid.
a b c
Fig 2.1-1 3a –c Th e gu ide w ire w as in serted at th e con rm ed en try poin t.
89
Pa rt II Case s
6 Fixa t io n
Me a s u re s cre w le n g t h Drillin g
a b x minus 2-3mm
Fig 2.1-1 4a –b Tw o m eth ods can be em ployed or Fig 2.1-1 5 Use on ly th e dedicated drill bit. A pow er drill
m easu rin g th e desired len gth o th e h eadless screw . w ill exert less orce on th e ragm en ts th an m an u al drillin g
In sert th e dedicated m easu rin g device over th e gu ide an d w ill redu ce th e risk o displacin g th e ragm en ts. A
w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly sm all pow er drill w ith slow rotation is th e pre erred
position ed on th e tu bercle or a reliable m easu rem en t ch oice. Use salin e solu tion to cool th e drill bit in order to
( a ). Altern atively, i th e dedicated m easu rin g device is m in im ize th erm al in ju ry. Ch eck th e position o th e tip o
n ot available, take an oth er gu ide w ire o th e sam e len gth th e drill bit u n der im age in ten si cation .
an d place its tip on to th e bon e at th e in sertion poin t ( b ).
Th e di eren ce betw een th e protru din g en ds o th e tw o
w ires in dicates th e len gth o th e drill h ole or th e screw .
Su btract 2–3 m m to determ in e th e screw len gth .
Se le ct t h e s cre w
a c d
Fig 2.1-1 6a –dSelect th e appropriately sized can n u lated (ie, h ollow ) h eadless com pression screw ( a –c ).
Th e selected screw is in serted in to th e in tern al th read o th e com pression sleeve ( d ).
2 Carpal bone s
6 Fixa t io n (co n t )
In s e r t t h e s cre w
Fig 2.1-1 7 Th e screw an d com pression sleeve are in serted a b c

over th e gu ide w ire.
Th e screw is tigh ten ed u n til su
Fig 2.1-1 8a –c cien t
com pression is ach ieved.
a b
Fig 2.1-1 9a –b Th e can n u lated screw driver is in serted.

Th e com pression sleeve is h eld still, u sin g th e th u m b an d
in dex n ger to rm ly h old th e com pression sleeve, as
th e screw driver tu rn s th e screw an d advan ces it ou t o
th e com pression sleeve an d in to th e bon e. Com pression
is m ain tain ed by th e com pression sleeve du rin g th is
action .
91
Pa rt II Case s
Ad va n ce a n d co u n t e rs in k t h e s cre w En s u re co rre ct s cre w a n d t h re a d le n g t h
a b c
Fig 2.1-20a –c Th e screwdriver h as th ree colored m arkin gs a b

th at are visible at th e edge o th e com pression sleeve. Th e
green m ark in dicates th e screw is still u lly retain ed with in Fig 2.1-2 1a –b It is vital th at th e th readed section o th e tip
th e com pression sleeve ( a ). Th e yellow m ark in dicates th e o th e screw passes com pletely beyon d th e ractu re plan e
screw h as been advan ced level with th e su r ace o th e bon e i in ter ragm en tary com pression is to be ach ieved. Also
( b ). Th e red m ark in dicates th e screw h as been cou n tersu n k en su re th at th e screw is n ot too lon g n or overtigh ten ed as
2 mm u n der th e bon e su r ace ( c). Cou n tersin k th e screw by it cou ld protru de beyon d th e cortical su r ace an d lose
tu rn in g th e screwdriver sh a t wh ile sim u ltan eou sly h oldin g com pression , or en dan ger th e so t tissu es, especially
th e com pression sleeve station ary. ten don s an d n eu rovascu lar stru ctu res.
Co m p le t e t h e fixa t io n
a b
Fig 2.1-2 2 Be ore n al tigh ten in g, Fig 2.1-2 3a –b In traoperative im ages o th e patien t sh ow
rem ove th e gu ide w ire. Make su re th e placem en t o th e h eadless screw in lin e w ith th e
th at th e th reads at th e n ear en d o lon gitu din al axis o th e scaph oid w ith th e screw crossin g
th e screw are u lly bu ried in th e th e ractu re lin e.
bon e at th e in sertion site. Ch eck
th e n al position o th e screw an d
scaph oid stability u sin g im age
in ten si cation or x-rays.
2 Carpal bone s
7 Re h a b ilit a t io n
Aft e rca re Fo llo w -u p
See th e patien t a ter 2–5 days to ch an ge th e dressin g.

A ter 10 days, rem ove th e su tu res an d con rm w ith
x-rays th at n o secon dary displacem en t h as occu rred.
Fig 2.1-2 4 Wh ile th e patien t is in bed, u se pillow s to keep

th e h an d elevated above th e level o th e h eart to redu ce
sw ellin g.
Im m o b iliza t io n Fu n ct io n a l e xe rcis e s
Fig 2.1-26 Followin g su rgery, begin active con trolled ran ge

o m otion exercises. Active m otion exercises an d later
resistan ce exercises sh ou ld be in itiated based u pon th e
su rgeon ’s decision as to tim e a ter su rgery an d patien t
com plian ce. Load-bearin g activities are u su ally delayed
u n til radiological eviden ce o bon e h ealin g. Th e im por-
tan ce o m obilization m u st be em ph asized to th e patien t
Fig 2.1-2 5 Rest th e w rist w ith a w ell-padded below -elbow an d reh abilitation sh ou ld be su pervised by a ph ysical
splin t or 48–72 h ou rs. For am bu latin g patien ts, dispen se th erapist.
w ith th e splin t an d apply an elastic ban dage. I n ecessary,
pu t th e arm in a slin g an d elevate to above th e h eart.
93
Pa rt II Case s
8 Ou t co m e
Fig 2 .1-2 7a –bAt th e 1-year ollow -u p, th e AP

a b an d lateral x-rays in dicated excellen t h ealin g.
a b c d
Fig 2.1-2 8a –d Th ere w as u ll clin ical m otion an d retu rn o n orm al stren gth .
Vid e o
Th is video dem on strates a scaph oid ractu re

Vid e o 2 .1 -1
procedu re treated w ith percu tan eou s xation w ith a 3.0
m m h eadless com pression screw .
2.2 Scaphoid—displaced fracture treated with a
headless compression screw
Fig 2.2-1a – b A 38-year-old

con stru ction w orker in ju red
h is dom in an t le t w rist w h en
h e ell rom a 3 m plat orm
at w ork. Th e in itial x-rays
con rm ed an u n stable
displaced ractu re o th e
a b w aist o th e scaph oid.
2 In d ica t io n s
Dis p la ce d s ca p h o id fra ct u re s Ch o ice o f im p la n t
a b
Fig 2.2-3a –b A 2.4 m m or 3.0 m m im plan t u sin g

retrograde in sertion (distal en try poin t) is in dicated or
Fig 2.2-2 Acu te scaph oid ractu res are con sidered to be scaph oid waist ractu res or w h en th e proxim al ragm en t is
displaced wh en th ere is a 1 m m gap between th e ragm en ts larger th an 10 m m ( a ). For sm aller proxim al ragm en ts,
on an y sin gle view . Displacem en t in an acu te ractu re th e u se o an an tegrade in sertion (proxim al en try poin t)
in creases th e risks o n on u n ion i th e in ju ry is m an aged w ith sin gle or m u ltiple m in i h eadless bon e screw s
n on operatively in a cast. Con sequ en tly, con sideration m u st (1.5 m m ) is advisable ( b ). As th is patien t h ad a scaph oid
be given to redu ction an d stabilization by in tern al xation . w aist ractu re, a palm ar retrograde in sertion w as requ ired.
An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s Im a gin g
Th e scaph oid’s u n iqu e an atom y an d vascu larity m u st also Obtain in g a u ll series o scaph oid x-rays o th e a ected
be con sidered. Re er to th e in dication s topic in ch apter an d n orm al con tralateral side is n ecessary or su rgical
2.1 Scaph oid—n on displaced ractu re treated percu tan e- plan n in g.
ou sly w ith a percu tan eou s screw or m ore in orm ation .
95
Pa rt II Case s

• 1.1 m m K-w ires
• Osteotom e
Fig 2.2-4 Position th e patien t su pin e an d place th e

orearm on th e h an d table. Su pin ate th e orearm . A
n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic
an tibiotics are option al.
Ap p ro a ch Hyp e re xt e n d t h e w ris t
Fig 2.2-5 In cases w h ere redu ction can n ot be ach ieved Fig 2.2-6 To assist in th e approach , place a rolled tow el or
closed, a direct open approach is n ecessary. Th e su rgical bolster u n der th e w rist an d h yperexten d it. Th e u se o th e
approach u sed or th is patien t w as a palm ar approach su pport h elps access th e correct en try poin t or a gu ide
in volvin g a radial lon gitu din al an gled skin in cision (see w ire. Th is position also h elps to redu ce th e scaph oid
ch apter 1.1 Palm ar approach to th e scaph oid). ragm en ts.
2 Carpal bone s
2.2 Scaphoid—displace d fracture tre ate d with a he adle ss compre ssion scre w
5 Re d u ct io n
De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire In s e r t t h e gu id e w ire
Palmar ridge
of trapezium
a b
Fig 2.2-7 Th e correct en try poin t or th e gu ide w ire is th e Fig 2.2-8a –b Th e gu ide wire sh ou ld be in serted th rou gh a
cen ter o th e distal pole o th e scaph oid. How ever, to get drill gu ide ( a ). I n o drill gu ide is available, u se a protective
proper access, it m ay be n ecessary to rem ove th e palm ar sleeve. Th e position o th e wire sh ou ld be as perpen dicu lar
ridge o th e trapeziu m w ith an osteotom e or a bon e as possible to th e ractu re lin e ( b ). In obliqu e ractu res, th is
n ibbler/ ron geu r. Th is reveals th e distal pole o th e prin ciple m ay h ave to be com prom ised. Do n ot pen etrate
scaph oid an d allow s th e path o th e gu ide w ire to be beyon d th e proxim al cortex o th e scaph oid.
m ade m ore cen trally w ith in th e bon e.
Fig 2.2-9 a –b A secon d K-w ire is u se u l to preven t rotation o

th e ragm en ts as com pression is ach ieved. Th e secon d K-w ire
sh ou ld be rem oved be ore n al tigh ten in g o th e screw . Im age
in ten si cation in at least tw o plan es is u sed to con rm accu rate
advan cem en t o th e gu ide w ire in th e scaph oid axis an d
perpen dicu lar to th e ractu re plan e. Redu ction can o ten be
ach ieved by com pression alon e as th e can n u lated screw is
a b care u lly in serted.
97
Pa rt II Case s
6 Fixa t io n
Me a s u re s cre w le n g t h
a b c x minus 2–3 mm
Fig 2.2-10a –c Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw . In sert th e dedicated
m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly position ed on th e tu bercle or a
reliable m easu rem en t ( a ) (as sh ow n on th e patien t) ( b ). Altern atively, i th e dedicated m easu rin g device is n ot available,
take an oth er gu ide w ire o th e sam e len gth an d place its tip on to th e bon e at th e in sertion poin t ( c ). Th e di eren ce
betw een th e protru din g en ds o th e tw o w ires in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to
determ in e th e screw len gth .
Drillin g Se le ct t h e s cre w
a b
Fig 2.2-1 1 Use on ly th e dedicated drill bit. A pow er drill Fig 2.2-1 2a –b Select th e appropriately sized can n u lated
w ill exert less orce on th e ragm en ts th an m an u al drillin g h eadless com pression screw ( a ). Th e selected screw is
an d w ill redu ce th e risk o displacin g th e ragm en ts. A in serted in to th e in tern al th read o th e com pression
sm all pow er drill w ith slow rotation is th e pre erred sleeve ( b ).
ch oice. Use salin e solu tion to cool th e drill bit in order to
m in im ize th erm al in ju ry. Ch eck th e position o th e tip o
th e drill bit u n der im age in ten si cation .
2 Carpal bone s
a b a b c
Fig 2.2-1 3a –b Th e screw an d com pression sleeve are Th e screw is tigh ten ed u n til su
in serted over th e gu ide w ire. com pression is ach ieved.
a b c
Fig 2.2-1 5a –c Th e can n u lated screw driver is in serted. Th e com pression sleeve is h eld still, u sin g th e th u m b an d in dex
n ger to rm ly h old th e com pression sleeve, as th e screw driver tu rn s th e screw an d advan ces it ou t o th e com pression
sleeve an d in to th e bon e. Com pression is m ain tain ed by th e com pression sleeve du rin g th is action .
99
Pa rt II Case s
a b c
Fig 2.2-16a –c Th e screwdriver h as th ree colored m arkin gs a b

th at are visible at th e edge o th e com pression sleeve. Th e
green m ark in dicates th e screw is still u lly retain ed with in Fig 2.2-1 7a –b It is vital th at th e th readed section o th e tip
th e com pression sleeve ( a ). Th e yellow m ark in dicates th e o th e screw passes com pletely beyon d th e ractu re plan e
screw h as been advan ced level with th e su r ace o th e bon e i in ter ragm en tary com pression is to be ach ieved. Also
( b ). Th e red m ark in dicates th e screw h as been cou n tersu n k en su re th at th e screw is n ot too lon g n or overtigh ten ed as
2 mm u n der th e bon e su r ace ( c). Cou n tersin k th e screw by it cou ld protru de beyon d th e cortical su r ace an d lose
tu rn in g th e screwdriver sh a t wh ile sim u ltan eou sly h oldin g com pression , or en dan ger th e so t tissu es, especially
th e com pression sleeve station ary. ten don s an d n eu rovascu lar stru ctu res.
Fig 2.2-1 8 Be ore n al tigh ten in g, rem ove th e gu ide w ire. Fig 2.2-1 9 Th e in traoperative x-ray con rm ed correct
Make su re th at th e th reads at th e n ear en d o th e screw position in g o th e im plan t togeth er w ith redu ction o th e
are u lly bu ried in th e bon e at th e in sertion site. Ch eck u n stable ractu re.
th e n al position o th e screw an d scaph oid stability u sin g
im age in ten si cation or x-rays.
2 Carpal bone s


sw ellin g.
Fig 2.2-2 2 Follow in g su rgery, begin active con trolled

ran ge o m otion exercises. Active m otion exercises an d
later resistan ce exercises sh ou ld be in itiated based u pon
th e su rgeon ’s decision as to tim e a ter su rgery an d patien t
an d reh abilitation sh ou ld be su pervised by a ph ysical
Fig 2.2-2 1 Th e type an d du ration o postoperative th erapist.
im m obilization depen ds on a n u m ber o actors in clu din g
th e qu ality o th e in tern al xation as w ell as patien t
activity an d reliability. It m ay be n ecessary to rest th e
w rist or several w eeks in a plaster or rem ovable splin t.
Du rin g th at tim e, th e patien t is en cou raged to rem ove th e
splin t or sh ort periods to allow gen tle w rist m otion .
101
Pa rt II Case s
8 Ou t co m e
a b
At th e 14-m on th ollow -u p, th e x-rays

Fig 2.2-2 3a –b
con rm ed h ealin g.
a b
c d
Fig 2.2-2 4a –d Th e patien t h ad ach ieved a u ll ran ge o m otion .
2.3 Scaphoid—multifragmentary fracture treated with
a headless compression screw and lag screw
Fig 2.3-1a – b A 29-year-old teach er

w as in volved in a h igh -speed
collision on h is m otorcycle. He
in ju red h is righ t dom in an t w rist.
Th e x-rays con rm ed a displaced
m u lti ragm en tary ractu re o th e
a b scaph oid.
2 In d ica t io n s
Mu lt ifra gm e n t a r y s ca p h o id fra ct u re s Ch o ice o f im p la n t
Fig 2.3-2 Acu te displaced an d m u lti ragm en tary scaph oid Fig 2.3-3 In m u lti ragm en tary ractu res, a 2.4 m m or
ractu res are o ten th e resu lt o h igh -en ergy im pact. Th ey 3.0 m m im plan t is in dicated or stabilization o th e large
are u n stable ractu res an d th ere is a stron g possibility o ragm en ts. For th e sm aller addition al ragm en ts, th e u se o
later displacem en t even i th ey do n ot appear displaced on m in i h eadless bon e screws or sm all cortical lag screws is
prim ary presen tation . Th ese in ju ries are at a h igh risk o advisable. K-wires are always an option i th e in trodu ction
n on u n ion i th e in ju ry is m an aged n on operatively in a o an im plan t proves di cu lt. For th is patien t, a com bin a-
cast. Con sequ en tly, con sideration m u st be given to open tion o a h eadless com pression screw an d a lag screw was
redu ction an d stabilization by in tern al xation . requ ired.
A system atic approach to th e stabilization o each o th e

large ragm en ts m ay be requ ired. Wh en th e ragm en ts are
too sm all or in dividu al stabilization , con sideration sh ou ld
be given to excision o th ese ragm en ts an d replacem en t
by prim ary bon e gra t.
103
Pa rt II Case s
An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s Im a gin g
Th e scaph oid’s u n iqu e an atom y an d vascu larity m u st also Obtain in g a u ll series o scaph oid x-rays o th e a ected
be con sidered. Re er to th e in dication s topic in ch apter an d n orm al con tralateral side is n ecessary or su rgical
2.1 Scaph oid—n on displaced ractu re treated percu tan e- plan n in g.
ou sly w ith a h eadless com pression screw or m ore
in orm ation .

• Modu lar screw set 1.5 or 2.0
• Poin ted redu ction orceps
• Osteotom e

orearm on th e h an d table. In m u lti ragm en tary ractu res,
a dorsal an tegrade or palm ar retrograde approach can be
u sed, depen din g on ractu re con gu ration . Pron ate th e
orearm on th e h an d table or a dorsal approach . In
u n u su al circu m stan ces, a com bin ed dorsal an d palm ar
approach m ay be requ ired. A n on sterile pn eu m atic
tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.
2 Carpal bone s
2.3 Scaphoid—multifragmentary fracture tre ate d with a he adle ss com pre ssion scre w and lag scre w
Ap p ro a ch
Fig 2.3-5 Th e su rgical approach u sed w as a dorsal

approach du e to th e particu lar ractu re con gu ration (see
ch apter 1.2 Dorsal approach to th e scaph oid).
a b
Fig 2.3-6a –b For th is patien t, a lon gitu din al dorsoradial skin in cision was m ade, startin g over th e distal
radiu s, an d exten din g toward th e base o th e th u m b passin g arou n d th e dorsal aspect o th e scaph oid.
105
Pa rt II Case s
5 Re d u ct io n
Dire ct re d u ct io n In s e r t K-w ire s
Fig 2.3-7 With m u lti ragm en tary scaph oid ractu res, it is Fig 2.3-8 I th e ractu re can n ot be redu ced w ith th e
o ten di cu lt to ach ieve closed redu ction . I open orceps, in sert a K-w ire in to each ragm en t an d u se th e
redu ction is requ ired, redu ce th e ractu re w ith sm all w ires as joysticks to m an ipu late th e ragm en ts.
poin ted redu ction orceps.
Fig 2.3-9 Th e correct en try poin t or th e gu ide w ire is in Fig 2.3-1 0 Th e gu ide w ire is in serted in th e axis o th e
th e cen ter o th e proxim al pole, directly adjacen t to th e sh a t o th e rst m etacarpal, in radial abdu ction . Du rin g
scaph olu n ate ligam en t in sertion . th e in trodu ction o th e gu ide w ire, th e w rist sh ou ld be in
f exion oth erw ise th e en try poin t can n ot be reach ed. Do
n ot pen etrate th e scaph otrapezial join t w ith th e gu ide
w ire. In m u lti ragm en tary ractu res, th e gu ide w ire also
h elps to m ain tain th e redu ction .
Im age in ten si cation in at least tw o plan es is requ ired to

con rm accu rate advan cem en t o th e gu ide w ire in th e
scaph oid axis an d to m ake su re th at th ere is n o rotation al
de orm ity.
2 Carpal bone s
6 Fixa t io n
In s e r t la g s cre w Us e o f la g s cre w s
a b
Fig 2.3-1 1 Mu lti ragm en tary ractu res in volvin g th e Fig 2.3-1 2a –b Be su re to in sert th e screw as a lag screw ,
proxim al h al o th e scaph oid can n ot be xed w ith a w ith a glidin g h ole in th e n ear cortex, an d a th readed
h eadless screw alon e. Addition al K-w ires, or as in th is h ole in th e ar cortex ( a ). In sertin g a screw across a
case an addition al lag screw , sh ou ld be con sidered. ractu re plan e th at is th readed in both cortices (position
screw ) w ill h old th e ragm en ts apart an d apply n o
A 1.5 m m lag screw is rst placed in to th e scaph oid to in ter ragm en tary com pression ( b ).
m ake th e 3-part ractu re in to 2 parts. Th e com m in u ted
ragm en t is directly secu red to th e body o th e scaph oid.
Co u n t e rs in k in g
a b
Fig 2.3-13a –b Also en su re to cou n tersin k th e screw to

redu ce th e risk o so t-tissu e irritation , so th at th e screw
h ead h as m axim al con tact area with th e bon e.
107
Pa rt II Case s
a b x minus 2–3 mm
Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw . In sert th e dedi-
Fig 2 .3 -1 4a –b
cated m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly position ed on th e tu bercle
or a reliable m easu rem en t ( a ). Altern atively, i th e dedicated m easu rin g device is n ot available, take an oth er gu ide w ire
o th e sam e len gth an d place its tip on to th e bon e at th e in sertion poin t ( b ). Th e di eren ce betw een th e protru din g en ds
o th e tw o w ires in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to determ in e th e screw len gth .
Drillin g
Fig 2.3-1 5 Use on ly th e dedicated drill bit. A pow er drill

w ill exert less orce on th e ragm en ts th an m an u al drillin g
an d w ill redu ce th e risk o displacin g th e ragm en ts. A
sm all pow er drill w ith slow rotation is th e pre erred
ch oice. Use salin e solu tion to cool th e drill bit in order to
m in im ize th erm al in ju ry. Ch eck th e position o th e tip o
th e drill bit u n der im age in ten si cation .
2 Carpal bone s
Se le ct a n d in s e r t t h e s cre w En s u re co rre ct s cre w a n d t h re a d le n g t h
a b a b
Fig 2.3-1 6a –b Select th e appropriately sized can n u lated Fig 2.3-1 7a –b It is vital th at th e th readed section o th e tip
h eadless compression screw. In sert th e screw over th e gu ide o th e screw passes com pletely beyon d th e ractu re plan e
wire. However, as th is is a m u lti ragm en tary ractu re, i in ter ragm en tary com pression is to be ach ieved. Also
stron g com pression / overcom pression with th e screw is n ot en su re th at th e screw is n ot too lon g n or overtigh ten ed as
recom m en ded becau se o th e possibility o collapse o th e it cou ld protru de beyon d th e cortical su r ace an d lose
ractu re. In stead o a com pression screw, a position screw is com pression , or en dan ger th e so t tissu es, especially
recom m en ded in th is situ ation , alth ou gh by virtu e o th e ten don s an d n eu rovascu lar stru ctu res.
di eren tial pitch o th e th reads on th e screw, th ere will be
som e com pression regardless. On e o th e advan tages o
th ese h eadless screws is th at th ey can be in serted with ou t
th e com pression sleeve, h elpin g to avoid th e possible
com plication o u n stable ractu re collapse.
Ad va n ce t h e s cre w Co m p le t e t h e fixa t io n
Th e proxim al en d o th e screw sh ou ld be advan ced u n til Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re
it is bu ried ben eath th e su bch on dral bon e. th at th e th reads at th e n ear en d o th e screw are u lly
bu ried in th e bon e at th e in sertion site. Ch eck th e n al
position o th e screw an d scaph oid stability u sin g im age
in ten si cation or x-rays.
109
Pa rt II Case s
Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s
Fig 2.3-18 Th e patien t sh ou ld receive th e stan dard

postoperative rest, in ju ry elevation , ollow -u p, rem oval o
stitch es, an d im m obilization as requ ired. Follow in g
su rgery, begin active con trolled ran ge o m otion exercises.
For u rth er in orm ation , see th e reh abilitation topic in
ch apter 2.2 Scaph oid—displaced ractu re treated w ith a
h eadless com pression screw .
8 Ou t co m e
a b c
Fig 2.3-19a –c At th e 2-year ollow-u p, PA, obliqu e, an d lateral x-rays con rm ed u ll h ealin g.
a b
Fig 2.3-2 0a –b Th e patien t h ad n early u ll ran ge o w rist exten sion an d f exion .
2.4 Scaphoid, proximal pole —fracture treated
with a headless compression screw
a b c
Fig 2.4-1a – c A 20-year-old u n iversity stu den t w as seen in th e em ergen cy departm en t ollow in g a all on to h is
ou tstretch ed righ t h an d. Th e m an su ered w rist pain , w h ich w as elicited by th e f exion o th e w rist, du rin g palpation
over th e sn u box, an d w h en axial com pression w as applied to th e th u m b. Th e in itial PA x-ray sh ow ed a tin y
ractu re o th e proxim al pole o th e scaph oid. Addition al CT scan s w ere per orm ed in th e tru e lon gitu din al axis o
th e scaph oid in th e coron al an d sagittal plan e, w h ich also in dicated th e proxim al pole ractu re. Th e sagittal view
sh ow ed th at th e ragm en t w as n ot as sm all as w as su spected w ith th e x-ray.
2 In d ica t io n s
Pro xim a l p o le fra ct u re s
Fig 2.4-2 Scaph oid ractu res are th e m ost com m on carpal ractu res an d approxim ately
10–20% o th ese in volve th e proxim al pole. Th e proxim al pole relies largely on a retro-
grade blood f ow , so th e bon e relies on distal to proxim al in traosseou s blood su pply or
h ealin g. Th is m akes proxim al pole ractu res h igh ly pron e to avascu lar bon e n ecrosis,
delayed u n ion , an d n on u n ion . Non operative treatm en t requ ires a prolon ged period o
im m obilization o 3–6 m on th s. Th ere ore, operative treatm en t via a dorsal approach
sh ou ld be con sidered.
111
Pa rt II Case s
Ch o ice o f im p la n t An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s
Th e scaph oid’s u n iqu e an atom y an d vascu larity are

critically im portan t in cases in volvin g th e proxim al pole.
Re er to th e in dication s topic in ch apter 2.1 Scaph oid—
n on displaced ractu re treated percu tan eou sly w ith a
h eadless com pression screw or m ore in orm ation .
Im a gin g
a b c
Fig 2.4-3a –c For proxim al pole ractu res, i th e proxim al Obtain in g a u ll series o scaph oid x-rays o th e a ected
ragm en t is large en ou gh , a 2.4 m m or 3.0 m m im plan t an d n orm al con tralateral side is n ecessary or su rgical
u sin g an tegrade in sertion is advisable ( a ). For sm aller plan n in g. Addition al CT scan s in th e tru e lon gitu din al
proxim al ragm en ts, sin gle or m u ltiple m in i h eadless bon e axis o th e scaph oid are h elp u l to iden ti y de orm ity.
screws (1.5 m m ) can be u sed ( b ). For very sm all ragm en ts
(f akes), K-wires m ay be a better option ( c). For th is patien t,
a h eadless com pression screw u sin g an an tegrade in sertion
was requ ired.


orearm on a h an d table. Pron ate th e orearm . A n on ster-
ile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics
are option al.
2 Carpal bone s
2.4 Scaphoid, proximal pole —fracture tre ate d with a he adle ss compre ssion scre w
Ap p ro a ch
Fig 2.4-5 Th e su rgical approach u sed was a dorsal approach

(see ch apter 1.2 Dorsal approach to th e scaph oid).
5 Re d u ct io n
Dire ct re d u ct io n De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire
Fig 2.4-6 Use sm all poin ted redu ction orceps to redu ce Fig 2.4-7 Th e correct en try poin t or th e gu ide w ire is in
th e ractu re. th e cen ter o th e proxim al pole, directly adjacen t to th e
scaph olu n ate ligam en t in sertion .
113
Pa rt II Case s
a b
Fig 2.4-8a –b Th e gu ide wire is in serted in th e axis o th e sh a t o th e rst m etacarpal,

in radial abdu ction ( a ). Du rin g th e in trodu ction o th e gu ide wire, th e wrist sh ou ld be
in f exion oth erwise th e en try poin t can n ot be reach ed. Do n ot pen etrate th e scaph o-
trapezial join t with th e gu ide wire. Th e gu ide wire was care u lly in serted across th e
patien t’s ractu re ( b ).
a b
Fig 2.4-9a –b Im age in ten si cation in at least two plan es was u sed to con rm accu rate
advan cem en t o th e gu ide wire in th e scaph oid axis an d perpen dicu lar to th e ractu re
plan e.
2 Carpal bone s
6 Fixa t io n
a b x minus 2–3 mm
Fig 2.4-1 0a –b Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw .
In sert th e dedicated m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly
position ed on th e tu bercle or a reliable m easu rem en t (as sh ow n on th e patien t) ( a ). Altern atively, i th e
dedicated m easu rin g device is n ot available, take an oth er gu ide w ire o th e sam e len gth an d place its tip
on to th e bon e at th e in sertion poin t ( b ). Th e di eren ce betw een th e protru din g en ds o th e tw o w ires
in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to determ in e th e screw len gth .
Drillin g
a b
Fig 2.4-1 1a –b Use on ly th e dedicated drill bit. A pow er drill w ill exert less orce on th e
ragm en ts th an m an u al drillin g an d w ill redu ce th e risk o displacin g th e ragm en ts. A
sm all pow er drill w ith slow rotation is th e pre erred ch oice ( a ). Use salin e solu tion to
cool th e drill bit in order to m in im ize th erm al in ju ry. Ch eck th e position o th e tip o
th e drill bit u n der im age in ten si cation . In traoperative im age o drillin g in to th e
a ected scaph oid ( b ).
115
Pa rt II Case s
Se le ct t h e s cre w
a b
Fig 2.4-1 2a –bSelect th e appropriately sized can n u lated h eadless com pression screw .
Th e selected screw is in serted in to th e in tern al th read o th e com pression sleeve.
a b
Fig 2.4-1 3a –bTh e screw an d com pression sleeve are in serted over th e gu ide w ire ( a ),
as sh ow n in th e in traoperative im age ( b ).
2 Carpal bone s
a b c
Th e screw is tigh ten ed u n til su

com pression is ach ieved.
a b
Fig 2.4-1 5a –b Th e can n u lated screw driver is in serted. Th e

com pression sleeve is h eld still, u sin g th e th u m b an d in dex
n ger to rm ly h old th e com pression sleeve, as th e screw -
driver tu rn s th e screw an d advan ces it ou t o th e com pression
sleeve an d in to th e bon e. Com pression is m ain tain ed by th e
com pression sleeve du rin g th is action .
117
Pa rt II Case s
a b c a b
Fig 2.4-16a –c Th e screwdriver h as th ree colored m arkin gs Fig 2.4-1 7a –b It is vital th at th e th readed section o th e tip
th at are visible at th e edge o th e com pression sleeve. Th e o th e screw passes com pletely beyon d th e ractu re plan e
green m ark in dicates th e screw is still u lly retain ed with in i in ter ragm en tary com pression is to be ach ieved. Also
th e com pression sleeve ( a ). Th e yellow m ark in dicates th e en su re th at th e screw is n ot too lon g n or overtigh ten ed as
screw h as been advan ced level with th e su r ace o th e bon e it cou ld protru de beyon d th e cortical su r ace an d lose
( b ). Th e red m ark in dicates th e screw h as been cou n tersu n k com pression , or en dan ger th e so t tissu es, especially
2 mm u n der th e bon e su r ace ( c). Cou n tersin k th e screw by ten don s an d n eu rovascu lar stru ctu res.
tu rn in g th e screwdriver sh a t wh ile sim u ltan eou sly h oldin g
th e com pression sleeve station ary.
a b
Fig 2.4-1 8 Be ore n al tigh ten in g, rem ove th e gu ide w ire. Fig 2.4-1 9a –bIn traoperative im ages sh ow ed th ere w as
Make su re th at th e th reads at th e n ear en d o th e screw correct position in g o th e screw .
are u lly bu ried in th e bon e at th e in sertion site. Ch eck
th e n al position o th e screw an d scaph oid stability u sin g
im age in ten si cation or x-rays.
2 Carpal bone s

8 Ou t co m e
a b
Fig 2.4-2 1a –b At th e 6-m on th ollow -u p ollow in g

th e in itial trau m a, th e PA an d lateral x-rays
sh ow ed com plete h ealin g o th e ractu re.
b
Fig 2.4-2 2a –b Th ere w as restored

ran ge o m otion an d an excellen t
u n ction al ou tcom e.
119
Pa rt II Case s
9 Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n
Us in g a n a d d it io n a l gu id e w ire
a b
Fig 2.4-2 3a –b Th e torqu e orces o th e screw on den se

bon e in you n g patien ts are h igh th at an addition al gu ide
w ire m ay be requ ired. Th is w as so or a 17-year-old
em ale sch ool stu den t su stain in g a ractu re to th e proxi-
m al pole o h er scaph oid a ter a all over h er ou tstretch ed
h an d du rin g sportin g activities.
10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n
In s e r t t h e gu id e w ire s
a b a b
Fig 2.4-2 4a –b In order to avoid u n desirable rotation o Fig 2.4-2 5a –b On ce th e location o th e gu ides h as been
th e distal ragm en t o th e scaph oid du rin g screw tigh ten - ch ecked, drillin g is per orm ed, ollow ed by th e in sertion
in g, in stead o on e gu ide w ire, tw o parallel gu ides w ere o th e screw . In cases o m u lti ragm en tation rom th e
u sed. Im age in ten si cation in at least tw o plan es is proxim al th ird to th e scaph oid w aist, th e addition al gu ide
recom m en ded to con rm th e accu rate location o both can be le t in place to rein orce th e xation .
gu ide w ires in th e scaph oid.
2 Carpal bone s
10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t )
Ou t co m e
a b a b
Fig 2.4-2 6a –b Con rm th e position o th e screw u sin g Fig 2.4-2 7a –b Th e x-rays sh ow ed com plete ractu re
im age in ten si cation . Note th at a u lly th readed screw h ealin g 1 year a ter th e in itial trau m a.
w as actu ally u sed in th is case, h ow ever, th e prin ciples
an d tech n iqu es rem ain th e sam e.
a b
c d e
Fig 2.4-2 8a –e Im portan tly or th is you n g aspirin g ath lete, th ere w as an excellen t u n ction al ou tcom e.
121
Pa rt II Case s
2.5 Scaphoid, proximal pole—nonunion treated with
a headless compression screw and bone graft
Fig 2.5-1a –b A 21-year-old m ale stu den t presen ted w ith

w rist pain , sw ellin g, an d lim itation o m otion h avin g h ad
a all on to an ou tstretch ed righ t h an d som e tim e earlier.
Th e redu ced ran ge o m otion in volved f exion o
15 degrees, exten sion o 40 degrees, w ith pron ation an d
su pin ation n orm al. Pain w as elicited by f exion o th e
w rist, du rin g palpation over th e sn u box, an d w h en
axial com pression w as applied to th e th u m b. Th e PA an d
a b lateral x-rays dem on strated a well-de n ed n on u n ion .
Fig 2.5-2 Th e im ages also dem on strated Fig 2.5-3 Th e CT scan sh ow ed a n on u n ion w ith a den se
sclerosis (h arden in g) o th e proxim al pole proxim al pole. Th e CT scan s w ere per orm ed in th e tru e
o th e scaph oid, su ggestin g avascu larity, lon gitu din al axis o th e scaph oid an d in dicated n on -
bu t th ere w ere n o m ajor ch an ges to th e u n ion with m u ltiple cysts located proxim al to th e dorsal
sh ape o th e bon e an d n o su bstan tial bon e apex ridge, w ith m in or dorsal displacem en t o th e distal
resorption w as eviden t. portion o th e scaph oid. No collapse w as eviden t an d
th e in trascaph oid an gle w as 35 degrees.
123
Pa rt II Case s
2 In d ica t io n s
Pro xim a l p o le n o n u n io n
Fig 2.5-4 Th ere are variou s reason s w h y a ractu re can ail to h eal, su ch as late diagn osis,
in adequ ate im m obilization , or severity o trau m a. Scaph oid ractu res su er a h igh rate o
n on u n ion an d th e poor vascu larity o th e scaph oid is o ten to blam e (re er to th e
in dication s topic in ch apter 2.1 Scaph oid—n on displaced ractu re treated percu tan eou sly
w ith a h eadless com pression screw ). Th ere are oth er actors th at can also in f u en ce th e
rate o scaph oid u n ion , su ch as th e trem en dou s orces o f exion an d exten sion th at act
over th is bon e, an d th e act th at approxim ately 80% o th e scaph oid su r ace is covered
w ith cartilage an d bath ed in syn ovial f u id, resu ltin g in bon e h ealin g by direct h ealin g
w ith ou t callu s orm ation .
Proxim al pole ractu res rely largely on a distal to proxim al in traosseou s blood f ow an d are th ere ore especially pron e to
delayed u n ion an d n on u n ion . A n on u n ion will resu lt in osteoarth ritis o th e wrist (also kn own as arth ritis). Non operative
treatm en t o acu te proxim al pole ractu res requ ires a prolon ged period o im m obilization (3–6 m on th s), th ere ore operative
treatm en t is recom m en ded at an early stage.
Go a ls o f s u rgica l t re a t m e n t o f a s ca p h o id n o n u n io n Ch o ice o f im p la n t
Th e ollow in g are th e m ain goals or th e su rgical

treatm en t o scaph oid n on u n ion s:
• To restore an atom y (m orph ology an d scaph oid len gth )
• To obtain h ealin g
• To stop progression o carpal in stability
• To redu ce progression o osteoarth ritis.
a b c
Fig 2.5-5 a – c For proxim al pole n on u n ion s, i th e
proxim al ragm en t is large en ou gh , a 2.4 m m or 3.0 m m
Im a gin g im plan t u sin g an tegrade in sertion is advisable ( a ). For
sm aller proxim al ragm en ts, sin gle or m u ltiple m in i
Obtain in g a u ll series o scaph oid x-rays o th e a ected an d h eadless bon e screw s (1.5 m m ) can be u sed ( b ). For very
n orm al con tralateral side is n ecessary or su rgical plan n in g. sm all ragm en ts (f akes), K-w ires m ay be a better option
Also, CT scan s in th e tru e lon gitu din al axis o th e scaph oid ( c ). For th is patien t, a h eadless com pression screw
are h elp u l in order to iden ti y de orm ity. com bin ed w ith bon e gra tin g w as requ ired.
2 Carpal bone s
2.5 Scaphoid, proximal pole —nonunion tre ate d with a he adle ss com pre ssion scre w and bone graft

• Au togen ou s bon e gra t equ ipm en t

orearm on a h an d table. Pron ate th e orearm . A
Ap p ro a ch
Fig 2.5-7 Th e su rgical approach u sed was a dorsal approach Fig 2.5-8 Th rou gh a sm all dorsal approach an d dorsal
(see ch apter 1.2 Dorsal approach to th e scaph oid). capsu lotom y, th e n on u n ion was iden ti ed. Min im al bon e
resorption an d m in im al ractu re sclerosis were n oted. Th e
brou s tissu e in terposed in th e n on u n ion area was re-
m oved u sin g a sm all cu rette u n til h ealth y bon e was ou n d
on both sides. Care was taken to en su re th e extern al sh ape
o th e scaph oid was n ot ch an ged sign i can tly to m ain tain
n orm al carpal kin em atics.
125
Pa rt II Case s
5 Re d u ct io n
Dire ct re d u ct io n Bo n e gra ft
Lister tubercle
Fig 2.5-9 Use sm all poin ted redu ction orceps to redu ce Fig 2.5-1 0 Harvest th e gra t m aterial rom th e distal
th e n on u n ion . radiu s. A good an d sa e place is proxim al an d sligh tly
radial to Lister tu bercle.
Ha r ve s t in g
2 cm
Fig 2.5-1 1 Make a 2 cm lon gitu din al in cision proxim al to Fig 2 .5 -1 2Use a ch isel to cu t th ree sides o a sm all squ are.
Lister tu bercle. Retract th e ten don s o th e secon d com - Li t th e dorsal radial cortex as a f ap. A ter h arvestin g
partm en t radially, an d th e exten sor pollicis lon gu s in an can cellou s bon e, replace th e “lid”, an d su tu re th e perios-
u ln ar direction . teu m an d th e skin in cision . Use a pu sh er in stru m en t to
im pact th e bon e gra t.
2 Carpal bone s
De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire
Fig 2.5-1 3 Can cellou s bon e gra t taken rom Fig 2.5-1 4 Th e correct en try poin t or th e gu ide w ire is in
th e distal radiu s w as in terposed in th e th e cen ter o th e proxim al pole, directly adjacen t to th e
n on u n ion area. scaph olu n ate ligam en t in sertion .
Fig 2.5-15 Th e gu ide wire is in serted in th e axis o th e sh a t Fig 2.5-1 6 Vascu larity w as evalu ated an d ou n d to be
o th e rst m etacarpal, in radial abdu ction . Du rin g th e adequ ate th rou gh direct observation o th e bleedin g spots
in trodu ction o th e gu ide wire, th e wrist sh ou ld be in on th e proxim al pole. Wh ile m on itorin g w ith th e im age
f exion oth erwise th e en try poin t can n ot be reach ed. Do in ten si er, th e gu ide w ire w as advan ced th rou gh th e drill
n ot pen etrate th e scaph otrapezial join t with th e gu ide wire. gu ide rom proxim al to distal in to th e bon e u n til th e tip
w as an ch ored in th e ar cortex.
Im age in ten si cation in at least tw o plan es sh ou ld be
u sed to con rm accu rate advan cem en t o th e gu ide w ire
in th e scaph oid axis an d perpen dicu lar to th e n on u n ion .
127
Pa rt II Case s
6 Fixa t io n
Sca p h o id fixa t io n
a b c
Fig 2.5-1 7a –c A ter m easu rin g an d drillin g, th e h eadless com pression screw w as settled on th e com pression sleeve,
placed th rou gh th e drill gu ide, an d care u lly tigh ten ed u n til com pression o th e n on u n ion w as ach ieved. Force u l
tigh ten in g w as avoided as th is cou ld cau se strippin g o th e sh a t th read. Predrillin g m ade it su bstan tially easier to in sert
th e screw in to den se bon e.
Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw , in sertin g th e
screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.4 Scaph oid,
proxim al pole— ractu re treated w ith a h eadless com pression screw .
En s u re co rre ct s cre w a n d t h re a d le n g t h Co m p le t e t h e fixa t io n
a b
Fig 2.5-1 8a –b It is vital th at th e th readed section o th e tip Fig 2.5-1 9 Be ore n al tigh ten in g, rem ove th e gu ide w ire.
o th e screw passes com pletely beyon d th e ractu re plan e Make su re th at th e th reads at th e n ear en d o th e screw
i in ter ragm en tary com pression is to be ach ieved. Also are u lly bu ried in th e bon e at th e in sertion site. Ch eck
en su re th at th e screw is n ot too lon g n or overtigh ten ed as th e n al position o th e screw an d scaph oid stability u sin g
it cou ld protru de beyon d th e cortical su r ace an d lose im age in ten si cation or x-rays.
com pression , or en dan ger th e so t tissu es, especially
ten don s an d n eu rovascu lar stru ctu res.
2 Carpal bone s
Fig 2.5-2 0 Th rou gh direct vision , it

w as con rm ed th at per ect redu ction a
w as ach ieved an d th at th e screw h ad
been su n k ben eath th e articu lar
cartilage.
Fig 2.5-2 1a –b With th e h elp o th e

im age in ten si er th e correct location
o th e screw w as con rm ed.

129
Pa rt II Case s
8 Ou t co m e
a b b
At th e 6-m on th ollow -u p th e postoperative

Fig 2 .5 -23 a – b Fig 2.5-2 4a –b Th ere w as also
x-rays sh ow ed th ere h ad been com plete h ealin g. excellen t u ln ar an d radial deviation .
a b
c d
Fig 2.5-2 5a –d At th is stage, excellen t ran ge o m otion w as also sh ow n .
2.6 Scaphoid, waist—nonunion with deformity
treated with a headless compression screw
and bone graft
Fig 2.6-1a –c A 47-year-old store

m an ager presen ted with a sym ptom atic
n on u n ion o th e scaph oid o h is righ t
h an d ollowin g an earlier in ju ry. He
presen ted with pain , lim ited ran ge o
m otion , and a weak grip. Th e PA, PA in
u ln ar deviation , an d lateral x-rays
revealed a well-de n ed n on u n ion with
a b c de orm ity o th e scaph oid.
Fig 2.6-2a –b Th e 2-D CT scan s clearly

de n ed th e n on u n ion bu t with ou t
a b radiograph ic eviden ce o osteoarth ritis.
a b c d
Fig 2.6-3a – d Wh ile th e MRIs sh ow ed preserved cartilage w ith in th e radioscaph oid join t, th e 3-D CT scan
sh ow ed a “h u m pback” de orm ity pattern o th e scaph oid.
131
Pa rt II Case s
2 In d ica t io n s
Sca p h o id w a is t n o n u n io n No n u n io n a n d t h e h u m p b a ck d e fo rm it y
40°
a b
Fig 2.6-4 For a variety o reason s, scaph oid ractu res Fig 2.6-5a –b In ractu res o th e waist o th e scaph oid, th e
su er a h igh rate o n on u n ion , an d a n on u n ion o a distal h al ten ds to rotate in to f exion in relation to th e
scaph oid w aist ractu re presen ts a w ell-recogn ized risk o proxim al h al , th e lu n ate, an d th e triqu etru m , wh ich all lie
developin g in tercarpal arth ritis. With scaph oid w aist in exten sion . Th is can resu lt in a rotation al an d an gu lar
n on u n ion s, th e goal is o ten n ot on ly to gain u n ion bu t de orm ity an d a n on u n ion kn own as h u m pback de orm ity.
also to restore th e n orm al u n ction al an atom y o th e Fu rth erm ore, du e to th e orces exerted over th e scaph oid in
scaph oid, w h ich m ay h ave becom e de orm ed. Addition - its palm ar aspect, it su ers bon e loss with con sequ en t sh ort-
ally, it is im portan t to correctly restore th e scaph oid’s en in g. Th ese ch an ges to th e bon e o ten in du ce carpal
relation sh ip to th e adjacen t lu n ate carpal bon e. collapse.
Sca p h o id n o n u n io n a d va n ce d co lla p s e Ca rp a l co lla p s e co rre ct io n
Du e to th e ch an ges o load over th e radiocarpal join t, Wh ere th ere are in dication s o carpal collapse as a resu lt
de orm ities o th e scaph oid can also be respon sible or o scaph oid de orm ity, an osteotom y or corticocan cellou s
cau sin g osteoarth ritis, w h ich can produ ce w h at is kn ow n bon e gra t m ay be requ ired to ll th e de ect. Th is w ill h elp
as scaph oid n on u n ion advan ced collapse (SNAC). I to in du ce h ealin g an d to preven t th e developm en t o
osteoarth ritis develops, on ly salvage recon stru ction osteoarth ritis bu t also h elps to restore scaph oid len gth .
procedu res can be o ered. Fixation w ith a screw to com plete th e procedu re th en
im proves overall stability.
Go a ls o f s u rgica l tre a tm e n t o f a s ca p h o id n o n u n io n
Th e ollowin g are th e m ain goals or th e su rgical treatm en t

o scaph oid n on u n ion s:
• To restore an atom y (m orph ology an d scaph oid len gth )
• To obtain h ealin g
• To stop progression o carpal in stability
• To redu ce progression o osteoarth ritis.
2 Carpal bone s
2.6 Scaphoid, waist—nonunion with de formity tre ate d with a he adle ss compre ssion scre w and bone graft
Ch o ice o f im p la n t Im a gin g
Obtain in g a u ll series o scaph oid x-rays o th e a ected an d

n orm al con tralateral side is n ecessary or su rgical plan n in g.
Also, CT scan s in th e tru e lon gitu din al axis o th e scaph oid
are h elp u l in order to iden ti y de orm ity.
Fig 2.6-6 For scaph oid w aist n on u n ion s, a 2.4 m m or

3.0 m m im plan t u sin g retrograde in sertion is advisable.
For th is patien t, a h eadless com pression screw com bin ed
w ith bon e gra tin g w as requ ired.

• Osteotom e

133
Pa rt II Case s
Ap p ro a ch Hyp e re xt e n d t h e w ris t
Fig 2.6-9 To assist in th e approach , place a rolled towel or

bolster u n der th e wrist an d h yperexten d it. Th e u se o th e
Fig 2.6-8Th e su rgical approach u sed was a palm ar ap- su pport h elps access th e correct en try poin t or a gu ide wire.
proach (see ch apter 1.1 Palm ar approach to th e scaph oid). Th is position also h elps to redu ce th e scaph oid ragm en ts.
a b
Fig 2.6-1 0a –b In itially, an in cision lin e w as m arked crossin g th e w rist crease at an an gle ( a ). A ter th e
in cision , th e su per cial palm ar bran ch o th e radial artery w as protected w ith a vessel lou pe ( b ).
a b
Fig 2.6-1 1a –b Th e palm ar capsu le w as th en open ed in a Z-plasty m eth od (u sin g a Z-sh aped
in cision to relieve ten sion in scar tissu e) ( a ). Th is w as don e to preserve th e orien tation o th e
radioscaph oid ligam en t. Th e n on u n ion w ith sclerotic m argin s w as th en exposed ( b ).
2 Carpal bone s
5 Re d u ct io n
Bo n e gra ft Ha r ve s t in g
2–4 cm
Iliac crest
Fig 2.6-1 2 Harvest th e corticocan cellou s gra t m aterial Fig 2.6-1 3 Make a 2 cm lon gitu din al in cision over th e
rom th e iliac crest. For m ost de ects, can cellou s or lateral aspect o th e palpable iliac crest avoidin g th e very
corticocan cellou s bon e gra t can be obtain ed rom th e an terior aspect an d th e ilio em oral n erve.
distal radiu s. How ever, or th ose n on u n ion s th at requ ire
su bstan tial debridem en t o sclerotic bon e en ds or h ave
xed rotatory de orm ities, a larger gra t rom th e iliac
crest sh ou ld be con sidered.
In s e r t t h e b o n e gra ft
a b
Fig 2.6-1 4 Expose th e crest over a 2–3 cm segm en t an d Fig 2.6-1 5a –b Disim pact th e tw o ragm en ts u sin g a
m ark ou t th e preplan n ed gra t size to be h arvested. K-w ire or den tal pick to m ake room or th e gra t. Per orm
Con sider th e sh ape an d size o th e de ect in th e scaph oid th e osteotom y an d decortication o th e n on u n ion site an d
an d h ow th e gra t su r aces w ill con tact th e tw o scaph oid en su re th e scaph oid is len gth en ed to its approxim ate
pieces. Harvest th e selected gra t u sin g a sh arp osteotom e. origin al size ( a ). Use a pu sh er in stru m en t to im pact th e
Con trol bleedin g w ith a w ou n d pack an d u se a sm all bon e gra t an d ll th e w h ole n on u n ion cavity ( b ).
su ction drain i n ecessary. Close th e skin an d apply a Con rm redu ction u sin g im age in ten si cation .
pressu re dressin g.
135
Pa rt II Case s
a b
Fig 2.6-1 6a –b A large n on u n ion de ect w as eviden t. Follow in g decortication o th e

n on u n ion site, corticocan cellou s bon e gra t w as placed in to th e de ect.
Dire ct re d u ct io n Te m p o ra r y K-w ire
Fig 2.6-1 7 Use sm all poin ted redu ction orceps to redu ce Fig 2.6-1 8 Altern atively, in sert a provision al K-w ire to
th e n on u n ion . stabilize th e ragm en ts an d to m ain tain rotation al
align m en t du rin g drillin g. Wh en in sertin g th e K-w ire, be
care u l n ot to con f ict w ith th e plan n ed track o th e gu ide
w ire or th e can n u lated screw .
Fig 2.6-1 9a –b Th e n on u n ion w as redu ced

an d th e scaph oid w as given a m ore n orm al
align m en t as seen in th e in traoperative
a b im ages.
2 Carpal bone s
Palmar ridge
of trapezium
Fig 2.6-2 0 Th e correct en try poin t or th e gu ide w ire is Fig 2.6-2 1 Th e gu ide w ire sh ou ld be in serted th rou gh a
th e cen ter o th e distal pole o th e scaph oid. How ever, to drill gu ide. I n o drill gu ide is available, u se a protective
get proper access, it m ay be n ecessary to rem ove th e sleeve. Th e position o th e w ire sh ou ld be as perpen dicu -
palm ar ridge o th e trapeziu m w ith an osteotom e or a lar as possible to th e n on u n ion plan e. Do n ot pen etrate
bon e n ibbler/ ron geu r. Th is reveals th e distal pole o th e beyon d th e proxim al cortex o th e scaph oid.
scaph oid an d allow s th e path o th e gu ide w ire to be
m ade m ore cen trally w ith in th e bon e.
a b
Fig 2.6-22a –b A ter exposu re o th e patien t’s scaph otrapezial join t, a gu ide wire was placed
th rou gh a drill gu ide. Th e placem en t o th e wire was con rm ed with in traoperative
im agin g.
137
Pa rt II Case s
6 Fixa t io n
a b c
Fig 2.6-2 3a –c With th e gu ide w ire in place an d w ith care n ot to dam age th e gra t, th e h eadless screw
w as in serted across th e scaph oid n on u n ion th rou gh th e distal pole.
Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw ,
in sertin g th e screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese
steps see ch apter 2.2 Scaph oid—displaced ractu re treated w ith a h eadless com pression screw .
a b
Fig 2.6-2 4a –b It is vital th at th e th readed section o th e tip

o th e screw passes com pletely beyon d th e ractu re plan e
i in ter ragm en tary com pression is to be ach ieved. Also Fig 2.6-2 5 Be ore n al tigh ten in g, rem ove th e gu ide w ire.
en su re th at th e screw is n ot too lon g n or overtigh ten ed as Make su re th at th e th reads at th e n ear en d o th e screw
it cou ld protru de beyon d th e cortical su r ace an d lose are u lly bu ried in th e bon e at th e in sertion site. Ch eck
com pression , or en dan ger th e so t tissu es, especially th e n al position o th e screw an d scaph oid stability u sin g
ten don s an d n eu rovascu lar stru ctu res. im age in ten si cation or x-rays.
2 Carpal bone s
a b
Fig 2.6-26a –b Correct placem en t o th e h eadless screw was Fig 2.6-2 7 Du rin g w ou n d closu re, th e
con rm ed th rou gh in traoperative im agin g. Note th e large capsu lar in cision w as care u lly closed to
corticocan cellou s gra t. approxim ate th e edges o th e capsu lar
ligam en ts.
Fig 2.6-28 Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow-u p, rem oval o stitch es, an d
im m obilization as requ ired. Followin g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation ,
see th e reh abilitation topic in ch apter 2.2 Scaph oid—displaced ractu re treated with a h eadless com pression screw.
8 Ou t co m e
a b c d
Fig 2.6-29a –d At th e 1-m on th ollow-u p, th e AP an d lateral x-rays sh owed th e h eadless screw an d bon e gra t were in th e
righ t position ( a –b ), an d at 3-m on th s, th e x-rays in dicated th at partial in corporation o th e bon e gra t h ad occu rred ( c–d ).
139
Pa rt II Case s
8 Ou t co m e (co n t )
At th e 3-year ollow -u p, th e AP an d lateral x-rays

Fig 2 .6 -3 0a – b
revealed total in corporation o th e bon e gra t an d com plete
a b h ealin g o th e n on u n ion .
a b
Fig 2.6-3 1a –d By th is stage,

th e patien t h ad obtain ed
an excellen t u n ction al
c d ou tcom e.
Fig 2.6-32a –b Good grip stren gth in

a b th e in ju red le t h an d w as also sh ow n .
2.7 Scaphoid, proximal pole—nonunion treated
with a vascularized bone graft
Fig 2 .7 -1 a –bA 30-year-old m ale sh opkeeper presen ted

w ith w rist pain , u n ction al lim itation , an d lim ited ran ge o
m otion o th e righ t w rist. He recalled an in ju ry to h is righ t
h an d su ered in a m otor veh icle acciden t 8 m on th s prior.
Th e PA an d lateral x-rays revealed a scaph oid proxim al
a b pole n on u n ion w ith ragm en tation at th e n on u n ion site.
Fig 2.7-2a –c Fu rth er

in vestigation with T1 an d T2
MRI im ages dem on strated
com plete absen ce o vascu larity
to th e proxim al pole ragm en t,
wh ile a 2-D CT im age sh owed
th e n on u n ion with a sm all
sclerotic proxim al pole
a b c ragm en t.
2 In d ica t io n s
Pro xim a l p o le n o n u n io n w it h a b s e n ce o f va s cu la rit y
Fig 2.7-3 As h as been previou sly discu ssed, scaph oid ractu res su er a h igh rate o
n on u n ion w ith th e poor vascu larity o th e scaph oid o ten at au lt (re er to th e in dica-
tion s topic in ch apter 2.1 Scaph oid—n on displaced ractu re treated percu tan eou sly w ith
a h eadless com pression screw ). Proxim al pole ractu res rely largely on a distal to
proxim al in traosseou s blood f ow an d are th ere ore especially pron e to delayed u n ion
an d n on u n ion . Avascu lar n ecrosis can also be th e cau se o scaph oid ractu re n on u n ion ,
occu rrin g m ost requ en tly in th e proxim al pole. Scaph oid n on u n ion s h ave a h igh risk
o progressin g to osteoarth ritis w ith in a ew years ollow in g th e in ju ry, yet e ective
h ealin g o th e n on u n ion dram atically redu ces th is risk.
141
Pa rt II Case s
Va s cu la rize d b o n e gra ft in g
a b
c d
Vascu larized bon e gra tin g in volves th e elevation o an appropriate size o gra t tissu e w ith a cen trally
Fig 2.7-4 a – d
located vessel ( a – c ). It is th en care u lly placed in to th e prepared ractu re or n on u n ion site ( d ).
Stu dies h ave sh ow n th at vascu larized bon e gra tin g can be u sed e ectively to provide im proved blood su pply an d
in crease th e poten tial or h ealin g. Wh ile eviden ce con tin u es to be gath ered regardin g w h eth er vascu larized bon e
gra tin g is con clu sively m ore e ective th an stan dard n on vascu larized tech n iqu es, it h as been con sidered logical to
em ploy a vascu larized gra t in situ ation s w h ere vascu larity h as been com prom ised. Addition ally, vascu larized bon e
gra t h arvested rom th e distal radiu s con ers sign i can t th eoretical advan tages an d also redu ces th e im pact o don or
site m orbidity rom a distan t site.
Go a ls o f s u rgica l t re a t m e n t o f a s ca p h o id n o n u n io n
Th e ollow in g are th e m ain goals or th e su rgical

treatm en t o scaph oid n on u n ion s:
• Restore an atom y (m orph ology an d scaph oid len gth )

• Obtain h ealin g
• Stop progression o carpal in stability
• Redu ce progression o osteoarth ritis.
2 Carpal bone s
2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft
Ch o ice o f im p la n t Im a gin g
Obtain in g a u ll series o scaph oid x-rays o th e a ected

an d n orm al con tralateral side is n ecessary or su rgical
plan n in g. A CT scan in th e tru e lon gitu din al axis o th e
scaph oid is also h elp u l in order to iden ti y de orm ity.
Gadolin iu m en h an ced T1 MRI scan s are in dicated w h en
assessin g th e vascu larity o th e proxim al ragm en t.
a b
Fig 2.7-5a –b For scaph oid n on u n ion s with loss o

vascu larity, i th e proxim al ragm en t is large en ou gh , a
2.4 m m or 3.0 m m im plan t u sin g an tegrade in sertion is
advised. For sm aller proxim al ragm en ts, sin gle or m u ltiple
m in i h eadless bon e screws (1.5 m m ) can be u sed. For th is
patien t, two m in i h eadless bon e screws com bin ed with
dorsal vascu larized bon e gra tin g was requ ired.
• Min i h eadless screw set 1.5

• Kn ow ledge o th e tech n iqu e or dorsal 1,2 in tercom -
partm en tal su praretin acu lar artery (1,2 ICSRA)
vascu larized bon e gra tin g
Fig 2.7-6 Position th e patien t su pin e an d

place th e orearm on a h an d table. Pron ate
th e orearm . A n on sterile pn eu m atic
tou rn iqu et is u sed. Proph ylactic an tibiotics
are option al.
143
Pa rt II Case s
Ap p ro a ch

(see ch apter 1.2 Dorsal approach to th e scaph oid). How-
ever, on th is occasion , th e in cision in volved a dorsoradial
lon gitu din al cu rved skin in cision , startin g over th e base o
th e th u m b an d exten din g proxim ally or abou t 6–8 cm . Th is
approach allows or a dorsal pedicled 1,2 ICSRA gra t.
2 Carpal bone s
5 Re d u ct io n
Do rs a l va s cu la rize d b o n e gra ft in g
Radial artery
1,2 ICSRA
a b
Radial sensory nerve
Fig 2.7-8a –c Pedicled vascu larized bon e gra ts u sed in

ECRL
scaph oid n on u n ion su rgery are based on tw o di eren t
Distal Proximal
arteries. On e vascu lar pedicle is ou n d on th e dorsal su r ace
o th e distal radiu s, th e oth er on th e palm ar su r ace. Th e
dorsal pedicle is based on th e 1,2 in tercom partm en tal
APL
1,2 ICSRA su praretin acu lar artery (1,2 ICSRA) ( a –b ). A dorsal
vascu larized gra t u sin g th ese vessels allows excellen t
m obility to treat n on u n ion s in all region s o th e scaph oid,
c in clu din g th e proxim al pole ( c ).
Excis in g t h e n o n u n io n
Fig 2 .7 -9 Prepare th e n on u n ion by excisin g brou s tissu e to h ealth y can cellou s

su r aces. Disim pact th e ragm en ts u sin g a K-w ire or den tal pick to m ake room
or th e gra t. En su re scaph oid len gth en in g to its approxim ate origin al size.
145
Pa rt II Case s
Ele va t e t h e b o n e gra ft
a b c
d e
Fig 2.7-1 0a –e Th e vascu larized bon e gra t is care u lly h arvested an d h an dled to avoid
tw istin g o th e vascu lar pedicle ( a –b ). It w ill later be in serted in to th e previou sly
prepared de ect in th e scaph oid ( c–d ). Ten sion on th e vascu lar pedicle m u st be
avoided. A tem porary K-w ire is a u se u l m eth od o stabilizin g th e redu ction an d
avoids risk o dam age to th e vascu lar pedicle ( e ).
a b
For th e patien t, th e vascu larized distal radiu s bon e gra t

Fig 2.7-1 1a –b
(1,2 ICSRA) w as elevated on its pedicle.
2 Carpal bone s
Pre p a re a t ro u gh if n e e d e d De t e rm in e in s e r t io n p o in t a n d in s e r t t h e gu id e w ire
Fig 2.7-12 A trou gh th at crossed th e n on u n ion Fig 2.7-13 I can n u lated h eadless bon e screws are u sed,
site or later in sertion o th e bon e gra t was determ in e th e gu ide wire en try poin t (in th e cen ter o th e
plan n ed. proxim al pole) an d in sert th e gu ide wire. Do n ot pen etrate
th e scaph otrapezial join t with th e gu ide wire. Im age
in ten si cation in at least two plan es sh ou ld be u sed to
con rm accu rate advan cem en t o th e gu ide wire in th e
scaph oid axis an d perpen dicu lar to th e n on u n ion .
6 Fixa t io n
Fig 2.7-14 Followin g creation o th e trou gh across th e n on u n ion site,

two 1.5 m m h eadless screws were placed across th e n on u n ion th rou gh
th e proxim al pole in to th e body o th e scaph oid. However, becau se th e
proxim al ragm en t was sm all it was decided to u se an in itial screw to
gu aran tee scaph oid sh ape an d stability be ore creation o th e trou gh .
Th e xation procedu re ollows th e u su al steps o m easu rin g screw

len gth , drillin g, selectin g th e screw, in sertin g th e screw, an d advan cin g
an d cou n tersin kin g th e screw. For u rth er in orm ation on th ese steps
see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated with a
h eadless com pression screw. However, in th is particu lar case, th e
1.5 m m m in i h eadless bon e screws are n on can n u lated an d th ere ore
requ ire n o gu ide wires.
147
Pa rt II Case s
a b
Fig 2.7-1 5a –b It is vital th at th e th readed section o th e tip Fig 2.7-1 6 Be ore n al tigh ten in g, rem ove an y gu ide
o th e screw passes com pletely beyon d th e ractu re plan e w ires (i can n u lated screw s w ere u sed). Make su re th at
i in ter ragm en tary com pression is to be ach ieved. Also th e th reads at th e n ear en d o th e screw s are u lly bu ried
en su re th at th e screw is n ot too lon g n or overtigh ten ed as in th e bon e at th e in sertion site. Ch eck th e n al position
it cou ld protru de beyon d th e cortical su r ace an d lose o th e screw s an d scaph oid stability u sin g im age in ten si -
com pression , or en dan ger th e so t tissu es, especially cation or x-rays.
ten don s an d n eu rovascu lar stru ctu res.
In s e r t a n d co m p le t e t h e va s cu la rize d gra ft
a b
Fig 2.7-1 7a –b With th e n on u n ion site n ow stabilized w ith on e screw previou sly placed, th e vascu -
larized gra t w as in serted in to th e trou gh across th e n on u n ion . Th is w as ollow ed w ith a secon d
screw u sed to x th e gra t to th e scaph oid. Th e w ou n d w as th en closed takin g care n ot to dam age
or com press th e vascu lar pedicle.
Note th at in cases w h ere th ere is bon e loss an d cyst orm ation at th e n on u n ion site, th e bon e gra t
sh ou ld be in serted in to th e de ect be ore stabilization w ith bon e screw s. How ever, w h en in trodu c-
in g th e gra t rst an d th en in sertin g screw s, be care u l th at screw in sertion does n ot orce ou t or
dam age th e gra t.
2 Carpal bone s
a b
Th e in traoperative im ages
Fig 2.7-1 8a –b
con rm ed th e correct placem en t o th e screw s.

149
Pa rt II Case s
8 Ou t co m e
Fig 2.7-20a –d At th e 3-year

ollow-u p, th e PA an d lateral
x-rays an d th e h yperpron a-
tion an d sem ipron ation
obliqu e x-rays sh owed
com plete h ealin g o th e
n on u n ion with stable screw
xation an d n o eviden ce o
avascu lar n ecrosis o th e
a b c d proxim al pole.
a b
c d
At th is stage, th e patien t
Fig 2 .7-21 a –f
e f h ad a n early u ll ran ge o m otion .
Excellen t grip
Fig 2 .7 -2 2a – b
a b stren gth h ad also been restored.
2 Carpal bone s
No n u n io n t re a t e d w it h a p a lm a r va s cu la rize d b o n e gra ft
a b c
Fig 2.7-2 3a –c Ju st as it is possible to treat a scaph oid n on u n ion w ith a dorsal vascu larized bon e gra t, it is also possible
to treat su ch in ju ries w ith a palm ar vascu larized bon e gra t. A 16-year-old stu den t an d recreation al skier lan ded
aw kw ardly w h ile skiin g. He h ad pain an d restricted m ovem en t in h is le t w rist bu t th ou gh t it likely to be a so t-tissu e
in ju ry. A ter 3 m on th s, h e atten ded h is local h ospital as h e w as still experien cin g pain w ith m ovem en t, w eakn ess o
grip, an d a n oticeable loss o exten sion (40 degrees com pared w ith 65 degrees in th e opposite w rist). Exam in ation
con rm ed a “ u lln ess” in th e an atom ical sn u box an d ten dern ess to rm pressu re. Plain PA an d lateral x-rays revealed
an establish ed n on u n ion at th e proxim al w aist o th e scaph oid w ith a h u m p-back de orm ity ( a –b ). A T1-w eigh ted MRI
scan w ith gadolin iu m en h an cem en t dem on strated dim in ish ed blood f ow in th e proxim al ragm en t ( c ). On u rth er
qu estion in g, h e recalled an in ciden t 18 m on th s earlier w h en h e h ad in ju red th e sam e w rist allin g rom h is skateboard.
Pa lm a r va s cu la rize d b o n e gra ft in g
a b
Fig 2.7-2 4a –b For palm ar vascu larized bon e gra t treatm en t o scaph oid w aist n on u n ion s,
th e palm ar pedicle is u sed, w h ich is based on th e palm ar radial carpal artery, an an astom otic
(m u ltibran ch ed) vessel betw een th e radial artery an d th e an terior in terosseou s artery. Th e
gra t provides a stron g stru ctu ral com pon en t to th e procedu re by virtu e o th e th ick cortical
bon e o th e palm ar cortex o th e distal radiu s.
151
Pa rt II Case s
9 Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )
a b c
Th is palm ar gra t is particu larly u se u l in scaph oid w aist n on u n ion s

Fig 2 .7 -2 5 a – c
w ith a h u m p back de orm ity, w h ere correction o th e de orm ity is as im portan t as
ach ievin g u n ion .
Su rgica l a p p ro a ch
a b
Fig 2.7-2 6a –bTh e su rgical approach u sed w as a palm ar approach (see ch apter 1.1 Palm ar approach to th e scaph oid).
Retrograde xation sh ou ld be per orm ed w ith eith er 1.5 m m m in i h eadless screw s or 2.4 m m / 3.0 m m can n u lated
h eadless com pression screw s.
2 Carpal bone s
Excis in g t h e n o n u n io n
a b
Fig 2.7-2 7a –b Prepare th e n on u n ion by excisin g brou s tissu e to h ealth y can cellou s su r aces.
For th is patien t, cyst orm ation w as n oted an d w as rem oved. Disim pact th e ragm en ts u sin g a
K-w ire or den tal pick to m ake room or th e gra t ( a ). En su re scaph oid len gth en in g to its
approxim ate origin al size ( b ).
Ele va t e t h e b o n e gra ft
Vascular pedicle
a b c
Fig 2.7-2 8a –c Th e palm ar radial carpal artery pedicle is ou n d distal to th e pron ator qu adratu s an d is care u lly separated
rom th e overlyin g ascia ( a –b ). Th e pron ator qu adratu s is retracted ( b ) to reveal th e periosteal vessels. Th e pedicle is
cau terized at its u ln ar lim it an d a prem easu red rectan gu lar bon e gra t is h arvested rom th e distal radiu s, still attach ed
to th e pedicle ( c ). A h ypoderm ic n eedle placed in th e radiocarpal join t preven ts in adverten t dam age to th e articu lar
su r ace du rin g h arvest o bon e gra t.
153
Pa rt II Case s
In s e r t t h e va s cu la rize d gra ft
Fig 2.7-2 9 In sert th e bon e gra t in to th e prepared de ect, Fig 2.7-3 0Th e patien t’s vascu larized gra t can
correctin g th e h u m p back de orm ity. Th e vascu larized be seen in place.
bon e gra t is care u lly h an dled to avoid tw istin g o th e
vascu lar pedicle attach ed to th e gra t, an d ten sion on th e
vascu lar pedicle m u st also be avoided. Con rm redu ction
u sin g im age in ten si cation .
De t e rm in e in s e r t io n p o in t a n d in s e r t t h e gu id e w ire
Fig 2.7-3 1 I can n u lated h eadless bon e screw s are u sed,

determ in e th e gu ide w ire en try poin t an d in sert th e gu ide
w ire. Im age in ten si cation in at least tw o plan es sh ou ld
be u sed to con rm accu rate advan cem en t o th e gu ide
w ire in th e scaph oid axis an d perpen dicu lar to th e
n on u n ion .
2 Carpal bone s
a b
Fig 2.7-3 2a –b Th e gu ide w ire sh ou ld be in serted th rou gh a drill gu ide.

I n o drill gu ide is available, u se a protective sleeve. In traoperative
im ages sh ow th e gu ide w ire in sertion .
Ad d it io n a l t e m p o ra r y K-w ire
Fig 2.7-3 3 An addition al tem porary K-w ire can be

in serted to stabilize th e ragm en ts an d to m ain tain
rotation al align m en t du rin g drillin g. Wh en in sertin g th e
addition al K-w ire, be care u l n ot to con f ict w ith th e
plan n ed track o th e gu ide w ire or th e can n u lated screw .
155
Pa rt II Case s
a b
Fig 2.7-34a –b A sin gle h eadless screw was placed in to th e body o th e

scaph oid an d th rou gh th e gra t.
Th e xation procedu re ollows th e u su al steps o m easu rin g screw len gth ,

drillin g, selectin g th e screw, in sertin g th e screw, an d advan cin g an d
cou n tersin kin g th e screw. Wh en an addition al tem porary K-wire h as been
u sed, it m u st be rem oved be ore n al tigh ten in g o th e screw. For u rth er
in orm ation on th ese steps see ch apter 2.2 Scaph oid—displaced ractu re
treated with a h eadless com pression screw.
A n al ch eck o position an d len gth o th e im plan t was per orm ed rom

several an gles to en su re n o overpen etration .
Ou t co m e
a b
Fig 2.7-3 5a –b Th e procedu re resu lted in h ealin g o th e n on u n ion

an d retu rn to n orm al m ovem en t an d activity levels.
2.8 Perilunate dislocation treated with K-wires
a b c
Fig 2.8-1a –c A 28-year-old salesm an an d am ateu r su r er was swept o h is su r board wh ile ridin g a large wave. He
presen ted to th e em ergen cy departm en t experien cin g pain , de orm ity, an d edem a o h is righ t wrist, accom pan ied by
n u m bn ess o th e n gers. On th e PA x-rays, a trian gu lar pro le o th e lu n ate was sh own rath er th an a n orm al qu adrilat-
eral sh ape ( a –b ). Th is was du e to an an terior dislocation an d widen in g between th e scaph oid an d lu n ate. Th e lateral x-ray
also sh owed th e palm ar dislocation o th e lu n ate. Th e capitate was displaced proxim ally toward th e distal radial articu lar
su r ace. Th e “spilled teacu p” con gu ration o th e lu n ate was a classic sign o a lu n ate dislocation ( c).
a b c
Fig 2.8-2a –c Th e sagittal 2-D CT scan s sh owed th e palm ar Fig 2.8-3 Th e dorsal view 3-D CT scan con rm ed th e
dislocation o th e lu n ate ( a ) an d th e em pty lu n ate acet o palm ar dislocation o th e lu n ate, alth ou gh th e scaph oid
th e radiu s with som e sm all ch ip ractu res o th e lu n ate kept its n orm al an atom ical relation sh ip with th e radiu s
( b ). However, th ere was a n orm al an atom ical relation sh ip an d th e distal carpal row. A sm all ch ip ractu re o th e
between th e h am ate an d th e triqu etru m ( c). dorsal aspect o th e lu n ate (arrow) presen ted th e
possibility (later con rm ed) th at th ere was an avu lsion
o th e dorsal scaph olu n ate ligam en t.
157
Pa rt II Case s
2 In d ica t io n s
Pe rilu n a t e d is lo ca t io n s
Perilu n ate dislocation s are ligam en tou s in ju ries th at resu lt rom h igh -en ergy trau m a an d in volve dam age to th e
capsu loligam en tou s con n ection s o th e lu n ate to its adjacen t carpal bon es an d th e radiu s. Th ey can lead to severe
disru ption o carpal an atom y, resu ltin g in pro ou n d ch an ges in w rist biom ech an ics. O all w rist dislocation s, perilu n ate
dislocation s are th e m ost com m on .
Ca rp a l liga m e n t a n a t o m y a n d ru p t u re
a Palmar intrinsic ligaments b Dorsal intrinsic ligaments
c Palmar extrinsic ligaments d Dorsal extrinsic ligaments
Fig 2.8-4a –d Bon es o th e wrist are given su pportin g stability by a wide ran ge o ligam en ts. Th e carpal rows are su pported
by stou t in trin sic ligam en ts ( a –b ), wh ich begin an d en d with in th e sam e carpal row. Th ese ligam en ts are rein orced by a
com plex system o palm ar an d dorsal extrin sic ligam en ts ( c–d ), wh ich begin an d en d in di eren t rows. Ru ptu re o th e
in trin sic ligam en ts is called “dissociation ”. Ru ptu re o th e extrin sic ligam en ts alon e cau ses a “n on dissociative” in ju ry.
2 Carpal bone s
2.8 Pe rilunate dislocation tre ate d with K-wire s
Th e Pe rilu n a t e In s t a b ilit y Cla s s ifica t io n
Th e progression o ligam en tou s dam age an d th e sequ en ce o in ju ries th at can occu r in a perilu n ate dislocation w ere
in vestigated by May eld an d colleagu es in an atom ical specim en experim en tation . Th eir n din gs con rm ed th at m ost
carpal dislocation s arou n d th e lu n ate are th e con sequ en ce o a sim ilar path om ech an ical even t, th e so-called progressive
perilu n ate in stability. Th e ou r types (or stages) o carpal destabilization w ere iden ti ed as ollow s:
• Stage I: Scaph olu n ate dissociation

• Stage II: Lu n ocapitate dislocation
• Stage III: Midcarpal dislocation
• Stage IV: Lu n ate dislocation .
Stage I: Scaph olu n ate dissociation
Fig 2.8-5a –b Stage I: Scaph -

olu n ate dissociation in volves
tearin g o th e scaph olu n ate
ligam en t. An y in creased
separation between th e
scaph oid an d lu n ate is kn own
as th e Terry Th om as or David
Letterm an sign , n am ed a ter
am ou s en tertain ers with
pron ou n ced gaps in th eir
a b ron t teeth .
Stage II: Lu n ocapitate dislocation
Fig 2.8-6a –b Stage II:

Lu n ocapitate dislocation is
wh ere th e lu n ate rem ain s
align ed n orm ally with th e
distal radiu s bu t th e su r-
rou n din g carpal bon es are
dislocated. Th e lu n ocapitate
a b join t becom es disru pted.
159
Pa rt II Case s
Stage III: Midcarpal dislocation
Fig 2.8-7a –b Stage III:

Midcarpal dislocation is
wh ere both th e lu n ate an d
capitate h ave lost align m en t
with th e distal radiu s. Th e
lu n otriqu etral ligam en t an d
or triqu etral bon e are
a b a ected.
Stage IV: Lu n ate dislocation
Radiolunate
ligament
a b
Fig 2.8-8 a – b Stage IV: A lu n ate dislocation is w h ere th ere is dislocation o th e lu n ate an d
in ju ry to th e dorsal radiolu n ate ligam en t. Th e u n iqu e teacu p appearan ce o th e lu n ate an d th e
extrem e an gle th at can resu lt in th is in ju ry creates w h at is kn ow n as th e spilled teacu p sign .
2 Carpal bone s
Co m p le t e d is lo ca t io n s o f t h e lu n a t e Dis ru p t io n o f t h e d o rs a l ra d io lu n o t riq u e t ra l liga m e n t

co m p le x
Radiolunotriquetral
ligament
a b a Normal b Spilled tea cup
Fig 2.8-9 a – b In stage IV com plete dislocation s o th e Fig 2.8-1 0a –b Th ere can also be a disru ption o th e dorsal
lu n ate, th e lu xation is u su ally in a palm ar direction . Th e radiolu n otriqu etral ligam en t com plex.
greater orce requ ired to produ ce th is in ju ry is respon sible
or m assive disru ption o both th e dorsal an d palm ar
ligam en ts.
Im a gin g
Diagn osis o sim ple ligam en t dissociation can be di cu lt as th ere m igh t be n o im m ediate carpal bon e m ovem en t or
dislocation , an d x-rays m ay appear n orm al. Takin g stress x-rays w ith th e h an d h oldin g a pen cil, or exam ple, m ay
cau se gaps betw een th e carpals to open an d be m ore clearly iden ti ed.
Perilu n ate dislocation s sh ou ld be su spected wh en a patien t presen ts with a pain u l an d swollen wrist a ter a h igh -en ergy
h yperexten sion in ju ry an d sign s o m edian n erve com pression . Th e n al diagn osis n eeds to be based on a care u l radio-
graph ic exam in ation . Alth ou gh in th e coron al view abn orm al overlappin g o th e carpal bon es an d alteration o “Gilu la´s
arcs” can be observed, a tru e lateral view is th e best way to m ake th e diagn osis ( or u rth er in orm ation on u sin g arcs to
determ in e carpal in ju ry see th e in dication s topic in ch apter 2.10 Tran striqu etral tran sscaph oid perilu n ate ractu re disloca-
tion treated with screws). Lateral x-rays can also sh ow th e spilled teacu p con gu ration o a dislocated lu n ate. Addition ally,
as th e capitate displaces proxim ally toward th e distal radial articu lar su r ace, on x-rays th e displaced lu n ate h as a trian gu lar
pro le ( Fig 2.8-1a –b ), rath er th an its n orm al qu adrilateral sh ape. Th ese can be di cu lt in ju ries to m an age, with m an y goin g
on to h ave ligam en t repair ailu re an d developin g som e osteoarth ritis o th e wrist.
A CT scan is also o great h elp o erin g m ore precise detail o th e in ju ry in order to plan th e su rgery in a m ore logical
an d accu rate w ay.
161
Pa rt II Case s
• 1.4 m m to 1.6 m m K-w ires

• Bon e an ch ors

orearm on a h an d table. Pron ate th e orearm . A n on sterile
pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are
option al.
Ap p ro a ch
a b
Fig 2.8-1 2a –b Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e
lu n ate an d perilu n ate in ju ries, h ow ever, on ly th e dorsal approach w as requ ired w ith th is patien t). Th is
approach in volves a radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision .
2 Carpal bone s
5 Re d u ct io n
Pre lim in a r y re d u ct io n o f t h e lu n a t e
a b c
Fig 2.8-1 3a –cClosed redu ction is a prelim in ary to operative treatm en t an d h as th ree ben e ts:
• It restores carpal align m en t
• It im proves th e patien t’s com ort
• It redu ces pressu re on th e m edian n erve.
Redu ction o th e dislocated lu n ate is ach ieved by distractin g th e w rist ( a ) an d applyin g direct th u m b
pressu re over th e lu n ate rom palm ar to dorsal ( b ). Th e h an d is th en gen tly f exed, an d on ce redu ction
h as occu rred, th e distraction is gen tly relaxed ( c ).
Op e n re d u ct io n o f t h e lu n a t e
I closed redu ction is n ot su ccess u l, open redu ction is n ecessary as soon as possible du e to th e risk o m edian n erve
com prom ise, o pain , an d to preserve blood su pply to th e lu n ate.
Fig 2.8-14 For th is patien t, a radially based capsu lotom y w as per orm ed an d th e
f ap w as elevated an d h eld w ith tw o su tu res exposin g th e dorsal aspect o th e
carpu s. Th e lu n ate w as redu ced by lon gitu din al traction an d by th e u se o a
periosteal elevator w ith care taken n ot to dam age th e articu lar cartilage.
163
Pa rt II Case s
As s e s s m e n t o f d o rs a l a n d p ro xim a l liga m e n t re m n a n t s
Fig 2.8-15 Th e scaph olu n ate ligam en t can be avu lsed rom eith er th e
scaph oid or rom th e lu n ate. In th is case, th e ligam en t was avu lsed rom th e
lu n ate, rem ain in g attach ed to th e scaph oid as is sh own by th e arrow. Th e
avu lsion site was appropriately debrided to im prove con tact an d h ealin g.
Op e n re d u ct io n o f t h e s ca p h o lu n a t e jo in t
a b
c d
Fig 2.8-16a –d Use two joystick K-wires, in sertin g th em deep in to th e bon e, to exten d th e
scaph oid an d f ex th e lu n ate, an d th en close th e gap. A poin ted redu ction orceps h elps
to secu re th e redu ction tem porarily. Con rm redu ction u sin g im age in ten si cation in
two plan es.
2 Carpal bone s
< 60°
Fig 2.8-1 7 On th e lateral view , w ith th e w rist n eu tral, Fig 2.8-18 Th e clin ical im age sh ows th e joystick K-wires
ch eck th at th e radiu s, lu n ate, an d capitate are in lin e, th at bein g in serted in to each o th e scaph oid an d th e lu n ate.
th e scaph olu n ate an gle is < 60 degrees, an d th at th ere is Th ey were u sed to com plete th e closu re o th e scaph olu n ate
n o dorsal tilt o th e lu n ate. diastasis.
6 Fixa t io n
Sca p h o lu n a t e liga m e n t re p a ir
Fig 2.8-1 9 Th e scaph oid an d lu n ate bon es sh ou ld be Fig 2.8-2 0 A ter th e gap betw een th e scaph oid an d th e
secu red by tran s xation w ith tw o K-w ires in serted lu n ate w as redu ced u sin g th e tw o joysticks an d m ain -
percu tan eou sly, rom scaph oid to lu n ate. Con rm th e tain ed by th e poin ted redu ction orceps, percu tan eou s
position o th e w ires u sin g im age in ten si cation . K-w ires were in trodu ced betw een th e scaph oid an d
lu n ate, betw een th e triqu etru m an d lu n ate, an d betw een
th e scaph oid an d th e capitate.
165
Pa rt II Case s
Pe a rl: a lt e rn a t ive K-w ire in s e r t io n
Th e tran s xation K-w ires can be in serted in to th e

Fig 2 .8 -21 a –c
scaph oid rom in side ou tw ard prior to th e redu ction an d th en
advan ced in to th e lu n ate across th e scaph olu n ate articu lation
c on ce redu ction h as been ach ieved.
a Tear at scaphoid b Tear at lunate
c Repair at scaphoid d Repair at lunate
Fig 2.8-22a –d Th e an ch or is in serted dorsally in to th e debrided area o th e scaph oid ( a ) or in to th e lu n ate i th e ligam en t is
avu lsed rom th at bon e ( b ). Th e en try poin t or th e an ch or m u st be placed in su ch a position th at th e lin e o pu ll o th e
su tu re is sligh tly obliqu e, to resist rotation al orces between both bon es. O ten on e an ch or will be su cien t bu t occasion ally
two an ch ors are n eeded. Th e an ch or su tu re is in serted in to th e torn en d o th e ligam en t ( c–d ).
2 Carpal bone s
Op t io n : t ra n s o s s e o u s liga m e n t re fixa t io n
Fig 2.8-2 3 I bon e an ch ors are n ot available, th e avu lsed ligam en t

is attach ed u sin g su tu res th at are passed th rou gh sm all tu n n els
drilled in to th e proxim al pole o th e scaph oid.
a Scaphoid b Lunate
Fig 2.8-2 4a –b Th e an ch or su tu res in th e ligam en t are th en tied.
Fig 2.8-25 For th is patien t, tw o an ch ors w ere in serted in to

th e debrided area o th e dorsal aspect o th e lu n ate, an d th e
an ch or su tu res w ere passed th rou gh th e ligam en t an d tied.
167
Pa rt II Case s
Lu n o t riq u e t ra l liga m e n t re p a ir
a b c d
Fig 2.8-26a –d In perilu n ate in ju ries, th e lu n otriqu etral ligam en t can also be torn . Th is can
occu r rom th e lu n ate (m ost com m on ) ( a ), in its m idsu bstan ce ( b ), or rom th e triqu etru m
( c ), an d th ere can be a bon y avu lsion rom eith er bon e ( d ).
Th ere m u st be su cien t ligam en t rem n an t or repair with bon e an ch ors, oth erwise it is
repaired by direct su tu re or tran s xation o both bon es with eith er K-wires or a sm all
screw depen din g on th e n atu re o th e in ju ry. Regardless o th e repair tech n iqu e u sed, it is
recom m en ded to su pport th e so t-tissu e repair u sin g tran s xation with two K-wires ( or
approxim ately 6–10 weeks).
Redu ction an d xation o th e lu n otriqu etral align m en t is u su ally possible u sin g a dorsal
approach .
2 Carpal bone s
Re p a ir w it h b o n e a n ch o rs
a b
Fig 2.8-27a –c Wh en th ere is su cien t ligam en t

rem n an t, th e lu n otriqu etral join t is redu ced an d
two K-wires are in serted percu tan eou sly rom th e
u ln ar side o th e triqu etru m across th e lu n otriqu -
etral join t in to th e lu n ate ( a ). Con rm th e position
o th e wires u sin g im age in ten si cation . I th e
detach m en t occu rs rom th e lu n ate, th e an ch or is
placed on th e lu n ate ( b ) so th e ligam en t can be
reattach ed u sin g th e su tu res o th e an ch or ( c ). I
th e detach m en t occu rs rom th e triqu etru m , th e
c an ch or is placed on th at bon e in stead.
169
Pa rt II Case s
Re p a ir w it h a s cre w Re p a ir w it h d ire ct s u t u re
Fig 2.8-2 8 Wh en th ere is bon y avu lsion o th e Fig 2.8-2 9 Direct su tu re o th e ligam en t m ay also be
lu n otriqu etral ligam en t rom eith er bon e, th e ragm en t possible.
can be xed w ith n e K-w ires or a sm all screw .
a b
Fig 2.8-3 0 Th e capsu lotom y f ap w as th en Fig 2.8-3 1a –b In traoperative im ages sh ow ed n orm al

xed u sin g m u ltiple su tu res. relation sh ips in th e lu n otriqu etral an d scaph olu n ate
join ts, an d in th e lateral view , th ere w as a n orm al
colin ear relation sh ip betw een th e capitate th e lu n ate
an d th e radiu s.
2 Carpal bone s


sw ellin g.
Fig 2.8-3 4 Wh en both cast an d K-w ires h ave been

rem oved, active con trolled ran ge o m otion exercises can
begin at th e w rist. Load-bearin g activities are u su ally
delayed u n til radiological eviden ce o bon e h ealin g. Th e
im portan ce o m obilization m u st be em ph asized to th e
patien t an d reh abilitation sh ou ld be su pervised by a
ph ysical th erapist.
Fig 2.8-3 3 In perilu n ate in ju ries in volvin g K-w ire

xation , th e K-w ires can be rem oved at 6–8 w eeks. It
m ay also be n ecessary to rest th e w rist or 8–12 w eeks in
a sh ort arm splin t or cast. Un til rem oval o th e cast,
atten tion m u st be paid to en su re active m obilization o
th e associated join ts o th e n gers, elbow , an d sh ou lder.
171
Pa rt II Case s
8 Ou t co m e
a b
Fig 2.8-35a –b At th e 8-week ollow-u p, th e x-rays sh owed n orm al

an atom ical relation sh ips with in th e carpu s. As a resu lt, th e K-wires
were rem oved an d th e patien t was sen t or ph ysical th erapy.
a b
c d
Fig 2.8-3 6a –d Th e patien t later regain ed n ear n orm al ran ge o m otion .
2.9 Transscaphoid perilunate fracture dislocation
treated with K-wires and a headless screw
a b c d
Fig 2 .9 -1a –dA 19-year-old m an su stain ed an in ju ry to h is righ t h an d du rin g an am ateu r

m otocross race acciden t, presen tin g w ith n oticeable sw ellin g at th e w rist. Th e AP an d lateral
x-rays dem on strated an terior dislocation o th e lu n ate w ith th e classic spilled teacu p position -
in g. Th e im ages also sh ow ed a m arkedly displaced ractu re o th e w aist o th e scaph oid.
a b
Fig 2.9-2a – b Follow in g closed redu ction o th e lu n ate

dislocation , th e 2-D CT scan s in th e ron tal plan e sh ow ed
th e displaced scaph oid ractu re.
173
Pa rt II Case s
1 Ca s e d e s crip t io n (co n t )
a b c
Fig 2.9-3 a – cSagittal view 2-D scan s also sh ow ed displacem en t in

th e ron tal plan e.
a b c
Fig 2.9-4 a – c Th e scaph oid ractu re w as also clearly dem on strated in th e 3-D CT scan s in th e sagittal plan e.
2 Carpal bone s
2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w
2 In d ica t io n s
Pe rilu n a t e fra ct u re d is lo ca t io n s
Fig 2.9-5 O all wrist dislocation s, perilu n ate dislocation s are th e m ost com m on . Th ey are ch aracterized by a progressive
disru ption o capsu loligam en tou s con n ection s o th e lu n ate to th e adjacen t carpal bon es an d radiu s. Th ere are m an y clin ical
orm s o perilu n ate dislocation an d th ey can be con ven ien tly classi ed in to two m ajor grou ps: th e pu re perilu n ate disloca-
tion an d th e perilu n ate ractu re dislocation , wh ere th e ligam en t disru ption is associated with a variety o carpal ractu res
arou n d th e lu n ate.
Perilu n ate ractu re dislocation s presen t an exten sive array o in ju ries. Fractu res o carpal bon es adjacen t to th e lu n ate can
occu r in stead o on ly ligam en tou s ru ptu res wh en th e disru ptin g orce propagates arou n d th e m idcarpal join t. However, it is
recogn ized th at m ore th an 90% o all perilu n ate ractu res in volve th e scaph oid. Recogn ition an d repair o all bon y an d
so t-tissu e com pon en ts are essen tial in order to restore carpal stability an d to preven t posttrau m atic degen erative join t
disease. Con cu rren t bon y an d so t-tissu e lesion s o th e carpu s are n ot m u tu ally exclu sive (eg, con com itan t scaph oid
ractu re an d scaph olu n ate ru ptu re). Bu t u n like th e pu re ligam en tou s in ju ry o th e perilu n ate dislocation , perilu n ate
ractu re dislocation in ju ries can be well treated by care u l atten tion to th e bon y elem en ts.
175
Pa rt II Case s
Lu n a t e d is lo ca t io n s w it h t ra n s s ca p h o id fra ct u re
a b
Fig 2.9-6a –b In stage IV com plete dislocation s o th e lu n ate, th e lu xation is u su ally in a palm ar direction ( a ). Wh en
th ere is an addition al tran sscaph oid ractu re, th e proxim al scaph oid ragm en t can ollow th e dislocated lu n ate ( b ).
Dis ru p t io n o f t h e d o rs a l ra d io lu n o t riq u e t ra l liga m e n t Ch o ice o f im p la n t

co m p le x
For perilu n ate in ju ries w ith a scaph oid ractu re, i th e
proxim al ragm en t is large en ou gh , 2.4 m m or 3.0 m m
im plan ts u sin g an tegrade in sertion can be con sidered.
Scaphoid
fracture
Im a gin g
Diagn osis o perilu n ate ractu re dislocation s is based on

th e h istory o trau m a, clin ical exam in ation , an d radio-
graph ic exam in ation . In th e coron al view , abn orm al
overlappin g o carpal bon es an d alteration o “Gilu la´s
Radioluno- arcs” can be observed, bu t a tru e lateral view is also
triquetral
ligament
recom m en ded ( or u rth er in orm ation on u sin g arcs to
determ in e carpal in ju ry see th e in dication s topic in
ch apter 2.10 Tran striqu etral tran sscaph oid perilu n ate
a Normal b Spilled tea cup ractu re dislocation treated w ith screw s). Lateral x-rays
can sh ow th e spilled teacu p con gu ration o a dislocated
Fig 2.9-7 a – bTh ere can also be a disru ption o th e dorsal
lu n ate (as sh ow n in Fig 2.9-1 d ). Also look or th e trian gu -
radiolu n otriqu etral ligam en t com plex.
lar pro le o a displaced lu n ate w h en th e capitate displac-
es proxim ally tow ard th e distal radial articu lar su r ace.
Obtain in g CT scan s can o er m ore precise detail o th e
in ju ry, in th is case dem on stratin g th is patien t’s scaph oid
ractu re in th e ron tal plan e ( Fig 2.9-2 a –b ) an d in th e
sagittal view ( Fig 2.9-3 a – c ).
2 Carpal bone s

• Bon e an ch ors
Fig 2.9-8 Position th e patien t su pin e an d place th e orearm

on a h an d table. Pron ate th e orearm . A n on sterile pn eu -
m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are
option al.
Ap p ro a ch
a b
Fig 2.9-9 a – b Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e lu n ate an d
perilu n ate in ju ries, h ow ever, on ly th e dorsal approach w as requ ired w ith th is patien t). Th is approach in volves a
radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision . Th e dorsal approach can also be
u tilized to repair oth er carpal in ju ries.
177
Pa rt II Case s
Fig 2.9-10 Th e scaph oid ractu re w as

exposed th rou gh th e dorsal approach .
5 Re d u ct io n
Pre lim in a r y re d u ct io n o f t h e lu n a t e
a b c
Fig 2.9-11a –c Closed redu ction is prelim in ary to operative treatm en t an d h as th ree ben e ts:
• It restores carpal align m en t
• It im proves th e patien t’s com ort
• It redu ces pressu re on th e m edian n erve.
Redu ction o th e dislocated lu n ate is ach ieved by distractin g th e wrist an d applyin g direct th u m b pressu re over th e lu n ate
rom palm ar to dorsal. Th e h an d is th en gen tly f exed, an d on ce redu ction h as occu rred, th e distraction is gen tly relaxed.
Op e n re d u ctio n o f th e lu n a te
I closed redu ction is n ot su ccess u l, open redu ction is n ecessary as soon as possible du e to th e risk o m edian n erve
com prom ise, o pain , an d to preserve blood su pply to th e lu n ate.
2 Carpal bone s
Dire ct re d u ct io n o f t h e s ca p h o id De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire
Fig 2.9-1 2 Use sm all poin ted redu ction orceps to redu ce Fig 2.9-1 3 Th e correct en try poin t or th e gu ide w ire is at
th e scaph oid ractu re. th e cen ter o th e proxim al pole, directly adjacen t to th e
scaph olu n ate ligam en t in sertion .
Fig 2.9-1 4 Th e gu ide wire is in serted in th e axis o th e sh a t Fig 2.9-1 5 Th e ractu re w as redu ced an d h eld
o th e rst m etacarpal, in radial abdu ction . Du rin g th e w ith a poin ted redu ction orceps an d th e K-w ire
in trodu ction o th e gu ide wire, th e wrist sh ou ld be in w as in serted u n der im age gu idan ce.
f exion oth erwise th e en try poin t can n ot be reach ed. Do
n ot pen etrate th e scaph otrapezial join t with th e gu ide wire.
Im age in ten si cation in at least two plan es sh ou ld be u sed

to con rm accu rate advan cem en t o th e gu ide wire in th e
scaph oid axis an d perpen dicu lar to th e ractu re.
179
Pa rt II Case s
6 Fixa t io n
a b
Usin g a dorsal approach or th is scaph oid w aist ractu re, stable xation w as ach ieved w ith in sertion o a
Fig 2.9-1 6a –b
3.0 m m h eadless screw .
screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.3 Scaph oid—
m u lti ragm en tary ractu re treated w ith a h eadless com pression screw an d lag screw .
Fig 2.9-17 In tran sscaph oid perilu n ate ractu re dislocation s, th e lu n otriqu etral ligam en t can also be torn . Th is can occu r rom
th e lu n ate (m ost com m on ), in its m idsu bstan ce, or rom th e triqu etru m , an d th ere can be a bon y avu lsion rom eith er bon e.
There must be su cient ligament remnant or repair with bone anchors otherwise it is repaired by direct suture or trans xation
o both bones with either K-wires or a small screw depending on the natu re o the injury. Regardless o the repair technique
used, it is recommended to support the so t-tissue repair using tran s xation with two K-wires ( or approximately 6–10 weeks).
Redu ction an d xation o th e lu n otriqu etral align m en t is u su ally possible u sin g a dorsal approach .
2 Carpal bone s
Re p a ir w it h b o n e a n ch o rs
a b
Fig 2.9-1 8a –c Wh en th ere is su cien t ligam en t rem n an t,

th e lu n otriqu etral join t is redu ced an d tw o K-w ires are
in serted percu tan eou sly rom th e u ln ar side o th e
triqu etru m across th e lu n otriqu etral join t in to th e lu n ate
( a ). Con rm th e position o th e w ires u sin g im age
in ten si cation . I th e detach m en t occu rs rom th e lu n ate,
th e an ch or is placed on th e lu n ate ( b ) so th e ligam en t can
be reattach ed u sin g th e su tu res o th e an ch or ( c ). I th e
detach m en t occu rs rom th e triqu etru m , th e an ch or is
c placed on th at bon e in stead.
181
Pa rt II Case s
Re p a ir w it h a s cre w Re p a ir w it h d ire ct s u t u re
Fig 2.9-1 9 Wh en th ere is bon y avu lsion o th e lu n otriqu - Fig 2.9-2 0 Direct su tu re o th e ligam en t m ay also be
etral ligam en t rom eith er bon e, th e ragm en t can be possible.
xed w ith n e K-w ires or a sm all screw .
Th e capsu lotom y f ap is th en closed.
a b c
Fig 2.9-2 1a –cIn traoperative im ages sh ow th e direct repair o th e dorsal lu n otriqu etral ligam en t an d
placem en t o tw o K-w ires across th e join t.
2 Carpal bone s
a b
Fig 2.9-22a –b Im m ediate postoperative x-rays dem on strate

th e an atom ical redu ction an d K-wire xation .

ch apter 2.8 Perilu n ate dislocation treated w ith K-w ires.
183
Pa rt II Case s
8 Ou t co m e
a b
Fig 2.9-2 4a –bAt th e 12-m on th ollow -u p, th e x-rays sh ow ed a

h ealed scaph oid ractu re an d n orm al lu n ate align m en t.
a b
c d
Fig 2.9-2 5a –d Th e patien t h ad ach ieved n ear u ll u n ction al recovery.
2 Carpal bone s
Tra n s s ca p h o id p e rilu n a t e fra ct u re d is lo ca t io n t re a t e d u s in g m u lt ip le s cre w s a n d via b o t h d o rs a l a n d p a lm a r

s u rgica l a p p ro a ch e s
a b c
Fig 2.9-2 6a –c A 21-year-old m an su stain ed a tran sscaph oid perilu n ate ractu re dislocation as a resu lt
o a m otorcycle in ju ry. Th e clin ical appearan ce o th e h an d an d w rist sh ow ed severe dorsal de orm ity
an d sw ellin g. Th e AP an d lateral x-rays dem on strated th at th e capitate w as dorsally dislocated over
th e lu n ate, an d th ere w as a displaced proxim al pole ractu re o th e scaph oid.
In d ica t io n s
Fig 2.9-27 In th is perilu n ate in ju ry, th e capitate h as becom e dislocated rom its
n orm al position in g, an d th e lu n ate h as lost its n orm al align m en t w ith th e distal
radiu s. Th e lu n otriqu etral ligam en t w as also a ected. Th is m akes it a stage III
m idcarpal ractu re dislocation .
In cases o exten sive displacem en t, m u lti ragm en tation , or scaph oid bon e de ect,
xation w ith a sin gle screw alon e is u n likely to give en ou gh stability. In th ese
cases, a com bin ation o tw o screw s or a screw an d a K-w ire m ay be n ecessary to
ach ieve th e requ ired stability. In addition , both dorsal an d palm ar su rgical
approach es m ay be n ecessary. Be ore th e n al xation , redu ce all displaced rag-
Stage III m en ts. In cases o m u lti ragm en tation , bon e gra tin g m ay be in dicated.
185
Pa rt II Case s
Co m b in e d d o rs a l a n d p a lm a r s u rgica l a p p ro a ch e s
a b
Fig 2.9-28a –b Alon g with th e u su al dorsal approach , an addition al palm ar approach will reveal th e ch aracteristic
disru ption s o th e extrin sic palm ar ligam en ts. A palm ar approach sh ou ld be con sidered wh en th ere is m edian
n erve dis u n ction or wh en it is n ot possible to do e ective redu ction by a dorsal on ly approach . By doin g th is, it
also allows better access to th e palm ar ban d o th e lu n otriqu etral ligam en t (see ch apter 1.3 Com bin ed approach to
th e lu n ate an d perilu n ate in ju ries).
a b
Fig 2.9-2 9a –b Th e dorsal ( a ) an d palm ar ( b ) approach es to th e w rist w ere ou tlin ed on th e skin .
2 Carpal bone s
Pa lm a r s id e
a b
Fig 2.9-3 0a –b Becau se o th e speci c n atu re o th is in ju ry, th e in itial su rgical approach w as on th e palm ar side
w ith release o th e tran sverse carpal ligam en t an d m edian n erve ( a ). Th e con ten ts o th e carpal tu n n el are
care u lly retracted in order to see th e tear in th e palm ar capsu lar ligam en ts an d th e position in g o th e lu n ate
an d capitate bon es ( b ).
Do rs a l s id e
A stan dard dorsal approach is th en also per orm ed (as

described earlier in th is ch apter).
187
Pa rt II Case s
Re d u ct io n o f ca rp a ls Re d u ct io n o f t h e s ca p h o id
Fig 2.9-31 On ce th e dorsal approach was per orm ed, th e Fig 2.9-3 2 Th e scaph oid ractu re w as th en redu ced an d
carpal bon es were redu ced in relation to th e lu n ate (as seen h eld w ith a poin ted redu ction orceps. A gu ide w ire w as
th rou gh th e dorsal exposu re). placed th rou gh a drill gu ide an d con rm ed w ith in traop-
erative im agin g.
Fixa t io n o f t h e s ca p h o id
a b
Fig 2 .9 -3 3 a – b Stable xation o th e scaph oid ractu re w as ach ieved w ith in sertion o tw o 2.4 m m h eadless com pression
screw s.
2 Carpal bone s
Fixa t io n o f t h e p a lm a r liga m e n t s
Fig 2.9-34 Th e palm ar approach reveals th e disru ption s o th e extrin sic

palm ar ligam en ts, wh ich occu r th rou gh th e space o Poirier (an
an atom ical weak spot in th e f oor o th e carpal tu n n el th at can allow
m ovem en t o th e distal carpal row away rom th e lu n ate). A ren t or
tear in th e palm ar capsu le, between proxim al an d distal ligam en t
arch es, exposes th e m idcarpal join t an d th e lu n otriqu etral ligam en t.
a b
Fig 2.9-3 5a –b Th e m idcarpal join t is irrigated, loose bodies or su bch on dral f akes are rem oved,
an d th e ren t is repaired an atom ically u sin g in terru pted resorbable su tu res.
189
Pa rt II Case s
a b c
Fig 2.9-3 6a –cTh e lu n otriqu etral join t w as stabilized w ith tw o sm ooth K-w ires an d th e lu n otriqu etral ligam en t w as
th en repaired u sin g a bon e an ch or in th e lu n ate.
Th e xation procedu re ollow s th e u su al steps o assessin g ligam en t rem n an t, percu tan eou s in sertion o K-w ires,
placin g o bon e an ch or, an d reattach in g th e ligam en t u sin g th e an ch or su tu res. Th is procedu re is explain ed m ore u lly
earlier in th is ch apter.
Ou t co m e
a b a b
Fig 2.9-3 7a –b At th e in itial ollow -u p at arou n d 6 w eeks, Fig 2.9-3 8a –bTh ere w as an excellen t radiological resu lt
th ere w ere sign s o e ective h ealin g. Th e K-w ires w ere by th e 1-year ollow -u p.
th en rem oved.
2 Carpal bone s
a b
c d
e f
Fig 2.9-3 9a –f At th is stage, n ear u ll w rist m otion w as ach ieved w ith n o residu al discom ort.
a b Fig 2 .9 -4 0a – b Good grip stren gth h ad also retu rn ed.
191
Pa rt II Case s
2.10 Transtriquetral transscaphoid perilunate
fracture dislocation treated with screws
a b a b
Fig 2.10 -1a –b A 23-year-old m ale u n iversity stu den t Fig 2.10 -2a –b Redu ction w as ach ieved u n der sedation in
su ered a all on h is ou tstretch ed righ t h an d w h ile ridin g th e em ergen cy departm en t providin g im m ediate im -
a bicycle. He presen ted to th e em ergen cy departm en t provem en t to patien t pain an d n u m bn ess o th e n gers.
w ith n u m bn ess in th e n gers, severe pain , an d de orm ity Th e su bsequ en t x-rays revealed per ect redu ction to th e
o th e w rist. Th e x-rays revealed overlappin g o th e carpal bon es an d th e scaph oid ractu re.
carpal bon es, loss o con tin u ity o Gilu la’s arcs, an d a
displaced ractu re o th e scaph oid. In th e lateral view , th e
capitate w as dislocated dorsally w h ile th e lu n ate m ain -
tain ed its n orm al an atom ical relation sh ip w ith th e radiu s.
a b c d
Fig 2.10-3a –d In addition , CT scan s revealed a per ect an atom ical relation sh ip between th e carpal bon es. How-
ever, wh ile th ere was per ect redu ction o th e scaph oid proxim al pole ractu re, th e CT scan revealed a previou sly
u n detected ractu re o th e triqu etru m . Th e triqu etral ractu re appeared displaced, raisin g th e su spicion (an d later
proved) th at th ere was also an avu lsion o th e lu n otriqu etral ligam en t. Th e axial view CT scan sh owed th e
ractu re o th e triqu etru m was on th e palm ar aspect, wh ich is wh ere th e stron ger part o th e lu n otriqu etral
ligam en t is attach ed.
193
Pa rt II Case s
Fig 2.10-4a –b Th e dorsal an d palm ar view 3-D CT

scan s o ered a m ore precise perspective o both th e
a b scaph oid an d triqu etral ractu res.
2 In d ica t io n s
Pe rilu n a te fra ctu re d islo ca tio n s in vo lvin g th e triq u e tru m
Fig 2.10 -5 Perilu n ate ractu re dislocation s presen t an

exten sive array o in ju ries. Fractu res o th e carpal bon es
adjacen t to th e lu n ate can occu r in stead o isolated
ligam en t ru ptu res, w h en th e disru ptin g orce propagates
arou n d th e m idcarpal join t. Wh ile m ost perilu n ate
ractu res in volve th e scaph oid, oth er carpal bon es
in clu din g th e triqu etru m can be in volved. Recogn ition
an d repair o all bon y an d so t-tissu e com pon en ts are
essen tial in order to restore carpal stability an d to preven t
posttrau m atic degen erative join t disease.
Arcs
Arcs are lin es th at can be draw n or im agin ed on x-ray/ CT im ages o th e h an d an d w rist to h elp assess th e align m en t o
th e carpu s. Cou n tless variation s o in ju ry pattern s can be iden ti ed depen din g on w h ich carpal bon es are a ected an d
th e direction o an y dislocation or ractu re displacem en t.
2 Carpal bone s
2.10 Transtrique tral transcaphoid pe rilunate fracture dislocation tre ate d with scre ws
Gilula’s arcs III

Gilula’s arcs II Greater arcs
Gilula’s arcs I
Lesser arcs
a b
Fig 2.10 -6a –b As an exam ple, Gilu la’s arcs ou tlin e th e borders o th e proxim al an d
distal carpal row s ( a ). A deviation in th e n orm al sm ooth lin e con tou r alon g th e row s
in dicates disru ption or dislocation am on g th e carpals. Th is is com m on in cases o
perilu n ate ractu re dislocation . Greater arc in ju ries in dicate ractu re dislocation s o
th e scaph oid, capitate, h am ate, an d/ or triqu etru m , w h ile lesser arc in ju ries are pu re
ligam en tou s in ju ries arou n d th e lu n ate ( b ). Th ese variou s arcs h elp greatly in
iden ti yin g th e location o an y carpal in ju ry.

• Bon e an ch ors

option al.
195
Pa rt II Case s
Ap p ro a ch
a b
Fig 2.10 -8a –b Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e
Fig 2.10-9 Th e in traoperative im age sh ow s th e dorsal approach to th e carpu s,

w h ich allow s redu ction an d stabilization o th e scaph oid ractu re to be clearly
seen w h ile en su rin g in tegrity o th e scaph olu n ate ligam en t.
2 Carpal bone s
5 Re d u ct io n
Sca p h o id re d u ct io n
Fig 2.10 -10 Use sm all poin ted redu ction orceps to
redu ce th e scaph oid ractu re.
De t e rm in e s ca p h o id in s e r t io n p o in t a n d in s e r t t h e gu id e w ire
a b
Fig 2.10-11a –b Th e correct en try poin t or th e gu ide wire is in th e cen ter o

th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion .
Th e gu ide wire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in
radial abdu ction . Du rin g th e in trodu ction o th e gu ide wire, th e wrist
sh ou ld be in f exion oth erwise th e en try poin t can n ot be reach ed ( a ). Do
n ot pen etrate th e scaph otrapezial join t with th e gu ide wire. Im age in ten si -
cation sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide wire in
th e scaph oid axis an d perpen dicu lar to th e ractu re ( b ).
197
Pa rt II Case s
6 Fixa t io n
a b c
Follow in g m easu rin g an d drillin g, an d u sin g im age in ten si cation , a can n u lated h eadless com pression
Fig 2.10 -12 a – c
screw w as in trodu ced in to th e scaph oid bon e u n til th e ractu re gap w as closed an d com pressed.
a b
In traoperative im ages sh ow ed th ere w as correct

Fig 2.10 -13 a – b
position in g o th e screw .
2 Carpal bone s
Triq u e t ru m fixa t io n
a b c d
Th e triqu etru m h ad been split in to palm ar an d dorsal com pon en ts. Alth ou gh th e palm ar ractu re
Fig 2.10 -14 a – d
ragm en t w as th e bigger ragm en t ( a – b ), it w as redu ced an d stabilized by in trodu cin g a 1.5 m m lag screw via th e dorsal
aspect o th e bon e ( c– d ).
Us e o f la g s cre w s Co u n t e rs in k in g
a b
a b
Fig 2.10 -15 a – bBe su re to in sert th e screw as a lag screw , Fig 2.10 -16 a – bAlso en su re to cou n tersin k th e screw to
w ith a glidin g h ole in th e n ear cortex, an d a th readed redu ce th e risk o so t-tissu e irritation , so th at th e screw
h ole in th e ar cortex ( a ). In sertin g a screw across a h ead h as m axim al con tact area w ith th e bon e.
ractu re plan e th at is th readed in both cortices (position
in ter ragm en tary com pression ( b ).
199
Pa rt II Case s
Fig 2.10-17 Th e redu ction an d

xation o th e triqu etral
ractu re was th en also ch ecked
in traoperatively.
a b c
Fig 2.10-18a –c Th e palm ar com pon en t o th e lu n otriqu etral ligam en t was redu ced th rou gh a
dorsal approach . Th e palm ar com pon en t is th e th icker an d stron ger aspect, an d it is im portan t to
en su re its repair. However, as th e ractu re xation s in th is case were m ade by a dorsal approach ,
an addition al palm ar approach was n ot n ecessary. Th e dorsal portion o th e lu n otriqu etral
ligam en t was th en repaired with su tu res. Th e lu n otriqu etral join t was stabilized with a K-wire.
Th e capsu lotom y f ap is th en closed. Th e patien t w as

im m ediately im m obilized u sin g a plaster splin t.
2 Carpal bone s

ch apter 2.8 Perilu n ate dislocation treated w ith K-w ires.
a b
For th is patien t, both th e K-w ire an d th e

Fig 2.10 -20 a – b
cast w ere rem oved at th e 8-w eek ollow -u p. Th e patien t
w as th en re erred or ph ysical th erapy.
8 Ou t co m e
a b
Fig 2.10-21a –b At th e 1-year ollow-u p, th e x-ray im ages

sh owed per ect align m en t o th e carpu s an d com plete
h ealin g o both th e scaph oid an d triqu etral ractu res.
201
Pa rt II Case s
a b
c d
e f
Good radial an d u ln ar deviation o th e w rist w as sh ow n , an d th ere

Fig 2.10 -22 a – f
w as an excellen t u n ction al ou tcom e.
Fig 2.1 0-23 a –bTh e patien t h ad ach ieved good grip

stren gth com pared w ith th e u n in ju red h an d, allow in g
a b h im to retu rn to h is previou s activities w ith ou t lim itation .
2.11 Multiple carpal perilunate fracture
dislocation and scaphocapitate syndrome
treated with screws
a b c
Fig 2.11 -1a –c A 21-year-old sem ipro ession al BMX bicycle rider su stain ed a h igh -en ergy in ju ry to h is dom in an t righ t
w rist a ter a all du rin g a racin g com petition . He presen ted to th e em ergen cy departm en t com plain in g o severe pain ,
w rist de orm ity, an d m edian n erve distribu tion n u m bn ess.
Follow in g exam in ation , a w ide ran ge o im ages w ere taken . Th e ollow in g in ju ries w ere in dicated:
• Dorsal perilu n ate dislocation o th e carpu s
• Fractu re o th e scaph oid proxim al th ird
• Fractu re o th e proxim al pole o th e h am ate
• Fractu re o th e h ead o th e capitate
• Displacem en t o th e capitate ractu re in th e dorsal aspect o th e carpu s an d rotated 90 degrees
• Th e lu n ate rem ain ed articu lated w ith th e proxim al pole o th e scaph oid an d w ith th e distal radiu s bu t it w as
su blu xed palm arly on th e lu n ate acet
• Fractu re o th e u ln ar styloid base.
Th e coron al view 2-D CT scan s sh ow ed

Fig 2 .1 1-2 a – b
greater detail o th is com plex in ju ry, in clu din g th e ractu re
o th e scaph oid, th e ractu re o th e h ead o th e capitate, th e
ractu re o th e h am ate, an d eviden ce o dissociation be-
a b tw een th e triqu etru m an d th e lu n ate (arrow ).
203
Pa rt II Case s
a b c d
e f g
Fig 2.11-3a –g Th e AP view 3-D CT scan ( a ) sh owed th e dorsal dislocation o th e carpu s, wh ile th e lu n ate rem ain ed
articu lated with th e radiu s an d to th e proxim al pole o th e scaph oid. Th e radial view CT scan ( b ) sh owed th e
scaph oid ractu re. Th e 3-D im ages also sh owed th at th e proxim al th ird o th e scaph oid was deeply displaced, th e
h ead o th e capitate h ad rotated 90 degrees, an d th at th ere were ractu res o th e h am ate an d th e u ln ar styloid
( c–d ). Th e lu n otriqu etral ligam en t disru ption was eviden ced ( e –f). Th e axial view 3-D CT scan s sh owed th e dorsal
dislocation o th e carpu s with m ore detail ( g ).
A ter evalu atin g all th e im ages, it was con clu ded th at th e patien t h ad received a dorsal perilu n ate ractu re
dislocation th at in volved scaph oid, capitate, h am ate, an d u ln ar styloid ractu res.
2 Carpal bone s
2.11 Multiple carpal pe rilunate fracture dislocation and scaphocapitate syndrome tre ate d with scre ws
2 In d ica t io n s
Pe rilu n a t e fra ct u re d is lo ca t io n w it h s ca p h o ca p it a t e s yn d ro m e
Fig 2.11 -4 As previou sly discu ssed, perilu n ate ractu re

dislocation s presen t an exten sive array o in ju ries an d
in clu de ractu res o carpal bon es an d ligam en tou s in ju ry
adjacen t to th e lu n ate. Wh ile m ost perilu n ate ractu res
in volve th e scaph oid, oth er carpal bon es in clu din g th e
capitate an d th e h am ate can be in volved. Addition al
ractu res can also occu r at th e radial styloid an d, as w ith
th is patien t, th e u ln ar styloid.
180°
a b c
Fig 2.11-5a –c Th e in ju ry to th is patien t also represen ts a speci c variation o m u ltiple

carpal perilu n ate ractu re dislocation kn own as scaph ocapitate (or n avicu locapitate)
syn drom e, an d is rare. In th is in ju ry, th e h igh -en ergy orce passes th rou gh th e n eck o
th e capitate, ractu rin g both th e scaph oid an d th e capitate. Th e resu lt is th at th e
proxim al portion o th e capitate can rotate 90 to 180 degrees, with th e articu lar su r ace
o th e h ead o th e capitate directed distally. Open redu ction an d in tern al xation is
alm ost always requ ired in order to restore carpal stability.
205
Pa rt II Case s

• A tooth ed orceps
• Bon e an ch ors

option al.
Ap p ro a ch
a b
Fig 2.11 -7a –b Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e
2 Carpal bone s
EPL
CH
Fig 2 .1 1-8 Th e w rist w as exposed th rou gh a dorsal approach

an d capsu lar in cision . Th e ractu re o th e h ead o th e capitate
becam e eviden t (CH), as w as its displacem en t in th e dorsal
aspect o th e carpu s w ith 90 degree rotation . Th e exten sor
pollicis lon gu s (EPL) w as retracted.
5 Re d u ct io n
Ca p it a t e re d u ct io n
Hamate
a b
Fig 2.11 -9a –b Usin g a tooth ed orceps, th e displaced proxim al h ead o th e capitate is reapproxim ated to its
correct an atom ical location . Th e in traoperative im ages sh ow th e h ead o th e capitate bein g h eld by th e orceps
( a ), w h ich w ere u sed to redu ce th e ractu re. An arrow iden ti es th e h am ate ractu re ( b ).
207
Pa rt II Case s
Ha m a t e re d u ct io n
SL Fig 2.11-10 On ce th e capitate is redu ced, th e h am ate

C
is th en stabilized an d redu ced. Th e in traoperative
H im age sh ows th e redu ction o th e m idcarpal join t,
in clu din g th e capitate (C) an d h am ate (H) redu ction .
Th e scaph olu n ate ligam en t (SL) rem ain ed u n a ected.
Th e scaph oid waist ractu re rem ain ed displaced at
th is stage (arrow).
Sca p h o id re d u ct io n De te rm ine sca phoid inse rtion point a nd inse rt the gu ide wire
Fig 2.11-11 Fu rth er traction on th e area Fig 2.11-12 Th e correct en try poin t or th e gu ide w ire is in
perm itted th e scaph oid ractu re to be redu ced. th e cen ter o th e proxim al pole, directly adjacen t to th e
Note th at n o com pression is yet applied scaph olu n ate ligam en t in sertion . Th e gu ide w ire is in serted
(arrow). in th e axis o th e sh a t o th e rst m etacarpal, in radial
abdu ction . Du rin g th e in trodu ction o th e gu ide w ire, th e
w rist sh ou ld be in f exion oth erw ise th e en try poin t can n ot
be reach ed. Do n ot pen etrate th e scaph otrapezial join t w ith
th e gu ide wire. Im age in ten si cation sh ou ld be u sed to
con rm accu rate advan cem en t o th e gu ide wire in th e
scaph oid axis an d perpen dicu lar to th e ractu re.
2 Carpal bone s
6 Fixa t io n
Ca p it a t e fixa t io n Ha m a t e fixa t io n
Fig 2.11 -13 Th e h ead o th e capitate w as devoid o an y Fig 2.11 -14 Th e proxim al pole o th e h am ate w as xed
attach m en t, so it w as an atom ically redu ced. Th e capitate w ith a 1.3 m m lag screw in an tegrade direction . Care w as
ragm en t can th en be stabilized w ith eith er a 1.5 m m taken to bu ry both th e capitate an d h am ate screw h eads
h eadless com pression screw or a 1.5 m m u lly th readed u n der th e articu lar cartilage.
cortex screw applied as a lag screw . In th is case, a 1.5 m m
lag screw w as in serted in an tegrade direction .
a b a b
Fig 2.11 -15 a – bBe su re to in sert th e screw as a lag screw , Fig 2.11 -16 a – bAlso en su re to cou n tersin k th e screw to
209
Pa rt II Case s
Fig 2.11 -17 Atten tion w as th en brou gh t to th e scaph oid

proxim al th ird ractu re. A ter an atom ical redu ction w as
per orm ed, xation w as ach ieved w ith a 3.0 m m h eadless
com pression screw . Th e dorsal scaph olu n ate ligam en t w as
u n in ju red.
Th e xation procedu re ollows th e u su al steps o m easu rin g

screw len gth , drillin g, selectin g th e screw, in sertin g th e
screw, an d advan cin g an d cou n tersin kin g th e screw. For
u rth er in orm ation on th ese steps see ch apter 2.4
Scaph oid, proxim al pole— ractu re treated with a h eadless
com pression screw.
a b
Fig 2.11-18a –b A m idsu bstan ce tear o th e lu n otriqu etral ligam en t was n oted an d repaired directly with n on absorbable
su tu res ( a ). Th e lu n otriqu etral join t was stabilized with a percu tan eou s K-wire ( b ).
Th e ligam en t repair procedu re ollows th e u su al steps o determ in in g i th e tear is m idsu bstan ce or bon y avu lsion ,
determ in in g size o ligam en t rem n an t or bon e an ch ors or direct su tu re, an d in sertion o K-wires. For u rth er in orm ation
on th ese steps see ch apter 2.8 Perilu n ate dislocation treated with K-wires.
2 Carpal bone s
Uln a r s t ylo id re p a ir
Th e DRUJ w as stable du rin g in traoperative exam in ation so

on th is occasion th e u ln ar styloid ractu re w as n ot xed.
a b
Th e in traoperative im ages sh ow th e
Fig 2.11 -19 a – b
variou s ractu re redu ction s an d xation s.

postoperative rest, in ju ry elevation , ollow-u p, rem oval o
stitch es, an d im m obilization as requ ired. Followin g su rgery,
begin active con trolled ran ge o m otion exercises. For
u rth er in orm ation , see th e reh abilitation topic in ch apter
2.8 Perilu n ate dislocation treated with K-wires.
Th e patien t in th is ch apter was im m ediately placed in to a

sh ort arm plaster splin t. Th ere were n o in traoperative or
postoperative com plication s, an d m edian n erve distribu tion
n u m bn ess resolved com pletely in th e im m ediate postopera-
tive period. Su tu res were rem oved 2 weeks a ter su rgery
an d th e splin t was replaced with a rem ovable orth osis. Nin e
weeks a ter su rgery th ere was radiograph ic eviden ce o
h ealin g o all ractu res th u s th e K-wire was rem oved. Th e
patien t was cleared or active an d passive ran ge o m otion
exercises at 12 weeks an d retu rn ed to im pact bike ridin g
sports at 4 m on th s.
211
Pa rt II Case s
8 Ou t co m e
a b
At th e 8-m on th ollow -u p, th e x-rays

Fig 2.11 -21 a – b
dem on strated h ealin g o all ractu res w ith ou t eviden ce o
avascu lar n ecrosis or collapse.
a b
c d
e f
At th is stage, th e patien t dem on strated a u n ction al ran ge o

Fig 2.11 -22 a – f
m otion . Note th e f exion lim itation o th e w rist, w h ich can be expected in
th is severe type o in ju ry. Th e patien t w en t on to ach ieve excellen t
recovery by th e 1-year ollow -u p, even tu ally retu rn in g to prior levels o
activity w ith ou t lim itation s.
2.12 Trapezium —displaced fracture treated
with lag screws
Fig 2 .1 2-1 A 44-year-old m ale retail w orker in ju red h is le t dom in an t th u m b w h en

h e tried to catch a large h eavy object as it ell tow ard h im at w ork. His th u m b w as
orcibly h yperexten ded. Th e in itial x-rays revealed a displaced ractu re in th e body
o th e trapeziu m .
2 In d ica t io n s
Tra p e ziu m fra ct u re s
Fig 2.12 -2 Fractu res o th e trapeziu m are rare an d accou n t or on ly 3–5% o all
carpal ractu res. Th e trapeziu m is an im portan t bon e an d con tribu tes to th e stability
an d pain - ree u n ction o th e th u m b in pin ch in g an d grippin g. Fractu res o th e
trapeziu m are eith er avu lsion ractu res o th e periph eral aspects o th e bon e
su stain ed du rin g a carpom etacarpal (CMC) join t dislocation (th e m ost com m on
type o trapezial ractu re), or a com pression ractu re a ectin g th e body o th e bon e.
Th e latter m ech an ism , illu strated in th is case, is alm ost alw ays th e con sequ en ce o a
Trapezium h igh -en ergy in ju ry. Displaced body ractu res o th e trapeziu m in volve th e CMC
join t o th e th u m b an d w ill h eal in articu lar m alu n ion , i n ot adequ ately redu ced
an d stabilized.
Ch o ice o f im p la n t
Th e bon e qu ality in th e trapeziu m is alm ost always good. As a con sequ en ce, ractu res are su itable or stabilization with lag
screws (u su ally 1.5 m m ) u n less th ere are cen tral areas o ragm en tation an d e ective bon e loss. In th ese circu m stan ces,
K-wires are a u se u l option i com pression o th e ragm en ts is con train dicated du e to m u lti ragm en tation .
213
Pa rt II Case s
• Modu lar h an d set 1.3 or 1.5

Fig 2.12 -3 Position th e patien t su pin e an d place th e

Ap p ro a ch
Superficial branch of the radial nerve
Radial artery
Fig 2.12 -4 Th e su rgical approach u sed w as a radiopalm ar Fig 2.12 -5 O th e tw o in cision option s available or th is
approach to th e th u m b (see ch apter 1.4 Radiopalm ar approach , on th is occasion a Wagn er in cision w as u sed,
approach to th e th u m b base). Th is approach allow ed w h ich ollow s th e th en ar em in en ce in a gen tle cu rve
access to th e trapeziu m im m ediately proxim al to th e tow ard its palm ar aspect.
m etacarpal.
2 Carpal bone s
2.12 Trape zium —displace d fracture tre ate d with lag scre ws
5 Re d u ct io n
a b
Fig 2.12-6a –b As part o th e su rgical approach , th e join t capsu le h as been open ed ( a ). Th is n ow

allows or direct in spection o th e articu lar redu ction . Poin ted redu ction orceps are u sed to
stabilize th e redu ction tem porarily ( b ).
6 Fixa t io n
Drillin g Scre w in s e r t io n
Fig 2.12 -7 Leavin g th e redu ction orceps in place, drill a Fig 2.12 -8 A m in im u m o tw o screw s u sed as lag screw s
glidin g h ole as perpen dicu lar to th e ractu re plan e as are n ecessary to provide su cien t stability in com pression
possible, u sin g a 1.5 m m drill bit or a 1.5 m m screw . an d rotation . Wh ile 1.5 m m screw s are recom m en ded,
In sert a 1.5 m m drill gu ide in to th e glidin g h ole. Use a 1.3 m m screw s m ay also be u sed i ragm en t size does n ot
1.1 m m drill bit to drill a th readed h ole in th e opposite perm it.
ragm en t, ju st th rou gh th e ar cortex. Repeat th e above
or a secon d screw .
215
Pa rt II Case s
a b a b
Fig 2.12 -9a –b Be su re to in sert th e screw as a lag screw , Fig 2.12 -10 a – bAlso en su re to cou n tersin k th e screw to
Con rm ation o redu ction an d xation sh ou ld be ob-

tain ed u sin g im age in ten si cation or x-rays. It w ill be
n ecessary to take several im ages at variou s an gles in order
to en su re th ere is n o articu lar pen etration w ith a lag
screw tip. Con rm ation o th is can be obtain ed by direct
in spection th rou gh th e previou sly created capsu lotom y.
2 Carpal bone s
2.12 Trape zium —displace d fracture tre ate d with lag scre ws

Fig 2.12 -11 Wh ile th e patien t is in bed, u se pillow s to

keep th e h an d elevated above th e level o th e h eart to
redu ce sw ellin g.
Fig 2.12 -13 As pain an d sw ellin g recede, con trolled

f exion an d exten sion exercises or th e th u m b an d h an d
gen tly progress. Th e im portan ce o m obilization m u st be
em ph asized to th e patien t an d reh abilitation sh ou ld be
su pervised by a ph ysical th erapist. A retu rn to n orm al
activities can be en cou raged a ter 6 w eeks.
Fig 2.12 -12 Th e w rist an d th u m b are im m obilized or 4 to

6 w eeks in a sh ort arm splin t. A rem ovable w rist splin t
in clu din g th e th u m b to th e in terph alan geal join t can be
u sed rom 2 w eeks, du rin g w h ich tim e th e patien t is
en cou raged to rem ove th e splin t or sh ort periods du rin g
th e day to allow gen tle th u m b m otion .
217
Pa rt II Case s
8 Ou t co m e
a b
Fig 2.12 -14 a – bCon gru en t redu ction w as con rm ed on

review o th e 6-w eek postoperative ollow -u p im ages.
Th e patien t w as th en able to retu rn to n orm al retailin g
w ork activities.
3 Ulna
Pa rt II Case s

3.1 Ulnar styloid–fracture treated with tension
band wiring
a b c d
Fig 3.1-1a – d A 38-year-old en gin eer w as in ju red w h ile participatin g in a dirt bike com petition . Wh en h e arrived in
th e em ergen cy departm en t h e com plain ed o pain in h is n on dom in an t le t w rist, an d th ere w as eviden ce o edem a
an d de orm ity. Th e x-rays an d 3-D CT scan s in dicated a ractu re at th e base o th e u ln ar styloid.
Th ere was also exten sive m u lti ragm en tation in both th e in term ediate an d radial colu m n s o th e distal radiu s, h owever,
treatm en t or th is patien t’s distal radial ractu res are discu ssed in detail in ch apter 4.6 Distal radiu s—m u lti ragm en tary
in traarticu lar ractu re treated with a palm ar plate. For th e pu rposes o th is ch apter, on ly th e u ln ar styloid ractu re is
discu ssed.
2 In d ica t io n s
Fra ct u re s o f t h e u ln a r s t ylo id
Fig 3.1-2 Th e u ln ar styloid can be avu lsed at its tip, th rou gh th e body, or at its base. Th e
level at w h ich th e avu lsion occu rred h as im plication s on th e in tegrity o th e attach m en t
o th e trian gu lar brocartilage com plex (TFCC) an d th e stability o th e distal radiou ln ar
join t (DRUJ). I th e in ju ry in volves th ese stru ctu res th ey m ay also requ ire repair.
221
Pa rt II Case s
Dis t a l ra d io u ln a r jo in t a s s e s s m e n t
Fractu res o th e u ln ar styloid th at requ ire xation are th ose th at produ ce eviden t DRUJ in stability. Th e DRUJ sh ou ld be
assessed or both orearm rotation an d stability. Th e ollow in g tw o m eth ods are recom m en ded to determ in e i
in stability exists.
Me t h o d 1: DRUJ b a llo t t e m e n t
a b a b
Fig 3.1-3a –b Th e elbow is f exed 90 degrees on th e arm Fig 3.1-4 a – bTh is is again repeated w ith th e w rist in u ll
table with th e orearm in n eu tral rotation an d displacem en t su pin ation an d u ll pron ation .
in a dorsal/ palm ar direction is assessed. Th is is repeated
with th e wrist in radial deviation , wh ich stabilizes th e
DRUJ, i th e u ln ar collateral com plex is n ot disru pted.
Me t h o d 2 : u ln a r co m p re s s io n t e s t
a b c
Fig 3.1-5 a – c In th is test, th e u ln a is com pressed again st th e radiu s ( a ). Th e orearm is rotated passively th rou gh u ll
su pin ation ( b ) an d pron ation ( c ).
I th ere is a palpable “clu n k”, in stability o th e DRUJ is presen t. Th is is an in dication to con sider in tern al xation o th e
u ln ar styloid ractu re by ten sion ban d w ire, lag screw , or plate. A DRUJ in stability can also resu lt rom so t-tissu e in ju ry
to th e TFCC.
3 Distal ulna
3.1 Ulnar styloid– fracture tre ate d with tension band wiring
Eq u ip m e n t
• 0.4 m m cerclage w ire

• Hypoderm ic n eedle
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
a b
c d
Fig 3.1-6 a – d Position th e patien t su pin e an d place th e orearm on a h an d table ( a ). Th e elbow is f exed, w h ich h olds th e
orearm in n eu tral rotation an d allow s or a direct approach to th e distal u ln a ( b ). In som e ractu res, it m ay also be
possible to sim ply rest th e patien ts orearm on th eir ch est ( c ). Altern atively, position in g patien ts on th eir side an d
restin g th e a ected orearm in a padded trou gh w ith th e elbow f exed w ill allow th e u ln ar styloid to be per ectly visible
w h en th e orearm is rotated in to u ll su pin ation ( d ). A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics
are option al.
223
Pa rt II Case s
Ap p ro a ch
a b
Fig 3.1-7a –b Th e su rgical approach u sed was an u ln ar

approach (see chapter 1.10 Uln ar approach to th e distal uln a)
( a ). Care was taken to avoid damagin g the dorsal cu taneou s
branch o th e u ln ar n erve du rin g th e approach ( b ).
5 Re d u ct io n
Re d u ct io n w it h s t a y s u t u re
Fig 3.1-8 A stron g stay su tu re can be in serted arou n d th e Fig 3.1-9 By pu llin g proxim ally on th is su tu re, th e u ln ar
tip o th e styloid to h elp w ith redu ction in preparation or styloid is redu ced.
th e later application o a ten sion ban d w ire.
3 Distal ulna
Dire ct re d u ct io n
Fig 3.1-1 0Redu ction can also be ach ieved u sin g a den tal
pick or a poin ted redu ction orceps.
6 Fixa t io n
Drill h o le
Dorsal branch
of ulnar nerve
Fig 3.1-1 1 Drill a h ole th rou gh th e u ln a approxim ately

2 cm proxim al rom th e tip o th e styloid. Care n eeds to
be taken to avoid in ju ry to th e dorsal cu tan eou s bran ch o
th e u ln ar n erve.
225
Pa rt II Case s
In s e r t t h e ce rcla ge w ire
a b c
Fig 3.1-1 2a –c Pass a w ire th rou gh th e h ole m ade proxim al to th e u ln ar styloid ractu re ( a ).
Th e clin ical im ages sh ow th e w ire placed th rou gh th e h ole m ade in to th e u ln a ( b – c ).
In s e r t t h e K-w ire s Cre a t e a figu re -o f-e igh t
a b
Fig 3.1-1 3a –b I th ere is en ou gh room , in sert tw o K-w ires Fig 3.1-14 Con tin u e th e wire th rou gh th e drill h ole an d,
rom th e tip o th e styloid in su ch a direction as to en gage u sin g a h ypoderm ic n eedle as a gu ide, pass th e wire
th eir tips in th e opposite cortex o th e u ln a, proxim al to arou n d th e K-wires distally to create a gu re-o -eigh t loop.
th e DRUJ ( a ). Im age in ten si cation sh ou ld be u sed to
en su re correct placem en t o th e K-w ires ( b ).
3 Distal ulna
Ap p ly t e n s io n t o t h e w ire Bu r y t h e K-w ire s
Fig 3.1-1 5 A ter creatin g th e gu re-o -eigh t, th e w ire Fig 3 .1 -1 6Usin g th e ben din g iron or K-w ires, th e w ires
tw ist is begu n , en su rin g th at each en d o th e w ire spirals are ben t at th e level o th e tip o th e styloid th rou gh
equ ally. Th e w ire is ten sion ed by pu llin g on th e tw ist 180 degrees an d cu t sh ort. Th ey are th en im pacted in to
u n til th e desired ten sion is ach ieved an d th en tw isted to th e bon e u sin g a sm all pu n ch or oth er appropriate tool.
take u p th e slack created. Cu t th e tw ist an d ben d it Con rm u sin g im age in ten si cation to en su re th at th e
tow ard th e bon e so as to n ot irritate th e so t tissu es. proxim al tips o th e K-w ires are n ot in th e in terosseou s
space.
a b
Fig 3.1-1 7a –b Th e in traoperative im ages sh ow th e Fig 3.1-1 8 In traoperative

location o th e K-w ires ( a ) an d th e cu t K-w ires em bedded im age in ten si cation also
in to th e bon e ( b ). en su res th at th e proxim al tips
o th e w ires are n ot in th e
in terosseou s space an d th at
th ere is per ect redu ction o
th e ractu re.
227
Pa rt II Case s
Th e AP an d lateral x-rays (also sh ow in g th e distal

Fig 3 .1 -19 a – b
radial ractu re) 1 w eek a ter su rgery sh ow s per ect redu ction o
a b th e ractu res an d correct location o th e im plan ts.


sw ellin g.
3 Distal ulna
7 Re h a b ilit a t io n (co n t )

Fig 3.1-2 1 Th e type an d du ration o postoperative th erapist.
im m obilization or distal u ln ar ractu res depen ds on a
n u m ber o actors in clu din g th e qu ality o th e in tern al
xation as w ell as patien t activity an d reliability. It m ay
be n ecessary to rest th e w rist or several w eeks in a cast or
rem ovable splin t. Du rin g th at tim e, th e patien t is
en cou raged to rem ove th e im m obilization or sh ort
periods to allow gen tle w rist m otion .
8 Ou t co m e
a b
Th e x-rays at th e 1-year
Fig 3.1-2 3a –b
ollow -u p con rm ed an atom ical h ealin g. c d
Fig 3.1-2 4a –d Th e patien t h ad n o pain an d cou ld ach ieve

u ll ran ge o m otion . He h ad retu rn ed to n orm al w ork
an d sportin g activities.
229
Pa rt II Case s
9 Alt e rn a t ive t e ch n iq u e
Alt e rn a t ive fixa t io n w it h a s cre w As s e s s m e n t o f DRUJ
Fig 3.1-25 Wh ile redu ction is m ain tain ed by pu llin g on th e Fig 3.1-2 6 Stable reattach m en t o th e u ln ar styloid w ith
su tu re, or by pressu re with a den tal pick, th e styloid can correct ten sion o th e TFCC sh ou ld be ach ieved w ith th is
also be xed with an appropriate sized screw in trodu ced sin gle screw . Th e stability o th e radiou ln ar join t is tested
rom th e tip o th e styloid in to th e lateral cortex o th e a ter in sertion o th e screw . Th e su tu re can n ow be
u ln ar sh a t. w ith drawn .
Th e u ln ar styloid n eeds to be overdrilled or th e screw to

h ave a lag screw e ect.
3.2 Ulna, head and neck—multifragmentary
fracture treated with a hook plate
a b c d
Fig 3.2-1a – d A 62-year-old salesm an in ju red h is le t w rist in a m otor veh icle acciden t.
He su ered a type II Gu stillo ractu re th at in volved both th e u ln a an d distal radiu s. Th e
AP an d lateral x-rays an d coron al CT scan dem on strated com plex u ln ar h ead an d n eck
ractu res w ith m arked displacem en t an d a m u lti ragm en tary ractu re o th e distal radiu s.
a b c d
Fig 3.2-2a – d Fu rth er 2-D axial CT scan s dem on strated su bstan tial m etaph yseal ragm en tation w ith in both th e u ln a
an d distal radiu s, w h ile 3-D CT recon stru ction s iden ti ed th e exten t o displacem en t o each ractu re. How ever, or
th e pu rposes o th is ch apter, on ly th e u ln ar ractu res are discu ssed.
231
Pa rt II Case s
2 In d ica t io n s
Fra ct u re s o f t h e d is t a l u ln a Ch o ice o f im p la n t
Mu lti ragm en tary ractu res o th e distal u ln a can be treated

with bridge or h ook platin g or with a m in icon dylar plate.
Hook platin g with a lockin g com pression plate (LCP) distal
u ln a plate allows better con trol o sm aller distal ragm en ts
an d was selected or th is patien t.
Fig 3.2-3 In m u lti ragm en tary u ln ar ractu res th ere

is in stability an d sh orten in g. An atom ical restoration
o th e u ln ar h ead an d n eck is essen tial to restore
n orm al distal radiou ln ar join t (DRUJ) u n ction .
Restoration o th e DRUJ creates in trin sic stability.
Eq u ip m e n t
• LCP distal u ln a plate 2.0

• 1.1 m m K-w ire
a b
Fig 3.2-4 a – b Position th e patien t su pin e an d place th e orearm on a h an d table ( a ). Th e elbow can also
be f exed, w h ich h olds th e orearm in n eu tral rotation an d allow s or a direct approach to th e distal u ln a
( b ). A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.
3 Distal ulna
3.2 Ulna, he ad and ne ck—multifragme ntary fracture tre ate d with a hook plate
Ap p ro a ch
Fig 3.2-5 Th e su rgical approach u sed was an u ln ar approach

(see ch apter 1.10 Uln ar approach to th e distal u ln a).
5 Re d u ct io n
Re d u ce t h e u ln a r h e a d
Fig 3.2-6 Un der direct vision , th e u ln ar h ead is redu ced Fig 3.2-7 Tem porary stabilization w ith a sm all K-w ire
to th e u ln ar sh a t u sin g a sm all periosteal elevator or a m ay be n ecessary, especially i th ere is a separate u ln ar
den tal pick. In m u lti ragm en tary su bcapital ractu res, styloid ragm en t.
correct align m en t an d correct rotation al align m en t o th e
h ead is veri ed. A redu ction orceps is u su ally n ot
applicable du e to th e sm all ragm en ts an d th e so t bon e
qu ality at th is level.
233
Pa rt II Case s
6 Fixa t io n
Se le ct t h e p la t e Ap p ly t h e p la t e
a b
Fig 3.2-8 a – bTh e distal u ln a plate is a precon tou red plate Fig 3.2-9 Th e poin ted h ooks are placed arou n d th e tip o
th at ts to th e su r ace o th e distal u ln a an d allow s th e u ln ar styloid an d th e plate is align ed on th e u ln ar
graspin g o th e u ln ar styloid w ith th e poin ted h ooks. sh a t. I a K-w ire h as been in serted, it w ou ld ideally sit
betw een th e distal h ooks o th e plate.
In s e r t t h e firs t s cre w
Fig 3.2-1 0 Han dlin g o th e plate m ay be acilitated u sin g Fig 3.2-1 1 An LCP drill gu ide is u sed to drill a h ole or a
th e LCP drill gu ide in serted in on e o th e LCP plate h oles. lockin g screw in th e u ln ar h ead. Avoid drillin g th rou gh
Im age in ten si cation can be u sed to veri y correct plate th e opposite cortex, as th e screw tip w ou ld pen etrate in to
position . th e distal radiou ln ar join t. Screw len gth is m easu red
pu sh in g th e h ook o th e depth gau ge again st th e opposite
cortex. A sligh tly sh orter screw is th en ch osen .
3 Distal ulna
Fig 3.2-1 2 Th e rst lockin g h ead screw is in serted in to th e Fig 3.2-1 3 A stan dard screw is in serted th rou gh th e
u ln ar h ead. oblon g plate h ole to redu ce th e sh a t ragm en t to th e
plate. At th is poin t redu ction is veri ed u n der im age
in ten si cation an d u n restricted pron ation an d su pin ation
is ch ecked.
In s e r t a d d it io n a l s cre w s
Addition al lockin g h ead screw s are in serted in to th e u ln ar h ead an d xation at th e sh a t ragm en t is com pleted u sin g
stan dard or lockin g h ead screw s. Th e m u ltiple option s or screw in sertion in th e plate allow a w ide ran ge o ractu re
pattern s to be secu rely stabilized.
Op t io n 1 : fra ct u re s re q u irin g le n g t h a d ju s t m e n t
a b c
Fig 3.2-1 4a –c In ractu res th at requ ire len gth adju stm en t, place on e or tw o 2.0 m m lockin g screw s in th e u ln ar h ead to
secu rely x th e im plan t distally, th en place a 2.0 m m cortex screw in th e oblon g h ole o th e sh a t an d obtain th e correct
len gth o redu ction ( a ). Use a com bin ation o cortex an d lockin g screw s in th e su rrou n din g h oles to stabilize th e
ractu re secu rely, as dictated by bon e qu ality ( b –c ).
235
Pa rt II Case s
Op tio n 2 : fra ctu re s re q u irin g s t a b ilit y o f th e u ln a r s t ylo id
a b a b
Fig 3.2-1 5a –b In th e case o u n stable ractu res o th e base Fig 3.2-1 6a –b In u n stable ractu res o th e tip o th e u ln ar
o th e u ln ar styloid, a 2.0 m m lockin g screw can be styloid, th e distal plate h ole is le t em pty. Rem ove th e
applied th rou gh th e m ost distal h ole in th e plate. A K-w ire i u sed or prelim in ary xation . Overdrill th e n ear
lockin g screw does n ot n eed to reach th e ar cortex or ragm en t w ith a 1.5 m m drill bit. In sert a 1.5 m m cortex
stable xation . screw in lag m ode betw een th e arm s o th e distal h ooks.
Pit fa ll: lo ck in g h e a d s cre w t o o lo n g Pe a rl: re t a in in g t h e K-w ire
a b
Fig 3.2-1 7 I a screw pen etrates th e opposite cortex o th e Fig 3.2-1 8a –b I a K-w ire h as been u sed or xation o th e
u ln ar h ead, th e screw tip w ill dam age th e cartilage o th e u ln ar styloid, an d h as n ot been rem oved or distal screw
radiou ln ar join t. placem en t, it m ay be le t in place i it en ters th e u ln ar
styloid betw een th e poin ted h ooks. Th e K-w ire is th en
ben t an d cu t sh ort.
3 Distal ulna
Fig 3.2-1 9 Th e in traoperative im age sh ow s th e u ln ar

ractu res stabilized u sin g th e LCP distal u ln a plate.

ch apter 3.1 Uln ar styloid– ractu re treated w ith ten sion
ban d w irin g.
237
Pa rt II Case s
8 Ou t co m e
Fig 3.2-2 1a – b At th e 6-m on th ollow -u p, th ere w as

a b h ealin g o th e u ln ar ractu res in good position .
a b
c d
Fig 3.2-2 2a –d Th ere w as a su ccess u l u n ction al resu lt sh ow in g good ran ge o m otion .
Vid e o
Vid e o 3.2-1Th is video dem on strates a distal u ln a su bcapital

ractu re with diaph yseal com m in u tion an d styloid ractu re
treated with an LCP distal u ln a plate.
4 Radius
Pa rt II Case s

4.1 Radial styloid—fracture treated with a radial
column plate
Fig 4.1-1a –b A 23-year-old em ale u n iversity

stu den t su ered an in ju ry to h er righ t wrist in a
tra c acciden t an d was in itially treated or a wrist
sprain by cast im m obilization . Sh e retu rn ed to th e
h an d clin ic or cast rem oval 3 weeks later, h owever,
th e ollow-u p PA an d lateral x-rays sh owed an
apparen tly ben ign n on displaced ractu re o th e
radial styloid. As th ere was su spicion o in traarticu -
lar displacem en t in th e lateral view, a CT scan was
a b requ ested.
a b c
Fig 4.1-2a – cTh e CT scan s revealed a displaced in traarticu lar ractu re

w ith a step-o o th e dorsal aspect o th e radial styloid.
A displaced ractu re o th e u ln ar styloid w as also eviden t; h ow ever, or

th e pu rposes o th is ch apter, on ly th e radial styloid is discu ssed. For
u rth er in orm ation on treatin g u ln ar styloid ractu res see ch apter 3.1
Uln ar styloid– ractu re treated w ith ten sion ban d w irin g.
241
Pa rt II Case s
2 In d ica t io n s
Ra d ia l s t ylo id fra ct u re s As s o cia t e d m e d ia n n e r ve co m p re s s io n
Median nerve
Fig 4.1-3 Sim ple radial styloid ractu res are ractu res Fig 4.1-4 I th ere is den se sen sory loss or oth er sign s o
w ith ou t m u lti ragm en tation . Th ey can occu r as a resu lt o m edian n erve com pression , th e m edian n erve sh ou ld be
sh earin g or com pression orces. As th ey in volve an decom pressed.
articu lar split o th e radial styloid, th ey are partial
articu lar ractu res. Th ese ractu res dem an d accu rate
redu ction sin ce th ey in volve th e articu lar su r ace. O ten
th e ractu re exists in th e sagittal plan e.
As s o cia t e d ca rp a l in ju rie s
Fig 4.1-5 Th ese in ju ries m ay be associated w ith sh earin g

in ju ries o th e articu lar cartilage, scaph oid ractu res, an d
ru ptu res o th e scaph olu n ate ligam en t. Every patien t
sh ou ld be assessed or th ese in ju ries.
4 Distal radius
4.1 Radial styloid—fracture tre ate d with a radial column plate
As s o cia t e d u ln a r in ju rie s Co n t ra in d ica t io n s
Th rou gh ou t th e ch apters in th e rem ain in g two section s o

th e book, patien t treatm en t m ostly in volves open redu ction
an d in tern al xation with a variety o plate an d screw
tech n ology. Th e reader is rem in ded th at in som e in stan ces
su rgical treatm en t or a distal radial ractu re is n ot recom -
m en ded, an d th ese can in clu de bu t are n ot lim ited to th e
type o displacem en t o th e ractu re, n erve com prom ise,
severe swellin g, poor state o so t tissu es, an d th e patien t
n ot bein g t or su rgery.
Fig 4.1-6 Th ese in ju ries can also be accom pan ied by

avu lsion o th e u ln ar styloid an d/ or disru ption o th e
distal radiou ln ar join t (DRUJ). I th ere is gross in stability
a ter th e xation o th e radial ractu re, it is recom m en ded
th at th e u ln ar styloid an d/ or th e trian gu lar brocartilage
disc (TFC) is reattach ed. Th is is n ot com m on in sim ple
ractu res bu t can occu r in som e h igh -en ergy in ju ries. Th e
u n in ju red side sh ou ld be tested as a re eren ce or th e
in ju red side. How ever, it m ay n ot be possible to assess
DRUJ stability u n til th e ractu re h as been stabilized.
a b c
Radial colum n plate L-plate Lag scre w
Fig 4.1-7 a – c A variety o plate an d screw option s are available or radial

styloid ractu res depen din g on ractu re pattern , th e state o th e a ected
so t tissu es, an d stability. Plates w ith variable an gle (VA) lockin g screw
option s can be u se u l. For th is patien t, a straigh t radial colu m n plate
w as selected an d u rth er su pported w ith an addition al lag screw .
243
Pa rt II Case s
• VA LCP distal radiu s set

• VA LCP radial colu m n plate 2.4
• 1.1 m m or 1.2 m m K-w ires
• 2.4 m m cortex screw
• Osteotom e

on th e h an d table. Pron ate th e orearm . Th e position o th e
lim b sh ou ld allow com plete im agin g in th e ron tal an d
sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic
Ap p ro a ch
Fig 4.1-9 Th e su rgical approach u sed was a dorsoradial

approach between th e rst an d secon d exten sor com part-
m en ts (see ch apter 1.5 Dorsoradial approach to th e distal
radiu s).
4 Distal radius
Fig 4.1-1 0 To im prove visibility o th e join t Fig 4.1-1 1 Fu rth er exam in ation o th e
su r ace, an arth rotom y o th e dorsal capsu le su r ace revealed th at th e articu lar ractu re
w as per orm ed. Th is revealed a bigger ragm en t w as orien ted in th e sagittal an d in th e
th an su spected rom th e x-rays. Addition ally, coron al plan e.
becau se th e su rgery w as per orm ed 3 w eeks
a ter th e in itial trau m a, open in g o th e early
callu s w ith an osteotom e w as requ ired.
5 Re d u ct io n
Pro vis io n a l re d u ct io n Pro vis io n a l fixa t io n
Fig 4.1-1 2 Redu ction is ach ieved by applyin g lon gitu din al
traction eith er m an u ally or u sin g n ger traps. Th e
redu ction is m ain tain ed by a tem porary splin t. I de n i-
tive su rgery is plan n ed bu t can n ot be per orm ed w ith in a Fig 4.1-1 3 In sert a K-w ire th rou gh th e tip o th e radial
reason able tim e scale, a tem porary extern al xator m ay styloid to provision ally h old th e ragm en ts. Con rm u sin g
be h elp u l. im age in ten si cation .
245
Pa rt II Case s
6 Fixa t io n
Co n t o u r t h e p la t e
a b
Fig 4.1-1 4a –b Plates u sed in treatin g radial an d in term edi- Fig 4.1-1 5 Variable an gle lockin g plates en able precise
ate colu m n in ju ries are available precon tou red. How ever, position in g o th e distal screw s in desired direction s
som e addition al con tou rin g m ay be n ecessary to accom - becau se th ere is 30 degrees o reedom or each screw
m odate th e in dividu al an atom y o th e patien t. in side th e plate h ole in order to address th e in dividu al
ractu re pattern s.
Pit fa ll: s cre w h o le d is t o r t io n Fixa t io n o f ra d ia l co lu m n

Se le ct a n d a p p ly t h e p la t e
Radial artery
a b
Superficial branch
Fig 4.1-1 6a –b Avoid con tou rin g th e plate th rou gh th e of radial nerve
lockin g h oles, oth erw ise th e lockin g h ead screw m igh t n o
lon ger t.
Fig 4.1-1 7 Th e appropriate plate is selected accordin g to

th e ractu re con gu ration an d con tou red i n ecessary.
Slide th e plate u n dern eath th e rst com partm en t an d
apply it on to th e radial colu m n .
4 Distal radius
St a b ilize t h e ra d ia l co lu m n Pit fa ll: in co rre ct p la ce m e n t
a b
Fig 4.1-18 Ideally wh ile applyin g th e plate, th e n otch in th e Fig 4.1-1 9a –b Placem en t o th e plate on th e dorsal aspect
distal tip o th e im plan t is placed again st th e tem porary o th e radial colu m n is to be avoided, as it w ill n ot
K-wire. bu ttress th e redu ction adequ ately again st axial sh ear
orces.
In s e r t t h e firs t s cre w
a b
Fig 4.1-2 0a –b In sert a stan dard cortex screw in to th e oblon g plate h ole
proxim al to th e ractu re ( a ). It is pre erable th at th e screw sh ou ld en gage
th e ar cortex, bu t in th is case th is w ou ld resu lt in pen etration o th e
DRUJ. Th e den se su bch on dral bon e in th is region allow s secu re xation i
bon e qu ality is good. Th e position o th e plate m ay be adju sted be ore th e
screw is tigh ten ed. Tigh ten in g th is screw w ill redu ce th e radial styloid ( b ).
247
Pa rt II Case s
In s e r t t h e firs t lo ck in g h e a d s cre w
a b
Fig 4.1-2 1a –b To preven t rotation o th e plate du rin g distal su bch on dral

lockin g screw xation , th e plate sh ou ld be secu red to th e bon e by in sertin g
th e m ost proxim al screw . To avoid overtigh ten in g th e lockin g screw a
torqu e lim itin g device sh ou ld be u sed.
In s e r t t h e d is t a l lo ck in g h e a d s cre w
X-ray beam
Fig 4.1-22 I a K-wire was u sed, it is n ow rem oved. In sert a Fig 4.1-2 3 Con rm th at th e screw does n ot protru de in to
lockin g h ead screw in to th e distal lockin g h ole o th e plate. th e join t u sin g th e im age in ten si er, w ith th e beam
Th e screw sh ou ld be placed in a su bch on dral position . an gled 20 degrees rom th e tru e lateral. Th is projection
w ill pro le th e radial articu lar su r ace an d sh ow an y
en croach m en t o th e screw in to th e join t.
4 Distal radius
Co m p le t e t h e fixa t io n Dis t a l ra d io u ln a r jo in t a s s e s s m e n t
A ter xation , th e DRUJ sh ou ld be assessed or both

orearm rotation an d stability. Th e ollow in g tw o m eth ods
are recom m en ded to determ in e i in stability exists.
Fig 4.1-2 4 To com plete th e xation , it m ay be n ecessary

to in sert a lag screw . In order to obtain th e lag e ect, u se
eith er partially th readed screw s or prepare a glidin g h ole
in th e radial styloid. Use a drill gu ide to en su re th at th e
so t tissu es are protected du rin g drillin g.
Me t h o d 1: DRUJ b a llo t t e m e n t
a b a b
Fig 4.1-25a –b Th e elbow is f exed 90 degrees on th e arm Fig 4.1-2 6a –b Th is is again repeated w ith th e w rist in u ll
table with th e orearm in n eu tral rotation an d displacem en t su pin ation an d u ll pron ation .
in a dorsal/ palm ar direction is assessed. Th is is repeated
with th e wrist in radial deviation , wh ich stabilizes th e
DRUJ, i th e u ln ar collateral com plex is n ot disru pted.
249
Pa rt II Case s
Me t h o d 2 : u ln a co m p re s s io n t e s t
a b c
Fig 4.1-2 7a –c In th is test, th e u ln a is com pressed again st th e radiu s ( a ). Th e orearm is rotated passively th rou gh u ll
su pin ation ( b ) an d pron ation ( c ). I th ere is a palpable “clu n k”, in stability o th e DRUJ is presen t. Th is is an in dication
to con sider in tern al xation o an u ln ar styloid ractu re by ten sion ban d w ire, lag screw , or plate. A DRUJ in stability
can also resu lt rom so t-tissu e in ju ry to th e trian gu lar brocartilage com plex (TFCC).
a b c
Fig 4.1-2 8a –c With th e poin ted redu ction orceps u sed to redu ce th e ractu re, th e plate w as placed on th e radial
colu m n an d th e screw s in serted ( a ). In traoperative im age in ten si cation sh ow ed th e displacem en t o th e ractu re an d
h elped to determ in e th e righ t location or th e plate ( b – c ).
4 Distal radius
a b
Fig 4.1-2 9a –b Follow in g plate xation , a 2.4 m m lag screw w as in serted perpen dicu lar to th e
ractu re in th e coron al plan e to u rth er stabilize th e ractu re ( a ). Th e poin ted redu ction orceps
w as th en rem oved ( b ).
a b
Fig 4.1-30a –b In traoperative im agin g sh owed th e

ractu re redu ction with th e VA LCP straigh t plate actin g
as a bu ttress to th e join t su r ace an d th e lag screw
placed th rou gh th e plate in to th e su bch on dral bon e.
251
Pa rt II Case s


sw ellin g.

Fig 4.1-32 Th e type an d du ration o postoperative im m obi- th erapist.
lization depen ds on a n u m ber o actors in clu din g th e
qu ality o th e in tern al xation as well as patien t activity
an d reliability. It m ay be n ecessary to rest th e wrist or
several weeks in a plaster or rem ovable splin t. Du rin g th at
tim e, th e patien t is en cou raged to rem ove th e splin t or
sh ort periods to allow gen tle wrist m otion .
4 Distal radius
8 Ou t co m e
a b
Fig 4.1-3 4a –b At th e 3-m on th ollow -u p, th e PA an d

lateral x-rays sh ow ed h ealin g o th e ractu re.
Fig 4.1-3 5a –b Th ere w as also n orm al

u ln ar an d radial deviation o th e w rist.
a b
c d
Fig 4.1-3 6a –d Th ere w as an excellen t u n ction al resu lt.
253
Pa rt II Case s
Ra d ia l s t ylo id fra ct u re t re a t e d w it h p e rcu t a n e o u s fixa t io n
a b
Extensor carpi Extensor carpi

radialis longus radialis brevis
Extensor pollicis Extensor pollicis Superficial branch

longus brevis of radial nerve
Radial artery
c
Fig 4.1-37a –c In som e cases o sim ple radial styloid ractu re ( a ), it can be possible to
redu ce an d x th e ractu re th rou gh a sm all percu tan eou s approach over th e tip o th e
styloid ( b ). Th e advan tages o percu tan eou s treatm en t in clu de preservin g so t tissu e
an d redu cin g im m obilization tim e. However, care m u st still be taken to avoid dam agin g
im portan t stru ctu res in th is region ( c ).
4 Distal radius
9 Alt e rn a t ive t e ch n iq u e (co n t )
Clo s e d re d u ct io n
Fig 4.1-38 Redu ce th e ractu re u sin g percu tan eou s poin ted
redu ction orceps, in serted th rou gh sm all stab in cision s, or
th e m ain sm all in cision over th e styloid process. Con rm
th e redu ction u sin g im age in ten si cation .
Fixa t io n
a b
Fig 4.1-3 9a –b In sert a gu ide w ire in to th e styloid ragm en t as perpen dicu lar as
possible to th e ractu re site ( a ). Pass th e w ire across th e ractu re site, gain in g
pu rch ase in th e u ln ar cortex o th e radiu s. I th e ragm en t is large en ou gh ,
place a secon d gu ide w ire as parallel to th e join t su r ace as possible ( b ).
255
Pa rt II Case s
a b
Fig 4.1-4 0a –b Drill over th e gu ide w ires an d in sert th e

appropriate screw s. Fractu re treatm en t can in volve screw
an d/ or K-w ire xation .
4.2 Distal radius—dorsally displaced extraarticular
fracture treated with a palmar plate
a b c
Fig 4.2-1a – c A 76-year-old w om an su ered a all on to h er ou tstretch ed righ t h an d. Sh e

w en t to th e em ergen cy departm en t h avin g severe pain , n u m bn ess o th e n gers, an d gross
de orm ity o th e w rist. Th e PA an d lateral 3-D CT scan sh ow ed dorsal displacem en t o a
n on articu lar distal radial ractu re w ith som e dorsal m etaph yseal m u lti ragm en tation ( a – b ).
Th ere w as also a displaced ractu re o th e u ln a n eck. An axial view 3-D CT scan m ore
clearly dem on strated th e m arked ractu re displacem en t ( c ).
For th is patien t, both th e distal u ln a an d radiu s w ere in volved, w ith th e u ln a bein g treated
u sin g a distal u ln a (h ook) plate. How ever, or th e pu rposes o th is ch apter, on ly th e distal
radiu s is discu ssed. For u rth er in orm ation on treatin g distal u ln ar ractu res see ch apter
3.2 Uln a, h ead an d n eck—m u lti ragm en tary ractu re treated w ith a h ook plate.
257
Pa rt II Case s
2 In d ica t io n s
Ext ra a r t icu la r fra ct u re s As s o cia t e d m e d ia n n e r ve co m p re s s io n
Median nerve
a b
Fig 4.2-2 a – b Fractu res o th e distal radiu s can in volve a Fig 4.2-3 I th ere is den se sen sory loss or oth er sign s o
dorsally displaced extraarticu lar ractu re o th e distal m edian n erve com pression , th e m edian n erve sh ou ld be
m etaph ysis (proxim al to bu t n ot in clu din g th e articu lar decom pressed.
su r ace). Th is is th e m ost com m on type o w rist ractu re.
Extraarticu lar distal radial ractu res are com m on am on g

elderly patien ts w ith lesser qu ality bon e w h ereas stron ger
you n ger patien ts ten d to su er th ese on ly a ter h igh -
en ergy im pact, o ten in volvin g in traarticu lar ractu res as
w ell. Fractu res an gu lated dorsally at > 25 degrees an d
associated w ith osteoporosis or residu al void a ter
redu ction can prove u n stable. Th ere ore, prim ary palm ar
platin g is o ten th e best treatm en t option .
Be ore palm ar platin g becam e a com m on ly u sed treat-

m en t, m ost o th ese ractu res w ere treated w ith closed
redu ction , w h ich w as th en m ain tain ed w ith eith er
K-w ires or a plaster cast. Man y su rgeon s n ow treat m ost
th ese ractu res w ith a palm ar plate an d o ten u se th e plate
as an aid to redu ction .
4 Distal radius
4.2 Distal radius—dorsally displace d e xtraarticular fracture tre ate d with a palmar plate
As s o cia t e d u ln a r in ju rie s Ch o ice o f im p la n t
a b
2-column plate Extraarticular plate
Fig 4.2-4 Head, n eck, an d m u lti ragm en tary ractu res o
th e distal u ln a o ten occu r in com bin ation w ith distal Fig 4.2-5 a – bA variety o plate option s are available or
radial ractu res. With th ese u ln ar ractu res th ere is extraarticu lar distal radial ractu res. Advan ces in plate
in stability an d sh orten in g, so th e distal u ln ar h ook plate design h ave provided an gu lar stable xation , w h ich
can be u sed to h old th e ractu re. Atten tion sh ou ld be paid allow s en h an ced stability an d ease o application even in
to restorin g correct rotation an d len gth in relation to th e th e presen ce o osteoporotic bon e. Plates w ith variable
radiu s. Com plete dislocation o th e radiocarpal join t is an gle (VA) lockin g screw option s can be u se u l. For th is
o ten associated w ith disru ption o th e distal radiou ln ar patien t, a VA lockin g com presion plate (LCP) 2-colu m n
join t (DRUJ). palm ar plate w as selected.

• VA LCP 2-colu m n plate 2.4

on a h an d table. Su pin ate th e orearm . Th e position o th e
259
Pa rt II Case s
Ap p ro a ch
Fig 4.2-7Th e su rgical approach u sed w as a palm ar

approach (see ch apter 1.6 Modi ed Hen ry palm ar
approach to th e distal radiu s).
5 Re d u ct io n a n d fixa t io n
Pro vis io n a l re d u ct io n
Fig 4.2-8 Redu ction is ach ieved by applyin g lon gitu din al
traction eith er m an u ally or u sin g n ger traps. Th e
redu ction is m ain tain ed by a tem porary splin t. I de n itive
su rgery is plan n ed bu t can n ot be per orm ed w ith in a
reason able tim e scale a tem porary extern al xator m ay be
h elp u l.
4 Distal radius
5 Re d u ct io n a n d fixa t io n (co n t )
Re d u ct io n u s in g t h e p la t e Alt e rn a t ive re d u ct io n
Fig 4.2-9 Select an d apply th e plate to th e distal ragm en t. Fig 4.2-1 0 Som e su rgeon s believe th at u sin g th e plate or
Th e distal en d o th e plate sh ou ld en d at th e an atom ical redu ction in patien ts w ith osteoporosis m ay cau se th e
watersh ed lin e o th e distal radiu s. In sert a K-wire th rou gh screw s to loosen in th e bon e. In su ch cases, m an u al
a screw h ole as close to th e su bch on dral bon e as possible redu ction an d prelim in ary xation w ith K-w ires m ay be
an d parallel to th e articu lar su r ace. Th e resu ltan t an gle o pre erable.
th e plate to th e sh a t sh ou ld equ al th e an gle o th e displace-
m en t. Con rm u sin g im age in ten si cation .
In s e r t t h e firs t d is t a l s cre w
20°
X-ray beam
Fig 4.2-1 1a –b Th e in itial screw is in serted in th e m ost Fig 4.2-1 2 Con rm screw position w ith a lateral view
u ln ar screw h ole. Th e reason is th at i th e in itial screw is u n der im age in ten si cation , w ith th e beam aim ed at an
placed on th e radial side it w ill block accu rate im agin g o an gle o 20 degrees to th e tru e lateral, clearly sh ow in g th e
th e u ln ar screw placem en t. Ch oose a lockin g h ead screw join t su r ace.
2–4 m m sh orter th an m easu red. Provided th e screw is
parallel to th e K-w ire it sh ou ld n ot en ter th e radiocarpal
join t.
261
Pa rt II Case s
In s e r t a d d it io n a l lo ck in g h e a d s cre w s Pit fa ll: s cre w t ip p ro t ru s io n
Fig 4.2-1 4 Du e to th e prom in en ce o Lister tu bercle, as

seen on th e lateral im age projection , a screw placed on
Fig 4.2-1 3a –b In sert at least tw o oth er distal lockin g h ead eith er side o th e tu bercle m ay appear n ot to protru de
screw s. th rou gh th e ar cortex. Protru sion o su ch a screw m ay
resu lt in exten sor ten don irritation an d ru ptu re.
Ap p ly t h e p la t e t o t h e s h a ft In s e r t t h e firs t p ro xim a l s cre w
Fig 4.2-15 Th e im plan t is th en u sed to redu ce th e ragm en ts Fig 4.2-16On ce satis actory redu ction is con rm ed, in sert
by pu sh in g it on to th e su r ace o th e radiu s. Brin g th e plate an appropriate cortex screw th rou gh th e oblon g plate h ole.
on to th e sh a t an d h old it with a orceps. Ch eck correct
placem en t with im agin g an d adju st th e position o th e distal
ragm en t i n ecessary by m ovin g th e plate.
4 Distal radius
Fig 4.2-1 7a –b In sert u rth er proxim al screw s to com plete Fig 4.2-18 In traoperative pictu re o th e redu ced ractu re
th e xation . xed with th e VA LCP 2-colu m n palm ar plate 2.4.
a b
Fig 4.2-1 9a –b A ter xation , th e DRUJ sh ou ld be assessed

or both orearm rotation an d stability. Th e m eth ods or
determ in in g i DRUJ in stability exists are sh ow n in th e
xation topic in ch apter 4.1 Radial styloid— ractu re
treated w ith a radial colu m n plate.
263
Pa rt II Case s

For u rth er in orm ation see th e reh abilitation topic in
ch apter 4.1 Radial styloid— ractu re treated w ith a radial
colu m n plate.
7 Ou t co m e
a b
a b c d
Fig 4.2-21a –b At th e 1-year ollow-u p, th e x-rays Fig 4.2-2 2a –dTh ere w as an excellen t u n ction al resu lt
revealed u ll h ealin g with an atom ical redu ction o w ith u ll orearm an d w rist m otion possible.
both th e distal radial an d u ln ar n eck ractu res.
4.3 Distal radius—lunate facet fracture treated
with a buttress plate
a b c
d e
Fig 4.3-1a –e A 48-year-old m ale en gin eer su ered a polytrau m a in a m otor

veh icle in ju ry su stain in g em oral ractu res, ractu res o th e distal h u m eru s,
an d a ractu re o th e sh a t o th e le t u ln a. All ractu res were treated su rgically.
However, th e patien t was seen in th e h an d clin ic 2 m on th s a ter th e in ju ry
h avin g pain , sign s o m edian n erve com pression , an d u n ction al lim itation o
th e righ t wrist. New PA an d lateral x-rays th en in dicated a previou sly u n de-
tected lu n ate acet ractu re o th e radiu s ( a –b ). Sagittal an d coron al 2-D scan s
alon g with a 3-D CT scan clearly sh owed th e displaced lu n ate acet ractu re as
an isolated distal radial in ju ry ( c–e ).
265
Pa rt II Case s
2 In d ica t io n s
Lu n a t e fa ce t fra ct u re s As s o cia t e d m e d ia n n e r ve co m p re s s io n
Median nerve
a b
Fig 4.3-2a –b Followin g h igh -en ergy impact a lu n ate acet Fig 4.3-3 I th ere is den se sen sory loss or oth er sign s o
ractu re can occur, wh ich is a partial articu lar ractu re where m edian n erve com pression , th e m edian n erve sh ou ld be
the rim o th e distal radiu s at th e radiocarpal join t is sh eared decom pressed.
o . Th is o ten occurs at th e palmar rim, as th e palmar lunate
acet projects anteriorly to th e f at palmar su r ace o the distal
radiu s an d is there ore relatively vu ln erable to in ju ry. Th e
resu lt o the in ju ry is join t in con gru ity an d palmar sublux-
ation o the carpus. Displaced lunate acet ractu res a ect
both radiocarpal an d radiou ln ar alignmen t an d u n ction .
Bu ttress platin g is the recommen ded treatmen t option .
Im a gin g Ch o ice o f im p la n t
As sh ow n w ith th is case, th e ractu re pattern m ay n ot

alw ays be clear on stan dard x-rays, so addition al CT
scan n in g is stron gly recom m en ded.
a b c
L-plate s 2-colum n plate
Fig 4.3-4a –c A variety o plate option s are available or

palm ar bu ttress platin g, an d th e size o th e palm ar rim
ragm en t/ s will in f u en ce th e ch oice o plate. Plates with
variable an gle (VA) lockin g screw option s can be u se u l. For
th is patien t, a VA lockin g com pression plate (LCP) L-sh aped
plate with two h oles in th e distal lim b was selected to
redu ce an d bu ttress th e ractu re.
4 Distal radius
4.3 Distal radius—lunate face t fracture tre ate d with a buttre ss plate

• VA LCP L-plate 2.4

orearm on a h an d table. Su pin ate th e orearm . Th e
position o th e lim b sh ou ld allow com plete im agin g in th e
ron tal an d sagittal plan e o th e distal radiu s. A n on sterile
option al.
Ap p ro a ch
Fig 4.3-6 Th e su rgical approach u sed w as an u ln ar palm ar Fig 4.3-7 On ce th e ractu re w as exposed it w as n oted th at
approach (see ch apter 1.7 Uln ar palm ar approach to th e th e ractu re lin e exten ded to th e m iddle o th e distal
distal radiu s). radial su r ace.
267
Pa rt II Case s
5 Re d u ct io n
Hyp e re xt e n d t h e w ris t
Fig 4.3-8 To assist in th e approach an d to h elp redu ce th e

ractu re, place a rolled tow el or bolster u n der th e w rist
an d h yperexten d it. Per ect an atom ical redu ction can be
ach ieved by direct m an ipu lation o th e distal ragm en t
u sin g a den tal pick or a n e h ook. Redu ction can be
m ain tain ed u sin g a poin ted redu ction orceps.
b
Fig 4.3-9 a – b Th e ractu re w as disim pacted to de n e th e

articu lar in ju ry. Th e redu ced ractu re w as h eld w ith a
poin ted redu ction orceps. Note th at a carpal tu n n el
release w as also per orm ed th rou gh a separate in cision .
6 Fixa t io n
a b
Fig 4.3-1 0a –b Th e distal en d o th e plate sh ou ld en d at th e an atom ical w atersh ed zon e o th e distal radiu s ( a ). On ce
position ed, en su re th at th e plate is con tou red so th at its distal lim b exerts even pressu re over th e ragm en t or ragm en ts
o th e palm ar rim o th e radiu s ( b ).
4 Distal radius
Ap p ly t h e p la t e in b u t t re s s m o d e In s e r t s e co n d s cre w
Fig 4.3-11 Attach th e plate to th e distal radial sh a t u sin g an Fig 4.3-12 Now tigh ten th e rst screw an d in sert a secon d
appropriate cortex screw th rou gh th e oblon g plate h ole. cortex screw . Ch eck or adequ ate bu ttress pressu re on th e
Be ore u lly tigh ten in g it, ch eck th e plate position u sin g palm ar rim ragm en t(s).
in traoperative im agin g, adju stin g th e position o th e plate
as n ecessary so as to provide an optim al bu ttress e ect.
In s e r t d is t a l s cre w s a n d co m p le t e t h e fixa t io n
b
a b
Fig 4.3-13a –b Secu re th e distal ragm en t(s) with at least De n itive xation w as ach ieved w ith a VA
Fig 4.3-1 4a –b
two screws th rou gh th e appropriate distal h oles, as dictated LCP L-plate 2.4.
by th e ractu re pattern . Th e screws m u st n ot pen etrate th e
dorsal radial cortex. I a plate is selected with th readed
h oles in th e distal lim b, th en lockin g h ead screws are u sed.
Con rm redu ction u sin g im age in ten si cation .
269
Pa rt II Case s

colu m n plate.
8 Ou t co m e
a b
a b c d
Fig 4.3-1 6a –bAt th e 12-m on th ollow -u p, th e x-rays Th e patien t h ad n early u ll h an d, w rist, an d

Fig 4.3-1 7a –d
sh ow ed e ective h ealin g h ad been ach ieved. orearm ran ge o m otion .
4 Distal radius
Vid e o
Th is video dem on strates a reverse Barton (ie,

Vid e o 4 .3 -1
palm ar) distal radial ractu re treated u sin g an LCP
2-colu m n plate.
Lu n a t e fa ce t fra ct u re t re a t e d w it h s cre w s
a b
Fig 4.3-1 8a –b A classical con cert gu itarist h ad a all on to

h is le t h an d w h ile ridin g h is bicycle w h en it becam e
stu ck in tram w ay lin es. He presen ted to th e em ergen cy
departm en t th e ollow in g day w ith con cern s abou t h is
playin g u tu re an d asked or a per ect u n ction al resu lt.
Th e PA an d lateral x-rays in dicated a sh earin g type o
lu n ate acet ractu re.
271
Pa rt II Case s
a b c
Fig 4.3-1 9a –c Axial an d sagittal 2-D CT scan s ( a –b ) sh ow ed th e displacem en t o th e isolated

lu n ate acet ractu re. A 3-D CT scan m ore clearly sh ow ed th e m orph ology o th e acet
ractu re ( c ).
a b
Fig 4.3-2 0a –b As th e patien t w as a pro ession al gu itarist, Fig 4.3-21 Th e h igh ly m otivated
an d ollow in g discu ssion o poten tial perioperative an d patien t u n dertook im m ediate
postoperative problem s, h e w as con sidered reliable or u n ction al a ter-treatm en t in th e
receivin g treatm en t w ith less stable xation . Th ere ore, h an d th erapy departm en t an d
ju st a ew days a ter presen tation , h e w as treated w ith qu ickly regain ed u ll m obility to
th ree can n u lated 2.7 m m screw s. Screw s rarely in ter ere h is wrist join t. He was soon able
w ith so t tissu es, especially f exor ten don s, w h ich allow ed to play the gu itar again with ou t
th e patien t to resu m e gu itar playin g qu ickly an d w ith pain an d per orm ed h is n ext
con sideration th at im plan t rem oval w as u n likely to be con cert 8 weeks postoperatively.
n ecessary in th e u tu re.
4.4 Distal radius—shearing fracture treated with
a buttress plate
Fig 4.4-1a –b A 35-year-old sales con su ltan t su ered a

all rom h is m otorcycle wh ile ridin g to work. He was
seen in th e em ergen cy departm en t h avin g pain an d
swellin g o th e righ t wrist. Th e PA an d lateral x-rays
dem on strated a sh earin g ractu re o th e distal radiu s
with palm ar displacem en t, with th e carpu s also
a b su blu xated rom its n orm al position .
a b c
Fig 4.4-2a – c Th ree 2-D CT ron tal plan e im ages dem on strated m u lti ragm en tation o
th e palm ar articu lar su r ace. Th ere w as a ractu re o th e radial styloid, m u lti ragm en -
tation o th e scaph oid acet, an d partial in volvem en t o th e lu n ate acet. On th e u ln a
th ere w as a displaced avu lsion ractu re o th e u ln ar styloid.
273
Pa rt II Case s
a b c a b
Fig 4.4-3 a – cTh e 2-D sagittal CT scan s sh ow ed th e palm ar Fig 4.4-4 a – b Th e 3-D CT scan s sh ow ed th at th e sigm oid
su blu xation o th e carpu s w ith a palm ar sh earin g ractu re n otch an d th e u ln ar corn er o th e lu n ate acet w ere n ot
an d a cen trally im pacted articu lar ragm en t o th e in ju red an d rem ain ed in con tin u ity w ith th e m etaph ysis.
scaph oid acet.
For th is patien t, a sm all u ln ar styloid ractu re was eviden t
in addition to th e radiu s in ju ry, h owever, or th e pu rposes
o th is ch apter, on ly th e distal radiu s is discu ssed. For
u rth er in orm ation on treatin g u ln ar styloid ractu res see
ch apter 3.1 Uln ar styloid— ractu re treated with ten sion
ban d wirin g.
2 In d ica t io n s
Sh e a rin g fra ct u re s
Fig 4.4-5a –b Fractu res are described as sh earin g wh en th e opposite

cortex rem ain s in tact. Th ese partial in traarticu lar ractu res can in volve
ragm en tation an d can occu r on eith er th e palm ar (as in th is case) or th e
dorsal side (see th e altern ative tech n iqu e later in th is ch apter). Sh earin g
ractu re in ju ries resu lt in join t in con gru ity an d su blu xation o th e carpu s
an d are best sh own in CT scan s. Most sh earin g ractu res are u n stable
an d displaced an d or th at reason requ ire operative treatm en t to restore
an atom y an d stability. An in tact opposite cortex allows a bu ttress platin g
a b tech n iqu e to be u sed as th e treatm en t o ch oice.
4 Distal radius
4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate
As s o cia t e d m e d ia n n e r ve co m p re s s io n As s o cia t e d u ln a r in ju rie s
Median nerve
Fig 4.4-6 I th ere is den se sen sory loss or oth er sign s o Fig 4.4-7 Th ese in ju ries can also be accom pan ied by
m edian n erve com pression , th e m edian n erve sh ou ld be avu lsion o th e u ln ar styloid an d/ or disru ption o th e
decom pressed. distal radiou ln ar join t (DRUJ). I th ere is gross in stability
disc (TFC) is reattach ed. Th is is n ot com m on in sim ple
in ju red side. How ever, it m ay n ot be possible to assess
DRUJ stability u n til th e ractu re h as been stabilized.
Fig 4.4-8 a – cA variety o plate option s are available to

treat sh earin g ractu res w ith bu ttress platin g, an d th e size
o th e palm ar rim ragm en t(s) w ill in f u en ce th e ch oice o
plate. Plates w ith variable an gle (VA) lockin g screw
a b c option s can be u se u l. For th is patien t, a 2-colu m n palm ar
2-column plates Palmar rim plate plate w ith a 7-h ole h ead w as selected.
275
Pa rt II Case s
• VA lockin g com pression plate (LCP) distal radiu s set


sagittal plan es o th e distal radiu s. A n on sterile pn eu m atic
Ap p ro a ch
Fig 4.4-1 0Th e su rgical approach u sed w as a m odi ed Fig 4.4-11 Th e m odi ed Hen ry palm ar approach was
Hen ry palm ar approach (see Ch apter 1.6 Modi ed Hen ry per orm ed with th e f exor carpi radialis an d th e f exor
palm ar approach to th e distal radiu s). pollicis lon gu s bein g separated u ln arly, protectin g th e
m edian n erve an d th e radial artery separated radially. Th e
pron ator qu adratu s m u scle was in cised on its radial border
an d was stripped o th e distal radiu s togeth er with th e
periosteu m . Th is m ade th e ractu re m ore visible.
4 Distal radius
5 Re d u ct io n
Fig 4.4-1 2 To assist in th e approach an d to h elp redu ce th e

ractu re, place a rolled tow el or bolster u n der th e w rist an d
h yperexten d it. Per ect an atom ical redu ction can be ach ieved
by direct m an ipu lation o th e distal ragm en t u sin g a den tal
pick or a n e h ook. Redu ction can be m ain tain ed u sin g a
poin ted redu ction orceps.
6 Fixa t io n
Co n t o u r t h e p la t e Ap p ly t h e p la t e in b u t t re s s m o d e
Fig 4.4-1 3a –b Th e distal en d o th e plate sh ou ld en d at Fig 4.4-14 Attach th e plate to th e distal radial sh a t u sin g an
th e an atom ical w atersh ed zon e o th e distal radiu s ( a ). appropriate cortex screw th rou gh th e oblon g plate h ole.
On ce position ed, en su re th at th e plate is con tou red so Be ore u lly tigh ten in g it, ch eck th e plate position u sin g
th at its distal lim b exerts even pressu re over th e ragm en t in traoperative im agin g, adju stin g th e position o th e plate
or ragm en ts o th e palm ar rim o th e radiu s ( b ). as n ecessary so as to provide an optim al bu ttress e ect.
277
Pa rt II Case s
In s e r t s e co n d s cre w In s e r t d is t a l s cre w s a n d co m p le t e t h e fixa t io n
Fig 4.4-1 5Now tigh ten th e rst screw an d in sert a secon d a

cortex screw . Ch eck adequ ate bu ttress pressu re on th e
palm ar rim ragm en t(s).
Fig 4.4-16a –b Secu re th e distal ragm en t(s) with at least

two screws th rou gh th e appropriate distal h oles, as dictated
by th e ractu re pattern . Th e screws m u st n ot pen etrate th e
dorsal radial cortex. I a plate is selected with th readed
h oles in th e distal lim b, th en lockin g h ead screws are u sed.
Con rm redu ction u sin g im age in ten si cation .
a b
Fig 4.4-1 7a –b A ter xation , th e DRUJ sh ou ld be assessed Fig 4.4-1 8 Th e VA LCP 2.4 w as applied to th e palm ar
or both orearm rotation an d stability. Th e m eth ods or aspect o th e radiu s. Care w as taken n ot to exten d past
determ in in g i DRUJ in stability exists are sh ow n in th e th e w atersh ed lin e w ith th e plate.
4 Distal radius

colu m n plate.
8 Ou t co m e
a b
Fig 4.4-2 0a –bAt th e 12-m on th ollow -u p, th e

AP an d lateral x-rays sh ow ed u ll h ealin g in
an atom ical position .
Fig 4.4-2 1a –b Th ere w as n orm al

radial an d u ln ar deviation
12 m on th s a ter th e in itial trau m a.
279
Pa rt II Case s
a b
c d
Fig 4.4-2 2a –d By th is stage, th e patien t h ad also obtain ed u ll w rist ran ge

o m otion .
Do rs a l s h e a rin g fra ct u re t re a t e d w it h d o rs a l p la t e s
a b c
Fig 4.4-2 3a –c Ju st as palm ar sh earin g distal radial ractu res can occu r, so
too can su ch ractu res occu r on th e dorsal side. A 24-year-old en gin eer
h ad a w ork-related m otor veh icle acciden t su stain in g gross de orm ity,
severe pain an d sw ellin g, an d m u ltiple skin abrasion s alon g th e palm ar
aspect o h is le t w rist, th u m b, an d orearm . A ter w ou n d clean in g an d
sedation , th e patien t w as im m obilized in a padded su gar-ton g splin t. Ten
days a ter th e in ju ry, w h en sw ellin g h ad su bsided an d in ection w as
ru led ou t, h e w as taken to th e operatin g room . New PA an d lateral x-rays
dem on strated a dorsal sh earin g articu lar ractu re.
4 Distal radius
a b c a b
Fig 4.4-2 4a –c Th ree 2-D lateral view CT scan s revealed th e radial Fig 4.4-2 5a –b Th e 3-D CT scan s u rth er sh ow ed
styloid an d th e dorsal rim o th e distal radiu s w ere displaced w ith th e m u lti ragm en tary dorsal sh earin g ractu re in
th e proxim al carpal row . th e le t w rist.
Do rs a l s h e a rin g fra ct u re s Ch o ice o f im p la n t
I th e distal radial ragm en ts are predom in an tly dorsal,

th ey can be h eld w ith dorsally applied plates, bu t i th ere
is a sign i can t radial styloid ragm en t, it is stabilized m ore
e ectively w ith a radial plate.
a b
Fig 4.4-26a –b Dorsal sh earin g ractu res are less com m on

th an palm ar sh earin g ractu res bu t are also o ten th e resu lt
o h igh -en ergy trau m a. Th ey are typically m u lti ragm en tary
ractu res an d associated with dorsal su blu xation o th e
carpu s. Th ere can be a spectru m o in ju ry types with
variation in th e size o th e dorsal ragm en ts.
281
Pa rt II Case s
Ap p ro a ch Ar t h ro t o m y
I direct vision o th e articu lar su r ace is n eeded, a lim ited

tran sverse radiocarpal arth rotom y is per orm ed.

(see ch apter 1.8 Dorsal approach to th e distal radiu s).
Pro vis io n a l re d u ct io n Pro vis io n a l in t e rm e d ia t e co lu m n fixa t io n
Fig 4.4.28 Redu ction is ach ieved by applyin g lon gitu din al
traction eith er m an u ally or u sin g n ger traps. Th e redu ction
is m ain tain ed by a tem porary splin t. I de n itive su rgery is
plan n ed bu t can n ot be per orm ed with in a reason able tim e I th e dorsal rim ragm en ts are large en ou gh ,
Fig 4.4-2 9
scale, a tem porary extern al xator m ay be h elp u l. obtain provision al xation w ith K-w ires.
4 Distal radius
Pro vis io n a l ra d ia l s t ylo id fixa t io n
Superficial
branch of
radial nerve
Fig 4.4-3 0 I th e ragm en t are too sm all th ey can be h eld Fig 4.4-3 1 Th e radial styloid ragm en ts are redu ced u n der
w ith su tu re an ch ors or tran sosseou s su tu res. direct vision w ith eith er a K-w ire on th e dorsoradial
aspect or percu tan eou sly. In th e latter case, in order n ot
to in ju re th e sen sory bran ch o th e radial n erve, m ake a
sm all in cision over th e tip o th e radial styloid an d u se a
protective drill gu ide to in sert tw o K-w ires. Con rm u sin g
im age in ten si cation .
In t e rm e d ia t e co lu m n fixa t io n
a b c
Follow in g redu ction o th e dorsal rim ractu res, th e distal radiu s w as

Fig 4.4-3 2a –c
su pported by xation o a VA L-plate 2.4.
Th e xation procedu re ollow s th e u su al steps o selectin g, con tou rin g, an d applyin g

th e plate, an d in sertin g proxim al an d distal screw s. For u rth er in orm ation on th ese
steps see ch apter 4.11 Distal radiu s—radiocarpal ractu re dislocation treated w ith
dou ble platin g.
283
Pa rt II Case s
Ra d ia l co lu m n fixa t io n
a b c
Fig 4.4-3 3a –c Th e radial colu m n plate w as placed u n dern eath th e rst com partm en t an d applied. In traoperative
im agin g sh ow s th e com pleted dou ble plate xation .
Th e xation procedu re ollow s th e u su al steps o selectin g, con tou rin g, an d applyin g th e plate, stabilizin g th e radial
colu m n , in sertin g proxim al an d distal screw s, an d con rm in g screw placem en t w ith im agin g or x-rays. For u rth er
in orm ation on th ese steps see ch apter 4.11 Distal radiu s—radiocarpal ractu re dislocation treated w ith dou ble platin g.
Pa lm a r liga m e n t o u s a vu ls io n re a t t a ch m e n t Ad d it io n a l e xt e rn a l fixa t io n
a b
Dorsal carpal su blu xation m ay be associated

Fig 4 .4 -3 4 a – b Fig 4.4-3 5 I th e dorsal rim ragm en ts are large en ou gh ,
w ith avu lsion o th e palm ar w rist capsu le rom th e distal th ey m ay be h eld in place w ith a bu ttress plate. I th ey are
radiu s ( a ). too sm all, K-w ires m ay be th e de n itive xation , in
w h ich case, an extern al xator sh ou ld be applied.
A ter dorsal xation , ch eck th e carpal position an d stability
u n der image in ten si cation . I th ere is carpal u ln ar an d/ or
palm ar tran slation , con sider an addition al palm ar approach
to repair so t tissu es. Th e capsu le can be reattach ed u sin g
m u ltiple su tu re an ch ors or tran sosseou s su tu res ( b ).
4 Distal radius
Ou t co m e
a b
Fig 4.4-3 6a –b Th e x-rays at th e 6-m on th

ollow -u p sh ow th e redu ction h ad been
m ain tain ed u n til bon e h ealin g.
a b
c d
Fig 4.4-3 7a –d Th ere w as an excellen t n al u n ction al resu lt
285
Pa rt II Case s
4.5 Distal radius—dorsally displaced intraarticular
fracture treated with double plating
a b
Fig 4.5-1a –b A 57-year-old m an ell on h is ou tstretch ed

righ t h an d wh ile carryin g groceries, su stain in g a closed
wrist in ju ry. Th e x-rays in dicated an in traarticu lar,
dorsally displaced distal radial ractu re.
a b c d
Fig 4.5-2a – d Th e 2-D CT im ages also sh ow ed a dorsal lu n ate acet com pon en t w ith im paction .
287
Pa rt II Case s
2 In d ica t io n s
Co m p le t e in t ra a r t icu la r fra ct u re s Prin cip le o f co lu m n s
n
m
u
l
o
c
n
n
m
e
m
t
u
a
u
i
l
d
o
l
o
c
e
c
m
l
a b
a
r
a
r
i
d
e
n
t
a
l
U
n
R
I
Fig 4.5-3a –b Com plete in traarticu lar ractu res o th e distal Fig 4.5-4 Th e distal orearm can be th ou gh t o in term s o
radiu s occu r wh en th ere is n o part o th e articu lar su r ace th ree colu m n s. Th e u ln a orm s on e colu m n (th e u ln ar
in con tin u ity with th e diaph ysis. Th is case in volves a colu m n ) wh ile th e radiu s can be separated in to two (th e
com plete in traarticu lar ractu re with a dorsou ln ar postero- in term ediate colu m n an d th e radial colu m n ). Th e 3-colu m n
m edial articu lar ragm en t associated with m etaph yseal prin ciple h elps in describin g th e location o wrist in ju ries
displacem en t. As with all in traarticu lar ractu res, it sh ou ld an d is u rth er explain ed in th e in dication s topic in ch apter
be treated with an atom ical redu ction an d absolu te stability 1.8 Dorsal approach to th e distal radiu s.
in order to m in im ize th e risk o su bsequ en t degen erative
ch an ges in th e join t. An atom ical redu ction an d stabilization In dorsal dou ble platin g, u n derstan din g th e prin ciple o
o th ese ractu res is also essen tial becau se o th e u n ction al colu m n s is im portan t as th e in term ediate an d radial
im plication s o th e in volvem en t o th e distal radiou ln ar colu m n s are each stabilized with a separate plate. Th e radial
join t (DRUJ). colu m n is stabilized by a plate placed radially, deep to th e
rst exten sor com partm en t. Th e in term ediate colu m n is
Dorsally displaced ractu res m ay in volve loss o radial stabilized with a separate precon tou red plate on th e dorsal
len gth an d a displaced coron al split in th e lu n ate ossa. aspect o th e in term ediate colu m n .
Optim u m h old an d stability is best obtain ed with separate
platin g o both th e radial an d in term ediate colu m n s. Th e
xation o sm all distal ragm en ts is m ore secu re with
lockin g plates.
4 Distal radius
4.5 Distal radius—dorsally displace d intraarticular fracture tre ate d with double plating
As s o cia t e d m e d ia n n e r ve co m p re s s io n As s o cia t e d ca rp a l in ju rie s
Median nerve
Fig 4.5-5 I th ere is den se sen sory loss or oth er sign s o Fig 4.5-6 Th ese in ju ries m ay be associated w ith sh earin g
m edian n erve com pression , th e m edian n erve sh ou ld be in ju ries o th e articu lar cartilage, scaph oid ractu res, an d
decom pressed. ru ptu res o th e scaph olu n ate ligam en t. Every patien t
a b c
Dorsal plates
Fig 4.5-7 a – cA selection o plates u sed or stabilizin g th e

radial an d in term ediate colu m n s is available. Plates w ith
variable an gle (VA) lockin g screw option s can be u se u l.
For th is patien t VA straigh t an d L-plates w ere u sed, w ith
th e in term ediate colu m n bein g treated rst.
289
Pa rt II Case s

• VA LCP in term ediate colu m n plate 2.4

sagittal plan es o th e distal radiu s. A n on sterile pn eu m atic
Ap p ro a ch
a b
Fig 4.5-9 Th e su rgical approach u sed w as a dorsal Fig 4.5-1 0a –b Followin g th e dorsal approach , th e exten sor
approach (see ch apter 1.8 Dorsal approach to th e distal pollicis lon gu s was elevated ( a ). Th e term in al bran ch o th e
radiu s). posterior in terosseou s n erve was iden ti ed ( b ).
4 Distal radius
Fig 4.5-11 Th rou gh th e

dorsal exposu re, th e in term e-
diate an d radial colu m n
in ju ries were clearly visible.
5 Re d u ct io n
Pro vis io n a l re d u ct io n Pro vis io n a l fixa t io n
traction eith er m an u ally or u sin g n ger traps. Th e redu c-
tion is m ain tain ed by a tem porary splin t. I de n itive
su rgery is plan n ed bu t can n ot be per orm ed with in a Fig 4.5-1 3 In sert a K-w ire th rou gh th e tip o th e radial
reason able tim e scale, a tem porary extern al xator m ay be styloid to provision ally h old th e ragm en ts. Con rm u sin g
h elp u l. im age in ten si cation .
291
Pa rt II Case s
6 Fixa t io n
Co n t o u r t h e p la t e s
a b
Fig 4.5-14a –b Plates u sed in treatin g radial an d in term edi- Fig 4.5-1 5 Variable an gle lockin g plates en able precise
ate colu m n in ju ries are available precon tou red. However, position in g o th e distal screw s in desired direction s
som e addition al con tou rin g m ay be n ecessary to accom m o- becau se th ere is 30 degrees o reedom or each screw
date th e in dividu al an atom y o th e patien t. in side th e plate h ole in order to address th e in dividu al
ractu re pattern s.
Pit fa ll: s cre w h o le d is t o r t io n Fixa t io n o f in t e rm e d ia t e co lu m n

Ar t h ro t o m y
a b
Fig 4.5-1 6a –b Avoid con tou rin g th e plate th rou gh th e

lockin g h oles oth erw ise th e lockin g h ead screw m igh t n o
lon ger t.
Fig 4.5-1 7 I direct vision o th e articu lar su r ace is

n eeded, a lim ited tran sverse radiocarpal arth rotom y is
per orm ed. Th e join t su r ace is n ow visible. Ch eck th e
proxim al carpal row or addition al ligam en t in ju ries. Th e
radial in sertion o th e trian gu lar brocartilage com plex
can also be ch ecked.
4 Distal radius
Re d u ce t h e u ln a r a r t icu la r fra gm e n t Se le ct a n d a p p ly t h e p la t e
Fig 4.5-1 8 Th e in term ediate colu m n m u st n ow be Fig 4.5-1 9 Th e appropriate plate is selected accordin g to
restored. Th e u ln ar ragm en t m ay be ou n d im pacted in to th e ractu re con gu ration . Th e plate sh ou ld t exactly th e
th e m etaph ysis. Th is m u st be levered u p to th e level o an atom y o th e in term ediate colu m n an d con tou red i
th e join t. An atom ically redu ce th e en tire radiocarpal join t n ecessary. Th e plate is position ed so th at it bu ttresses th e
u n der direct vision . Prelim in ary xation w ith K-w ires is in term ediate colu m n an d su pports th e recon stru cted
an option . radiocarpal join t su r ace. Fix th e plate provision ally to th e
bon e w ith a stan dard cortex screw in serted th rou gh th e
oblon g plate h ole. Be ore u lly tigh ten in g it, ch eck th e
plate position u sin g in traoperative im agin g, adju stin g th e
position o th e plate as n ecessary.
a b c
Fig 4.5-2 0a –c For th is patien t, ollow in g placem en t o a sm all n eedle in to th e radiocarpal

join t or orien tation , a VA L-plate 2.4 w as position ed an d h eld w ith a 1.2 m m K-w ire ( a ).
In traoperative im agin g con rm ed th e position o th e plate an d redu ction o th e in term e-
diate colu m n ( b – c ).
293
Pa rt II Case s
In s e r t p ro xim a l s cre w s In s e r t d is t a l s cre w s
X-ray beam
a b
Fig 4.5-21 In sert proxim al screws as n ecessary to com plete Fig 4.5-2 2a –b Follow in g in sertion o th e distal lockin g
th e xation o th e in term ediate colu m n plate. screw s, an gled lateral im ages are taken to con rm
extraarticu lar placem en t. I th e screw s appear to en ter th e
radiocarpal join t, th ey can be reposition ed i a VA LCP h as
been u sed.
Fixa t io n o f ra d ia l co lu m n St a b ilize t h e ra d ia l co lu m n
Fig 4.5-24 Ideally wh ile applyin g th e plate, th e n otch in th e

distal tip o th e im plan t is placed again st th e tem porary
K-wire.
Fig 4.5-2 3 Th e appropriate plate is selected accordin g to

th e ractu re con gu ration an d con tou red i n ecessary.
Slide th e plate u n dern eath th e rst com partm en t an d
apply it on to th e radial colu m n .
4 Distal radius
Pit fa ll: in co rre ct p la ce m e n t
70°–90°
a b c
Fig 4.5-25a –c To optim ally stabilize th e radial styloid, th e plates m u st be position ed

correctly at 70–90 degrees to each oth er. Avoid placem en t o th e radial plate on th e
dorsal aspect o th e radial colu m n , as it will n ot bu ttress th e redu ction adequ ately
again st axial sh ear orces.
In s e r t t h e firs t s cre w in t h e ra d ia l co lu m n p la t e In s e r t t h e firs t lo ck in g h e a d s cre w
Fig 4.5-2 6 In sert a stan dard cortex screw in to th e oblon g Fig 4.5-2 7 To preven t rotation o th e plate du rin g distal
plate h ole proxim al to th e ractu re. Th e screw sh ou ld lockin g screw xation , th e plate sh ou ld be secu red to th e
en gage th e ar cortex. Th e position o th e plate m ay be bon e by in sertin g th e m ost proxim al screw .
adju sted be ore th e screw is tigh ten ed. Tigh ten in g th is
screw w ill redu ce th e radial styloid.
295
Pa rt II Case s
In s e r t d is t a l lo ck in g h e a d s cre w s a n d co m p le t e t h e Dis t a l ra d io u ln a r jo in t a s s e s s m e n t
fixa t io n
a b
a b Fig 4.5-2 9a –b A ter xation , th e DRUJ sh ou ld be assessed

Fig 4.5-2 8a –b I a K-w ire w as u sed, it is n ow rem oved. determ in in g i DRUJ in stability exists are sh ow n in th e
Distal lockin g h ead screw (s) are in serted to su pport th e xation topic in ch apter 4.1 Radial styloid— ractu re
radial styloid. Con rm screw position in g u sin g th e im age treated w ith a radial colu m n plate.
in ten si er.
a b
Fig 4.5-30a –b In traoperative view o th e dou ble

plate xation . Th e in traoperative im age con rm ed
an an atom ical redu ction an d stable in tern al xation .
4 Distal radius

colu m n plate.
8 Ou t co m e
a b
a b c d
Fig 4.5-32a –bTh e 4-m on th ollow-u p Fig 4.5-3 3a –d Th ere was excellen t pain - ree m otion an d
x-rays sh owed com plete ractu re u n ion . recovery.
297
Pa rt II Case s
Vid e o
Th is video dem on strates an in traarticu lar

Vid e o 4 .5 -1
distal radial ractu re treated u sin g dorsal dou ble plate
xation .
4.6 Distal radius—multifragmentary intraarticular
fracture treated with a palmar plate
a b c d
Fig 4.6-1a – d A 38-year-old en gin eer w as in ju red w h ile participatin g in a

dirt bike com petition . Wh en h e arrived at th e em ergen cy departm en t h e
com plain ed o pain in h is n on dom in an t le t w rist, an d th ere w as
eviden ce o edem a an d de orm ity. Th e x-rays an d CT scan s in dicated
exten sive m u lti ragm en tation in both th e in term ediate an d radial
colu m n s o th e distal radiu s, an d on th e coron al plan e, th e articu lar
com pon en t an d cen tral im paction ragm en ts w ere apparen t.
a b c
Fig 4.6-2 a – c Th e 3-D CT scan s dem on strated th e palm ar an d dorsal m u lti-

ragm en tation as w ell as an u ln ar styloid ractu re.
299
Pa rt II Case s
Fig 4.6-3 A view o th e join t su r ace o th e radiu s in th e 3-D CT scan

sh owed th e severity o th e articu lar com pon en t.
In addition to th e obviou s distal radial in ju ries th ere was also a

ractu re at th e base o th e u ln ar styloid, so all th ree colu m n s were
in volved. Treatm en t or th is patien t’s u ln ar styloid ractu re h as
already been discu ssed in detail in ch apter 3.1 Uln ar styloid— ractu re
treated with ten sion ban d wirin g, so or th e pu rposes o th is ch apter,
on ly th e m u lti ragm en tary distal radial ractu re is discu ssed.
2 In d ica t io n s
Mu lt ifra gm e n t a r y co m p le t e in t ra a r t icu la r fra ct u re s
a b
Fig 4.6-4 a – b Com plete in traarticu lar ractu res o th e distal radiu s occu r w h en th ere is n o part o th e articu lar su r ace in
con tin u ity w ith th e diaph ysis, an d th ey requ ire an atom ical redu ction except in low dem an d patien ts. Wh en th e
ractu re is m u lti ragm en tary it can be classi ed accordin g to th e exten t o th e m etaph yseal ragm en tation , varyin g rom
th ose in volvin g ragm en tation o th e articu lar su r ace bu t w ith a sim ple m etaph yseal ractu re, as seen on th e le t h an d
o th is patien t, to th ose in volvin g severe ragm en tation in th e m etaph ysis, or th e m ost com plex w ith ractu re lin es
exten din g w ell in to th e diaph ysis.
Plate xation is appropriate or th ese ractu res. As lon g as th e articu lar su r ace is accu rately redu ced an d is xed in th e
correct position in relation to th e radial sh a t, it is n ot n ecessary to x all th e m etaph yseal ragm en ts an d th e plate can
be u sed in a bridgin g m ode.
4 Distal radius
4.6 Distal radius—multifragmentary intraarticular fracture tre ate d with a palmar plate
As s o cia t e d u ln a r in ju rie s Im a gin g
It is n ot possible to m ake an accu rate assessm en t o th e

details o th ese in ju ries w ith ou t a CT scan .
Fig 4.6-5 Th ese in ju ries can also be accom pan ied by

avu lsion o th e u ln ar styloid an d/ or disru ption o th e
distal radiou ln ar join t (DRUJ). I th ere is gross in stability
(TFC) disc is reattach ed. Th is is n ot com m on in sim ple a b c
Palm ar plate 2-colum n plate Volar colum n plate
in ju red side. How ever, it m ay n ot be possible to assess Fig 4.6-6 a – c In m ost com plete in traarticu lar ractu res
DRUJ stability u n til th e ractu re h as been stabilized. w ith m u lti ragm en tation o th e articu lar su r ace, stan dard
palm ar lockin g plates are lon g en ou gh to obtain adequ ate
proxim al h old. How ever, i th ere is m u lti ragm en tation
in volvin g a sign i can t len gth o th e m etaph ysis, stan dard
palm ar plates m ay be too sh ort to provide adequ ate
stabilization . Specially design ed lon ger an gu lar stable
plates an d plates w ith larger m u ltiple-h ole h eads an d
variable an gle (VA) lockin g screw option s h ave been
developed to h elp stabilize th e distal an d proxim al
ragm en ts. For th is patien t, a volar colu m n distal radiu s
plate w as selected.
301
Pa rt II Case s

• VA LCP volar colu m n plate 2.4

option al.
Ap p ro a ch
Fig 4.6-8 Th e su rgical approach u sed w as a m odi ed Fig 4.6-9Th e radiu s was exposed th rou gh th e m odi ed
Hen ry palm ar approach (see ch apter 1.6 Modi ed Hen ry Hen ry approach wh ere severe ractu re ragm en tation
palm ar approach to th e distal radiu s). becam e apparen t.
4 Distal radius
5 Re d u ct io n
a b
Fig 4.6-1 0a –b Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g
n ger traps. Man ipu lative redu ction is u sed to provision ally h old th e ragm en ts. Th e redu ction
is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed
w ith in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.
6 Fixa t io n
Se le ct t h e p la t e
a b
Fig 4.6-1 1a –f A volar colu m n distal radiu s plate

c d w as u sed to stabilize th e ractu re in th is case.
Volar colu m n plates (VCP) are precon tou red or
an atom ical t on th e palm ar aspect o th e distal
radiu s. Mu ltiple lockin g screw h oles in th e h ead
o th e plate provide addition al xation o th e
radial an d in term ediate colu m n s, w ith screw
trajectories design ed to address a w ide variety o
e f ractu re types.
303
Pa rt II Case s
Ap p ly t h e p la t e a n d in s e r t t h e firs t s cre w
Fig 4.6-1 2 Apply th e VCP to th e bon e so th at th e distal Fig 4.6-1 3 Th is sagittal view MRI sh ow s h ow close th e
en d o th e plate en ds at th e an atom ical w atersh ed zon e o f exor ten don s are to th e radiu s (yellow arrow s), m akin g
th e distal radiu s. In sert an appropriate cortex screw it clear th at th e plate sh ou ld be placed proxim ally to th e
th rou gh th e oblon g plate h ole in to th e proxim al radial an atom ical w atersh ed zon e to avoid ten don irritation an d
ragm en t. Select a screw th at is lon g en ou gh to en gage ru ptu res.
both cortices. Be ore u lly tigh ten in g it, ch eck th e plate
position u sin g in traoperative im agin g, adju stin g th e
position o th e plate as n ecessary.
In s e r t t h e firs t d is t a l s cre w
Fig 4.6-1 4 Th e in itial distal screw sh ou ld be placed

th rou gh th e u ln ar sided screw h oles to stabilize th e
in term ediate colu m n . Th is distal screw sh ou ld be placed a b
ju st in th e su bch on dral bon e to bu ttress th e articu lar
Fig 4.6-1 5a –b Th e in traoperative im ages sh ow th e
ragm en ts an d to avoid later displacem en t.
plate bein g applied to th e bon e. On ce th e rst screw
was in trodu ced th rou gh th e proxim al oblon g plate
h ole, th e im age in ten si er was u sed to evalu ate th e
direction o th e m ost u ln ar distal screw.
4 Distal radius
In s e r t a d d it io n a l d is t a l s cre w s
a b
Fig 4.6-17a –b Precise m easu rem en t is requ ired to

avoid an y screw tip protru din g th rou gh th e dorsal
b
aspect o th e radiu s (red lin e) to avoid ten don
Fig 4.6-1 6a –b In sert distal lockin g h ead screw s to secu re ru ptu res. Screws placed in th e radial styloid sh ou ld
articu lar redu ction . reach th e tip o th e radial styloid or th e best
pu rch ase. Th is can be evalu ated u sin g th e im age
in ten si er.
Co n firm s cre w p o s it io n in g
90°
a b
Fig 4.6-18 a –d A sagittal im age w ith th e an gle o th e x-ray

beam directed 20 degrees obliqu ely to th e radiu s can
con rm th at th e screw is n ot pen etratin g th e radiocarpal
join t. With th is view , th e su bch on dral position in g o th e
distal screw s is accu rately evalu ated. I th e screw is ou n d
to pen etrate th e articu lar su r ace, it m u st be rem oved
c d an d reposition ed.
305
Pa rt II Case s
In s e r t p ro xim a l s cre w s a n d co m p le t e t h e fixa t io n
Fig 4.6-1 9 Th is in traoperative im age

dem on strates h ow placin g th e drill
gu ide in to th e distal h oles o th e plate
assists in evalu atin g th e direction o
th e screws.
Fig 4.6-2 0a –bIn sert u rth er proxim al screw s as requ ired

an d com plete th e xation .
a b
Fig 4 .6 -21 Fu rth er screw s w ere in serted
an d th e distal radiu s xation later Fig 4.6-2 2a –b A ter xation , th e DRUJ sh ou ld be assessed
com pleted. or both orearm rotation an d stability. Th e m eth ods or
4 Distal radius
a b
Fig 4.6-23a –b AP an d lateral x-rays were taken 1 week

a ter su rgery to con rm per ect redu ction o th e
ractu res an d correct location o im plan ts.

colu m n plate.
307
Pa rt II Case s
8 Ou t co m e
a b
Fig 4.6-2 5a –bAt th e 1-year ollow -u p, th ere

w as an excellen t radiological ou tcom e.
a b
c d
Fig 4.6-2 6a –d Th ere w as also an excellen t u n ction al ou tcom e

w ith n o pain . Th e patien t h ad retu rn ed to h is n orm al w ork an d
m otor bike sportin g activities.
4.7 Distal radius—multifragmentary
intraarticular fracture with defect treated
with a palmar plate
a b c
Fig 4.7-1a –c A 57-year-old pro ession al h ou sekeeper tripped

an d ell on to h er ou tstretch ed righ t wrist wh ile walkin g a
dog. Sh e presen ted to th e em ergen cy departm en t with a
swollen wrist bu t with a n orm al n eu rovascu lar exam in ation .
Th e AP, lateral, an d obliqu e x-rays dem on strated a m u lti-
ragm en tary com plete in traarticu lar ractu re o th e distal b
radiu s with exten sion in to th e m etaph ysis as well as a
com plex ractu re o th e distal u ln a exten din g in to th e u ln ar Fig 4.7-2a –b Th e axial 2-D CT
h ead. scan s clearly sh owed th e articu lar
in ju ry with im paction an d
rotation o articu lar ragm en ts.
Fig 4.7-3a –b Th e exten sion o th e radial ractu re in to th e

distal diaph yseal-m etaph yseal ju n ction is sh own in th e
3-D CT scan s.
For th is patien t, both th e distal u ln a an d radiu s su stain ed

m u lti ragm en tary ractu res requ irin g open redu ction an d
in tern al xation . However, or th e pu rposes o th is ch apter,
on ly th e distal radiu s is discu ssed. For u rth er in orm ation on
treatin g distal u ln ar ractu res see ch apter 3.2 Uln a, h ead an d
a b n eck—m u lti ragm en tary ractu re treated with a h ook plate.
309
Pa rt II Case s
2 In d ica t io n s
Mu lt ifra gm e n t a r y co m p le t e in t ra a r t icu la r fra ct u re s w it h As s o cia t e d u ln a r in ju rie s

m e t a p h ys e a l d e fe ct
a b
Fig 4.7-4 a – b In som e in stan ces, com plete in traarticu lar Fig 4.7-5 Head, n eck, an d m u lti ragm en tary ractu res o
ractu res o th e distal radiu s can in volve severe ragm en - th e distal u ln a o ten occu r in com bin ation w ith distal
tation in th e m etaph ysis resu ltin g in a m etaph yseal radial ractu res. With th ese u ln ar ractu res th ere is
de ect. Th ere are o ten sm all articu lar ragm en ts an d in stability an d sh orten in g, so th e distal u ln a h ook plate
im pacted ragm en ts. An atom ical redu ction an d stabiliza- can be u sed to h old th e ractu re. Atten tion sh ou ld be paid
tion o th ese in traarticu lar ractu res is essen tial becau se o to restorin g correct rotation an d len gth in relation to th e
th e u n ction al im plication s o th e in volvem en t o th e radiu s. Com plete dislocation o th e radiocarpal join t is
distal radiou ln ar join t (DRUJ). Plate xation is appropri- o ten associated w ith disru ption o th e distal radiou ln ar
ate provided th e distal ragm en ts are large en ou gh to be join t (DRUJ).
h eld w ith screw s. As lon g as th e articu lar su r ace is
accu rately redu ced an d is xed in th e correct position in
relation to th e radial sh a t it is n ot n ecessary to x all th e
m etaph yseal ragm en ts.
Im a gin g
It is n ot possible to m ake an accu rate assessm en t o th e

details o th ese in ju ries w ith ou t a CT scan .
4 Distal radius
4.7 Distal radius—multifragmentary intraarticular fracture with de fe ct tre ate d with a palmar plate
Fig 4 .7 -6a –c In m ost com plete in traarticu lar ractu res w ith
m u lti ragm en tation o th e articu lar su r ace, stan dard palm ar
lockin g plates are lon g en ou gh to obtain adequ ate proxim al
h old. How ever, i th ere is m u lti ragm en tation in volvin g a
sign i can t len gth o th e m etaph ysis, stan dard palm ar plates
m ay be too sh ort to provide adequ ate stabilization . Specially
design ed lon ger an gu lar stable plates an d plates w ith larger
m u ltiple-h ole h eads an d variable an gle (VA) lockin g screw
option s h ave been developed to h elp stabilize th e distal an d
a b c proxim al ragm en ts. For th is patien t, a 2-colu m n palm ar plate
Palm ar plate 2-colum n plate Volar colum n plate w ith th e lon ger 3-h ole sh a t w as selected.

• Sm all extern al xator or th e distal radiu s
• Ball tip redu ction orceps
• Lam in ar spreader

option al.
311
Pa rt II Case s
Ap p ro a ch
Fig 4.7-8 Th e su rgical approach u sed w as a m odi ed Fig 4.7-9 Th rou gh th e m odi ed Hen ry approach , th e
Hen ry palm ar approach (see ch apter 1.6 Modi ed Hen ry palm ar ractu re lin es w ere exposed.
palm ar approach to th e distal radiu s).
5 Re d u ct io n
a b
4 Distal radius
Pro vis io n a l fixa t io n w it h K-w ire s Re d u ct io n w it h a s p re a d e r/ m a n u a l t ra ct io n
In cases o m oderate ragm en tation on th e dorsal an d

palm ar cortex, it is di cu lt to m ain tain tem porary
redu ction w ith K-w ires. Redu ction w ith th e h elp o a
spreader an d/ or m an u al traction is th en recom m en ded.
Fig 4.7-11 In sert a K-wire across th e ractu re, th rou gh th e

radial styloid, to provide provision al stabilization . Th e m ajor
articu lar ragm en ts can be redu ced with th e aid o a poin ted
redu ction orceps. Tem porary xation o th e m ajor articu lar
ragm en ts with K-wires is also an option . Th e aim is to
ach ieve an accu rate an atom ical redu ction o th e articu lar
ragm en ts be ore th e plate is applied.
Pro vis io n a l re d u ct io n w it h a n e xt e rn a l fixa t o r
Fig 4.7-1 2 In cases o exten sive m etaph yseal an d/ or

diaph yseal com m in u tion , redu ction can be ach ieved an d
m ain tain ed w ith th e h elp o an extern al xator.
313
Pa rt II Case s
Re d u ct io n u s in g a b a ll t ip re d u ct io n fo rce p s
a b
Fig 4.7-13a –c An altern ate m eth od to en su re

redu ction is by u sin g a ball tip redu ction orceps
( a ). Usin g a bolster or towel to assist with f exin g
th e wrist can som etim es m ake it di cu lt to access
th e distal segm en ts o th e radiu s, yet lyin g th e
wrist f at on th e table can m ake access easier bu t
ractu re redu ction m ore di cu lt. With th e ball tip
redu ction orceps, th e th ick ru bber on th e dorsal
side h elps to redu ce th e dorsal aspect o th e
ractu re with ou t pu ttin g stress on th e ten don s or
c th e skin ( b –c).
4 Distal radius
6 Fixa t io n
Se le ct a n d a p p ly t h e p la t e a n d in s e r t d is t a l s cre w s
Fig 4.7-1 4a –b Th e lockin g plate is rst position ed distally on th e f at

a
redu ced palm ar su r ace o th e distal radiu s at th e an atom ical
w atersh ed zon e an d xed w ith distal lockin g screw s parallel to th e
articu lar su r ace w ith at least on e bu t pre erably tw o screw (s) in
each articu lar ragm en t, depen din g on th e qu ality o bon e stock.
Th e rst screw in serted is th e u ln ar on e an d its position sh ou ld be
ch ecked u n der im age in ten si cation w ith th e h an d elevated
b 20–30 degrees o th e table, in lu n ate acet view . On ce th e articu lar
block is secu rely h eld to th e plate an y K-w ire(s) can be rem oved.
a b
Fig 4.7-1 5a –bIn traoperative im ages con rm ed th e

placem en t o th e plate an d prelim in ary screw placem en t.
315
Pa rt II Case s
De t e rm in e co rre ct b o n e le n g t h In s e r t firs t p ro xim a l s cre w
Fig 4.7-1 6 Th e correct len gth o th e radiu s in relation to Fig 4.7-1 7a –b On ce th e correct len gth is ach ieved, th e
th e u ln a sh ou ld be establish ed preoperatively by takin g plate is provision ally xed proxim ally w ith an appropriate
x-rays o th e opposite w rist. Th e len gth o th e radiu s in cortex screw th rou gh th e oblon g h ole.
relation to th e u ln a is th en ach ieved by in sertin g a
u n icortical screw , ju st proxim al o th e proxim al en d o
th e plate, an d th en u sin g a spreader as illu strated to m ove
th e plate gen tly distally.
In s e rt p ro xim a l lo ckin g s cre w s a n d co m p le te th e xa tio n
Fig 4.7-1 8a –b Th e relation sh ip o th e radiu s to th e distal

u ln a is ch ecked u n der im age in ten si cation be ore th e
plate is xed w ith addition al proxim al lockin g screw s.
4 Distal radius
a b
Fig 4.7-19a –b Two views o th e VA LCP palm ar plate 2.4 in position a ter placem en t o th e rem ain in g screws.
a b

Fig 4.7-2 0 In traoperative xation topic in ch apter 4.1 Radial styloid— ractu re
im age ollow in g xation o treated w ith a radial colu m n plate.
th e distal radiu s.
317
Pa rt II Case s

colu m n plate.
8 Ou t co m e
a b
a b c
Fig 4.7-23a –b At th e 6-m on th ollow-u p, th e AP an d Fig 4.7-2 4a –cBy th is stage, n early u ll w rist an d orearm
lateral x-rays dem on strated u ll h ealin g in an m otion h ad been ach ieved.
an atom ical position .
fracture treated with triple plating
a b c
Fig 4.8-1a –c A 48-year-old o ce m an ager ell on to h er dom in an t ou tstretch ed le t h an d

wh en sh e tripped over a box in h er o ce. Sh e su stain ed a m u lti ragm en tary in traarticu lar
ractu re o th e le t distal radiu s. Th e PA an d lateral x-rays revealed th e com plex n atu re o
th e distal radial ractu re. Axial 2-D CT scan s u rth er dem on strated th e in volvem en t o th e
articu lar su r aces o both colu m n s o th e distal radiu s an d th e articu lar su r ace o th e distal
radiou ln ar join t.
a b c d
Fig 4.8-2a –d Addition al sagittal an d coron al 2-D CT scan s revealed th e im pacted an d displaced
in traarticu lar com pon en t o th e radial ractu re in both radial an d in term ediate colu m n s ( a ), as
well as th e com m in u ted n atu re o th e articu lar ragm en ts ( b ), th e palm ar displacem en t o th e
lu n ate acet com pon en t ( c ), an d th e im pacted an d u n stable n atu re o th e scaph oid acet
com pon en t ( d ).
319
Pa rt II Case s
2 In d ica t io n s
Co m p le t e in t ra a r t icu la r fra ct u re s w it h im p a ct io n
a b c
Fig 4 .8 -3 a –cA stron g orce or all can be en ou gh to cau se a com plete

in traarticu lar ractu re o th e distal radiu s w ith n o part o th e articu lar su r ace
in con tin u ity w ith th e diaph ysis. Mu lti ragm en tation can resu lt, as can
ractu re lin es exten din g in to th e diaph ysis. Addition ally, th e in ju ry can
in volve im paction , w h ich can occu r in th e m ore osteoporotic bon e o an
elderly patien t or in you n ger patien ts typically as a resu lt o h igh -en ergy
trau m a. As th ese are in traarticu lar ractu res, w h ere possible, th ey sh ou ld be
treated w ith an atom ical redu ction an d absolu te stability to m in im ize th e risk
o su bsequ en t degen erative ch an ges in th e join t. Use o CT scan s can be
h elp u l or treatm en t decision s.
4 Distal radius
4.8 Distal radius—multifragmentary intraarticular fracture tre ate d with triple plating
Prin cip le o f co lu m n s
n
m
u
l
o
c
n
n
m
e
m
t
u
a
u
i
l
d
o
l
o
c
e
c
m
l
a
r
a
r
i
d
e
n
t
a
l
U
n
R
I
Fig 4.8-4 Th e distal orearm can be th ou gh t o in term s o th ree colu m n s.
Th e u lna orm s on e colu m n (th e u ln ar colu m n ) wh ile th e radiu s can be
separated in to two (th e in term ediate colu m n an d th e radial colu m n ). Th e
3-colu m n prin ciple h elps in describin g th e location o wrist in ju ries an d is
u rth er explain ed in th e in dication s topic in ch apter 1.8 Dorsal approach to
th e distal radiu s.
In in ju ry types sim ilar to th is patien t, u n derstan din g o th e 3-colu m n

prin ciple is particu larly h elp u l in preparin g a plan or su rgical redu ction an d
stabilization an d will assist in in terpretation o th e im agin g. It m u st be
rem em bered th at th e in term ediate colu m n provides articu lar su r aces or
both th e radiocarpal an d th e distal radiou ln ar join ts, so in ju ries to th is
colu m n dem an d atten tion to recon stru ct both com pon en ts.
Wh en acin g in ju ries o th is n atu re, open redu ction an d a com bin ation o
palm ar an d dorsal in tern al xation are likely to be requ ired. Th e ration ale or
u sin g both palm ar an d dorsal approach es in clu des: th e displaced palm ou ln ar
ragm en t (in term ediate colu m n ) an d th e rotated radial styloid (radial
colu m n ) requ irin g a palm ar approach ; an d th e displaced an d u n stable dorsal
ragm en t with cen tral im paction (in term ediate colu m n ) requ irin g a dorsal
approach an d arth rotom y. Appreciation o in ju ries to each colu m n assists in
plan n in g th e order o xation .
321
Pa rt II Case s
As s o cia t e d m e d ia n n e r ve co m p re s s io n Ch o ice o f im p la n t
Median nerve
a b c
Dorsal plate s 2-colum n plate
Fig 4.8-5 I th ere is den se sen sory loss, or oth er sign s o
m edian n erve com pression , th e m edian n erve sh ou ld be Th is case in volves treatm en t o both th e
Fig 4.8-6 a – c
decom pressed rom th e level o th e ractu re in to th e dorsal an d palm ar aspect, an d so speci c palm ar an d
palm , releasin g th e carpal tu n n el. dorsal plates w ere selected in clu din g variable an gle
lockin g com pression plate (VA LCP) dorsal distal radiu s
plates an d a VA LCP 2-colu m n plate on th e palm ar side.


on a h an d table. Th e palm ar approach will requ ire th e
orearm to be placed in su pin ation . A dorsal approach
requ ires th e orearm to be pron ated. Th e position o th e
4 Distal radius
Pa lm a r a n d d o rs a l a p p ro a ch e s
a b
Fig 4.8-8 a – b Th e in itial su rgical approach w as a m odi ed Hen ry

palm ar approach (see ch apter 1.6 Modi ed Hen ry palm ar approach
to th e distal radiu s). Su bsequ en tly, a dorsal approach w as requ ired to
redu ce an d stabilize th e dorsal com pon en ts w ith dorsal im plan ts an d
to per orm an arth rotom y to assess articu lar redu ction an d to in spect
th e in tegrity o th e in trin sic ligam en ts (see ch apter 1.8 Dorsal
approach to th e distal radiu s).
a b
Fig 4.8-9 a – b Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g
Redu ction is ach ieved by rst recreatin g a stable palm ar cortex so th at th e dorsal an d articu lar
ractu res can be redu ced again st it in bu ttress m ode.
323
Pa rt II Case s
Fig 4.8-1 0 A h ypoderm ic n eedle

w as placed in to th e radiolu n ate
join t u n der im age in ten si cation
to accu rately de n e th e distal
lim it o th e distal radiu s or
placem en t o th e im plan t.
Re d u ct io n u s in g t h e p la t e
a b
Fig 4.8-1 1a –b Select an d apply th e palm ar plate to th e distal ragm en t ( a ). In sert

tem porary K-w ires to stabilize th e im plan t an d to secu re th e correct position or
im plan t placem en t. Th e n om in al an gle drill gu ide block is u sed to preven t in adverten t
in traarticu lar screw pen etration . Con rm u sin g im age in ten si cation . A VA LCP
2-colu m n plate w as applied to th e palm ar su r ace o th e distal radiu s u n der im age
in ten si cation ( b ).
4 Distal radius
In s e r t d is t a l s cre w s Ap p ly t h e p la t e t o t h e s h a ft
Fig 4.8-13 Th e im plan t is th en u sed to redu ce th e ragm en ts

a by pu sh in g it on to th e su r ace o th e radiu s. Brin g th e plate
on to th e sh a t an d h old it with a orceps. Ch eck correct
placem en t with im agin g an d adju st th e position o th e distal
ragm en t i n ecessary by m ovin g th e plate.
Fig 4.8-1 2a –b Sh ort n om in al an gle lockin g screw s are

in serted in to th e palm ar ragm en ts on ly.
In s e r t p ro xim a l s cre w s
Fig 4.8-14On ce satis actory redu ction is con rm ed, in sert

an appropriate cortex screw th rou gh th e oblon g plate h ole.
Fig 4.8-1 5a –b Usin g th e palm ar su rgical

approach , xation o th e palm ar ragm en ts o
th e in term ediate colu m n (lu n ate acet) w as
ach ieved u sin g th e VA LCP 2-colu m n plate
2.4 w ith sh ort lockin g screw s. Th e palm ar
bu ttress w as th en reestablish ed.
325
Pa rt II Case s
a b
Fig 4.8-16a –b Th e procedu re restores th e palm ar bu ttress

th at h ad been lost du e to th e ractu re pattern . In traopera-
tive im ages con rm th e redu ction an d stabilization o th e
displaced palm ar ragm en ts o th e in term ediate colu m n .
It m u st be appreciated th at n eith er th e dorsal ragm en ts o

th e in term ediate colu m n n or th e ragm en ts o th e radial
colu m n h ave yet been redu ced or stabilized. However, th e
restoration o an in tact an d stable palm ar bu ttress allows
th ese com pon en ts o th e ractu re to be treated.
Do rs a l p la t e s fixa t io n
a b c
Fig 4.8-1 7a –c Th e dorsal su rgical approach allow s placem en t o VA LCP dorsal distal
radiu s plates. In itially, th e dorsal ragm en ts o th e in term ediate colu m n (an d th ere ore
also th e distal radiou ln ar join t) w ere redu ced by bu ttressin g again st th e n ew ly stabi-
lized palm ar su r ace/ im plan t. Th e in term ediate colu m n can th en be redu ced an d
stabilized. Th e lu n ate acet o th e distal radiu s an d th e distal radiou ln ar join t su r aces
w ere restored.
4 Distal radius
a b c
d e f
Fig 4.8-18a –f Fin ally, th e radial colu m n is stabilized by th e application o a radial VA LCP dorsal distal radiu s plate
th at also acts in bu ttress m ode, th is tim e bu ttressin g again st th e redu ced an d stabilized in term ediate colu m n . Th e total
com bin ation o plates provides per ect redu ction o all ragm en ts an d stable xation . In traoperative im ages an d
illu stration s sh ow th e com pleted triple platin g o th e distal radial ractu re. For u rth er in orm ation on th e steps or
dorsal platin g see ch apter 4.5 Distal radiu s—dorsally displaced in traarticu lar ractu re treated with dou ble platin g.
Fig 4.8-19 Th e patien t sh ou ld receive th e stan dard postop-

erative rest, in ju ry elevation , ollow-u p, rem oval o stitch es,
an d im mobilization as requ ired. Followin g su rgery, begin
active con trolled ran ge o m otion exercises. For u rth er
in orm ation see th e reh abilitation topic in ch apter 4.1
Radial styloid— ractu re treated with a radial colu m n plate.
327
Pa rt II Case s
7 Ou t co m e
a b
a b c d
At th e 2-year ollow -u p, x-rays con -

Fig 4.8-2 0a –b Fig 4.8-21a –d Th e patien t retu rn ed to n orm al u n ction with
rm ed th e ractu res h ad h ealed an atom ically. n o pain an d a m in or degree o restriction o f exion .
a b
Fig 4.8-22a –b Th e in ju red side (th e

dom in an t le t h an d) was n ow dem on -
stratin g greater grip stren gth th an th e
u n in ju red n on dom in an t side.
fracture with associated scaphoid fracture
treated with triple plating and screw
a b c d
Fig 4.9-1a – d A 32-year-old salesm an ell on to h is ou tstretch ed le t h an d w h ile ru n n in g du rin g a soccer m atch . He
su stain ed a m u lti ragm en tary in traarticu lar distal radial ractu re an d an associated ractu re o th e proxim al pole o
th e scaph oid. Th e PA an d lateral x-rays o th e le t h an d revealed th e com plex n atu re o th e ractu res in th e radiu s
an d th e scaph oid. Axial 2-D CT scan s u rth er dem on strated th e m ajor articu lar in volvem en t o th e distal radiu s
scaph oid acet.
a b c
Fig 4.9-2a – c Addition al sagittal 2-D CT scan s m ade clear th e distal

radial an d scaph oid ractu res, sh ow in g th e dorsal displacem en t ( a ),
th e cen trally im pacted in traarticu lar com pon en t o th e radial ractu re
( b ), an d th e proxim al pole ractu re o th e scaph oid ( c ).
329
Pa rt II Case s
a b c
Th e 3-D CT im ages iden ti ed both palm ar an d dorsal m etaph yseal aspects o

Fig 4.9-3 a – c
th e radial ractu re an d th e m u lti ragm en tation o th e articu lar su r ace.
2 In d ica t io n s
Co m p le t e in t ra a r t icu la r fra ct u re s w it h a s s o cia t e d ca rp a l in ju rie s
a b
Fig 4.9-4a –b Wh en com plete in traarticu lar ractu res o th e distal radiu s occu r, m u lti ragm en tation can o ten resu lt, as can
ractu re lin es exten din g in to th e diaph ysis, an d treatm en t m u st in volve an atom ical redu ction an d stabilization . Yet an y
patien t wh o su ers h igh -en ergy im pact on to an ou tstretch ed h an d can also su stain in tercarpal ligam en t in ju ries an d carpal
ractu res. Th ese can easily be m issed on in itial clin ical assessm en t. Use o CT scan s can be h elp u l or treatm en t decision s.
For in ju ries described above, open redu ction an d a com bin ation o palm ar an d dorsal in tern al xation m ay be requ ired.
Th e ration ale or u sin g both palm ar an d dorsal approach es in clu des: th e h yperexten ded palm ou ln ar ragm en t (in term ediate
colu m n ) an d th e rotated radial styloid (radial colu m n ) requ irin g a palm ar approach ; an d a displaced dorsal ragm en t an d
th e im pacted cen tral articu lar ragm en t (in term ediate colu m n ) requ irin g a dorsal approach an d arth rotom y, an d in th is case
a dorsal approach to treat th e scaph oid proxim al pole ractu re.
4 Distal radius
4.9 Distal radius—multifragme ntary intraarticular fracture with associate d scaphoid fracture tre ate d with triple plating and scre w
As s o cia t e d m e d ia n n e r ve co m p re s s io n As s o cia t e d s ca p h o id in ju rie s
Median nerve
Fig 4.9-5 I th ere is den se sen sory loss, or oth er sign s o Fig 4.9-6 With h igh -en ergy distal radial in ju ries o th is
m edian n erve com pression , th e m edian n erve sh ou ld be n atu re, associated carpal ligam en t in ju ries an d ractu res
decom pressed. in clu din g th e scaph oid can occu r. Th e scaph oid proxim al
pole relies largely on a retrograde blood f ow an d so it
relies on distal-to-proxim al in traosseou s blood su pply or
h ealin g. Th is m akes th ese ractu res h igh ly pron e to
avascu lar bon e n ecrosis, delayed u n ion , an d n on u n ion . I
th e proxim al ragm en t is large en ou gh , a 2.4 m m or
3.0 m m im plan t u sin g an tegrade in sertion is advisable.
An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s Ch o ice o f im p la n t
Th e scaph oid’s u n iqu e an atom y an d vascu larity are

critically im portan t in cases in volvin g th e proxim al pole.
Re er to th e in dication s topic in ch apter 2.1 Scaph oid—
n on displaced ractu re treated percu tan eou sly w ith a
h eadless com pression screw or m ore in orm ation .
a b c d
Dorsal plate s 2-colum n plate He adle ss
com pre ssion scre w
Fig 4.9-7a –d Th is case in volves treatm en t o both th e dorsal

an d palm ar aspect, an d so speci c palm ar an d dorsal plates
were selected in clu din g variable an gle lockin g com pression
plate (VA LCP) dorsal distal radiu s plates an d a VA LCP
2-colu m n plate on th e palm ar side. A 3.0 m m h eadless
com pression screw was u sed to treat th e scaph oid ractu re.
331
Pa rt II Case s

• 2.4 m m or 3.0 m m h eadless com pression screw

orearm on a h an d table. As th e rst step in volves a
palm ar approach , su pin ate th e orearm . I a dorsal
approach is also requ ired, pron ate th e orearm at th at
stage. Th e position o th e lim b sh ou ld allow com plete
im agin g in th e ron tal an d sagittal plan e o th e distal
radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed.
Proph ylactic an tibiotics are option al.
Fig 4.9-9a –b Th e su rgical approach in itially u sed was a

m odi ed Hen ry palm ar approach (see ch apter 1.6 Modi-
ed Hen ry palm ar approach to th e distal radiu s). Later, a
dorsal approach was requ ired to apply dorsal platin g an d
to treat th e scaph oid ractu re (see ch apter 1.8 Dorsal
a b approach to th e distal radiu s).
4 Distal radius
5 Re d u ct io n
a b
n ger traps. Man ipu lative redu ction is u sed to provision ally h old th e ragm en ts. Th e redu ction is
m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in
a reason able tim e scale a tem porary extern al xator m ay be h elp u l.
Pro vis io n a l fixa t io n w it h K-w ire s
Fig 4.9-1 1 In sert a K-w ire across th e ractu re th rou gh th e

radial styloid to provide provision al stabilization . Th e
m ajor articu lar ragm en ts can be redu ced w ith th e aid o a
poin ted redu ction orceps. Tem porary xation o th e
m ajor articu lar ragm en ts w ith K-w ires is also an option .
Th e aim is to ach ieve as accu rate an an atom ical redu ction
as possible o th e articu lar ragm en ts be ore th e plate is
applied.
Altern atively, u se o a poin ted redu ction orceps or an

extern al xator to ach ieve redu ction m ay be requ ired.
333
Pa rt II Case s
6 Fixa t io n
Pa lm a r p la t e fixa t io n
a b
Fig 4.9-1 2a –bUsin g a palm ar approach , xation o th e distal radial ragm en ts w as

rst attem pted u sin g a VA LCP 2-colu m n plate 2.4.
Th e xation procedu re ollow s th e u su al steps o selectin g an d applyin g th e plate,

in sertin g distal screw s, determ in in g correct bon e len gth , in sertin g proxim al screw s,
an d in traoperative im agin g. For u rth er in orm ation on th ese steps see ch apter 4.7
Distal radiu s—m u lti ragm en tary in traarticu lar ractu re treated w ith a palm ar plate.
Do rs a l p la t e fixa t io n
a b
Fig 4.9-13a –b Un ortu n ately, th e dorsal ragm en ts were n ot

redu ced solely with th e palm ar plate, so addition al dorsal im plan ts
were requ ired. Th ese ragm en ts were th en stabilized u sin g VA LCP
dorsal distal radiu s plates, on e in th e radial colu m n , wh ich was able
to be in serted th rou gh th e existin g palm ar approach , an d th e oth er
in th e in term ediate colu m n u sin g a dorsal L-plate to bu ttress th e
ragm en ts (bu t with n o distal screws in serted in to th e h ead o th e
plate), an d wh ere a n ew dorsal approach was requ ired. Th e total
com bin ation o plates provided per ect redu ction o all ragm en ts
an d stable xation . For u rth er in orm ation on th e steps or dorsal
platin g see ch apter 4.5 Distal radiu s—dorsally displaced in traarticu -
lar ractu re treated with dou ble platin g.
4 Distal radius
Sca p h o id re d u ct io n a n d fixa t io n
a b
Fig 4.9-1 4a –b Follow in g redu ction an d in sertion o a gu ide w ire in to th e

scaph oid, th e scaph oid proxim al pole ractu re xation w as ach ieved u sin g a
3.0 m m h eadless com pression screw . For u rth er in orm ation on treatin g
scaph oid proxim al pole ractu res see ch apter 2.4 Scaph oid, proxim al
pole— ractu re treated w ith a h eadless com pression screw .
335
Pa rt II Case s
a b
c d e
Fig 4.9-1 5a –e Im m ediate postoperative x-rays ( a –b ) an d illu strated

version s ( c– e ) sh ow th e com pleted triple platin g o th e distal radial
ractu re an d th e in tern al screw xation o th e scaph oid.
Fig 4.9-16 Th e patien t sh ou ld receive th e stan dard postop-

erative rest, in ju ry elevation , ollow-u p, rem oval o stitch es,
an d im mobilization as requ ired. Followin g su rgery, begin
active con trolled ran ge o m otion exercises. For u rth er
in orm ation see th e reh abilitation topic in ch apter 4.1
Radial styloid— ractu re treated with a radial colu m n plate.
4 Distal radius
8 Ou t co m e
Fig 4.9-17a –b At th e 20-m on th ollow-u p,

x-rays were taken with u ln ar deviation o
th e wrist, an d lateral view. Th e ractu res
were sh own to h ave h ealed in n ear
a b an atom ical position .
a b
c d
e f
Th e patien t cou ld per orm n ear u ll w rist an d orearm

Fig 4 .9 -1 8a – f
ran ge o m otion an d th ere h ad been an excellen t u n ction al resu lt.
337
Pa rt II Case s
a b
Excellen t grip stren gth h ad retu rn ed w h en

Fig 4.9-1 9a –b
com pared w ith th e u n in ju red side.
4.10 Distal radius—displaced intraarticular
fracture treated with a bridge plate
a b c d
Fig 4.10 -1a –d A 29-year-old pro ession al m otorcyclist w as in volved in a h igh -speed crash w h ile com petin g,
su stain in g an isolated righ t w rist in ju ry. Upon adm ission to th e em ergen cy departm en t h e h ad m edian
n erve dys u n ction , w h ich resolved w ith lon gitu din al traction u sin g n ger traps an d closed redu ction . Th e
in itial obliqu e an d lateral x-rays dem on strated m arked dorsal displacem en t o th e articu lar su r ace w ith
ragm en ts th at w ere sm all an d close to th e join t ( a – b ). Later AP an d lateral x-rays w ere taken ollow in g
plaster splin t application , yet w h ile th e m edian n erve sym ptom s w ere resolved an d redu ction im proved,
th e redu ction rem ain ed u n satis actory ( c–d ).
Given th e u n stable ractu re pattern in an d arou n d th e articu lar su r ace, an d th e proxim ity o th e ractu res
to th e join t, it w as decided th at in tern al xation w as in dicated u sin g a bridgin g plate tech n iqu e. (Note:
som e addition al in traoperative im ages rom a 46-year-old w om an w ith a sim ilar ractu re h ave been u sed in
th is case or u rth er illu strative su pport).
339
Pa rt II Case s
2 In d ica t io n s
In t ra a r t icu la r w ris t fra ct u re s re q u irin g b rid ge p la t in g
a b
Fig 4.10 -2a –b Th e patien t in th is case h ad su ered displacem en t o th e articu lar su r ace w ith ragm en tation th at w as
sm all an d close to th e join t. In som e in traarticu lar distal radial ractu res, th e u se o an exten ded su rgical approach an d a
lon ger plate th at bridges (or span s) th e en tire join t m u st be con sidered. Th e cu rren t in dication s or u sin g th is treatm en t
tech n iqu e in clu de:
• Extrem ely ragm en ted in traarticu lar ractu res in w h ich ragm en t speci c xation m ay be u n attain able du e to th e
sm all size o th e ragm en ts
• Distal ractu res th at are so close to th e join t th at xation w ith plates becom es extrem ely di cu lt or im possible
• High -en ergy in ju ries in polytrau m atized patien ts w h ere early w eigh tbearin g on th e u pper extrem ities is deem ed
n ecessary to h elp m obilize th e patien t in th e early postoperative period, or w h ere w eigh tbearin g w as th ou gh t n ot as
reliable w h en u sin g oth er con stru cts
• Patien ts w ith osteoporotic ractu res w ith sign i can t ragm en tation th at m igh t lead to collapse o th e ractu re i th e
com pressive orces at th e w rist are n ot properly n eu tralized
• High -en ergy m u lti ragm en tary ractu res w ith exten sion in to th e m etaph yseal-diaph yseal region o th e distal radiu s
in w h ich distal xation w ith diaph yseal/ m etaph yseal plates m ay be ten u ou s or im possible.
By span n in g th e w rist join t, th e bridge plate acts as a bridgin g in tern al xator an d as a tem porary m eth od o xation . It
requ ires rem oval abou t 8–12 w eeks a ter placem en t. Th e dorsal bridge plate provides both in tern al distraction an d
bu ttress su pport to th e dorsal part o th e ractu re. Un like extern al xation , th e bridge plate can be le t in place w ith ou t
th e risk o pin loosen in g or in ection .
Co n t ra in d ica t io n s o f b rid ge p la t in g
Relative con train dication s o bridge platin g in clu de ractu res in you n g in dividu als th at are am en able to palm ar platin g
or ragm en t speci c xation . It is also im portan t to rem em ber th at bridge platin g requ ires a secon d su rgery or im plan t
rem oval an d carries th e addition al risks o w rist sti n ess an d exten sor ten don irritation .
4 Distal radius
4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate
b c
Fig 4.10-3a –c A n u m ber o im plan ts are available to u n ction as a bridge plate in clu din g a stan dard lim ited con tact dyn am ic
com pression plate (LC-DCP), th e specialized plates or distal radiu s total arth rodesis, or speci cally design ed plates u sin g 2.7
m m screws. Plate selection is based on th e size o th e patien t an d th e proxim al exten t o ragm en tation alon g th e distal
radiu s. Lay th e plate on th e skin over th e radial diaph ysis to th e m etadiaph ysis o th e secon d or th ird m etacarpal an d u se
th e im age in ten si er to en su re th at a m in im u m o th ree cortex screws can be placed both proxim al to th e ractu re an d
distal in to th e m etacarpal. Plates can be precon tou red with a ben d or sim ply in serted straigh t. A straigh t plate 2.7 was u sed
or th is patien t.
Im a gin g
It is n ot possible to m ake an accu rate assessm en t o th e details o th ese in ju ries w ith ou t a CT scan . Im age in ten si cation
is requ ired th rou gh ou t th e procedu re.
• Bridge plate 2.7

• 1.1 or 1.2 m m K-w ires
• Fin ger trap traction system

orearm on th e h an d table. Pron ate th e orearm . Th e
option al. For th is patien t th e h an d was su pported with a
rolled towel.
341
Pa rt II Case s
4 Clo s e d re d u ct io n
a b c d
Fig 4.10 -5a –d In th is in ju ry type, redu ction is requ ired prior to per orm in g th e su rgical
approach . A closed redu ction m an eu ver is per orm ed th at in volves a com bin ation o
lon gitu din al traction an d palm ar tran slation to restore radial len gth , radial in clin ation ,
an d palm ar an gu lation . Redu ction is ach ieved by applyin g lon gitu din al traction u sin g
n ger traps to th e in dex an d m iddle n gers ( a –b ). Usin g th e im age in ten si er or
gu idan ce, radial len gth is restored ( c ). Lon gitu din al traction is also u sed to assist in th e
redu ction o th e articu lar su r ace ( d ). Th is m an eu ver w ill determ in e th e in tegrity o th e
palm ou ln ar corn er o th e radiu s. Fin ally, pron ate th e h an d to correct th e su pin ation
de orm ity.
4 Distal radius
De t e rm in e p la t e p o s it io n in g
Th e rst step in con siderin g th e su rgical approach is to decide w h ich m etacarpal (eith er th e secon d or th ird) w ill be
u sed or plate xation . Note th at a m in im u m o th ree screw s sh ou ld be able to be placed in th e m etacarpal. Th e
determ in in g actor is th e position th at provides best redu ction .
Th e m eth od or determ in in g w h ich m etacarpal to u se is as ollow s:

1. Provision ally redu ce th e ractu re
2. Place th e plate on to th e dorsal su r ace o th e w rist
3. Usin g th e im age in ten si er, m ake sm all adju stm en ts in radial-u ln ar deviation allow in g th e optim al plate location to
be determ in ed over eith er th e secon d or th ird m etacarpal
On ce th is im portan t step is accom plish ed th e in cision s are m ade.
a b
Fig 4.10-6a –b Wh en th e th ird m etacarpal is selected, th e carpu s is in

sligh t radial deviation an d th e plate lies obliqu ely over th e radiu s with
th e proxim al en d o th e plate on th e u ln ar side o th e diaph ysis ( a ).
Wh en th e secon d m etacarpal is selected, th e carpu s is in sligh t u ln ar

deviation an d th e plate lies obliqu ely over th e radiu s with th e
proxim al en d o th e plate on th e radial side o th e diaph ysis ( b ). Th is
allows better correction o radial h eigh t an d in clin ation , h owever, th e
decision always depen ds on ractu re align m en t as seen via im age
in ten si cation .
It is acceptable or th e plate to lie obliqu ely on th e radial sh a t as lon g

as th e screws en gage both cortices.
343
Pa rt II Case s
Ap p ro a ch
Distal extension
Dorsal approach
Proximal extension
a b
Fig 4.10 -7a –b Th e su rgical approach u sed w as an exten ded dorsal approach ( a )
(see ch apter 1.9 Exten ded dorsal approach to th e distal radiu s). In m ost cases,
th is tech n iqu e requ ires th ree in cision s ( b ). For th is patien t, a th ree-in cision
tech n iqu e w as u sed in volvin g a dorsal approach w ith both proxim al an d distal
addition al in cision s.
Fig 4.10-8 Th e plate is placed on th e dorsal su r ace an d assists in determ in in g

wh ich m etacarpal sh ou ld be u sed or xation . Th is tech n iqu e is u lly explain ed
in th e approach ch apter 1.9 Exten ded dorsal approach to th e distal radiu s.
4 Distal radius
6 Op e n re d u ct io n
Fig 4.10 -9a –b Align m en t alon g th e th ird m etacarpal w as

a ch osen as providin g th e best redu ction an d th ree in cision
lin es w ere draw n ( a ). Th e rst 3 cm in cision w as m ade at
th e base o th e th ird m etacarpal an d con tin u ed over th e
sh a t. Th e secon d in cision o 2 cm w as th en m ade directly
over Lister tu bercle ( b ). Th e exten sor pollicis lon gu s (EPL)
w as released an d retracted u ln arly. Mobilizin g th e EPL
h elped w ith plate in sertion an d redu ction o th e articu lar
su r ace an d assisted w ith slidin g th e plate u n der th e
secon d com partm en t ten don s. Wh ile th e th ird (m ost
proxim al) in cision lin e w as draw n , it w as n ot m ade u n til
b a ter plate in sertion .
7 Fixa t io n
De t e rm in e p la t e in s e r t io n d ire ct io n
Retrograde
Antegrade
Fig 4.10-10a –b Con sider th e direction o th e ractu re displace-

m en t be ore in sertin g th e plate to h elp avoid catch in g th e plate
on ractu re ragm en ts as it is advan ced. With redu ction
ach ieved by traction applied th rou gh th e n ger traps, th e plate
is placed u n der th e secon d dorsal com partm en t th rou gh eith er
retrograde or an tegrade in sertion . Retrograde in sertion is
recom m en ded in dorsal displacem en t o ragm en ts ( a ).
An tegrade in sertion is recom m en ded in palm ar displacem en t
o ragm en ts ( b ). Th e plate is in serted u n dern eath th e ten don s
an d m u scle bellies an d advan ced in th e ch osen direction .
345
Pa rt II Case s
Ap p ly t h e d rill gu id e
Fig 4.10 -11 Th e drill gu ide can be screw ed in to on e o th e

distal h oles o th e plate so it can be u sed as a h an dle to
acilitate th e slidin g o th e plate.
In s e r t t h e p la t e
EPL ECRL ECRB EPB APL

a b
Th e plate is passed proxim ally u n der th e secon d com partm en t ten don s. Th e m iddle in cision is recom -
Fig 4.10 -12 a – b
m en ded to avoid an y dam age to th e EPL. Th e in traoperative im age sh ow s th e plate in sertion in retrograde ash ion .
4 Distal radius
Ma ke t h e p ro xim a l in cis io n
Fig 4.10 -13 A 3 cm radial sh a t in cision is m ade over th e Fig 4.10 -14 An option al tooth ed orceps can be placed in
dorsal aspect o th e radiu s ju st proxim al to th e m u scle th e sh a t to preven t th e plate rom m ovin g too u ln arly or
bellies o th e abdu ctor pollicis lon gu s (APL) an d th e radially. Du rin g drillin g, th e u n iversal drill gu ide can also
exten sor pollicis brevis (EPB), in lin e w ith th e exten sor h elp stabilize th e plate’s position as requ ired.
carpi radialis lon gu s (ECRL) an d exten sor carpi radialis
brevis (ECRB) ten don s. Th is in cision w as previou sly
m arked du rin g in itial im agin g w ith th e plate over th e
dorsal su r ace bu t con rm atory im ages can be taken
be ore in cision .
Th e exact location o th e in cision m ay depen d on w h eth er

th e plate will attach distally at th e secon d or th ird m eta-
carpal. As th is plate w as attach ed to th e th ird m etacarpal,
th e in terval betw een th e rst an d secon d com partm en ts
w as developed an d th e diaph ysis o th e radiu s exposed.
Care was taken to avoid in ju ry to th e su per cial bran ch o
th e radial n erve. Retract th e rst com partm en t m u scles
u ln arly an d th e secon d com partm en t radially. Th e
proxim al h oles o th e plate sh ou ld be visible at th is poin t.
347
Pa rt II Case s
In s e r t d is t a l s cre w s In s e r t p ro xim a l s cre w s
2 1 3
6 5 4
a a
2 1 3
6 5 4
b b
Th e m etacarpal sh a t is n arrow an d does

Fig 4.10 -15 a – b Be ore secu rin g th e plate proxim ally,
Fig 4.10 -16 a – b
n ot tolerate lateral sh i tin g o th e plate. For th is reason , it con rm th at u ll passive m otion o all digits is possible. I
is recom m en ded to in sert th e th ree m etacarpal screw s u ll n ger f exion is n ot possible, plate im pin gem en t o
rst (w ith recom m en ded sequ en ce o screw in sertion th e exten sor ten don s is th e likely cau se, an d th ese m u st
sh ow n ). Care m u st be taken to cen ter th e plate to en su re be released.
all screw s en gage both cortices.
Fix th e plate to th e radiu s w ith th ree or ou r screw s
It is recom m en ded to u se at least on e lockin g screw in proxim al to th e ractu re. On ce radial sh a t xation is
both th e m etacarpal an d th e radiu s. Th is allow s th e plate com pleted, appropriate len gth an d redu ction o th e
to be u sed as an in tern al xator. Th e u se o lockin g ractu re sh ou ld be ach ieved w ith n o m ore th an 5 m m o
screw s in th e m etacarpal is also ben e cial becau se th e distraction at th e radiocarpal join t.
screw h eads lie f u sh w ith th e plate an d avoid exten sor
ten don irritation .
Re d u ce t h e a r t icu la r s u r fa ce
With th e plate in its n al position an d radial len gth

restored, th e su rgeon can n ow ocu s on redu ction o th e
articu lar su r ace.
4 Distal radius
Op t io n : b o n e gra ft in g Op t io n : s cre w in s e r t io n
Bone graft
a a
b b
Fig 4.10 -17 a – bAn y m etaph yseal voids can be lled by Fig 4.10 -18 a – bFu rth er bu ttressin g o th e lu n ate acet can
u sin g bon e gra t in serted th rou gh th e m iddle in cision . be provided by a 3.5 m m lockin g screw in serted th rou gh
Th e prim ary objectives o bon e gra tin g are to take th e m id-portion o th e plate ju st u n der th e su bch on dral
advan tage o th e m ech an ical e ect o bu ttressin g th e bon e o th e lu n ate acet. Altern atively, a 2.7 m m cortex
articu lar ragm en ts an d to accelerate th e process o screw can be u sed bu t m u st en gage both cortices.
h ealin g.
Op t io n : K-w ire in s e r t io n Ad d it io n a l p a lm a r p la t in g
Fig 4.10 -19 Som e ragm en ts th at requ ire redu ction m igh t Fig 4.10 -20 Som e displaced palm ar lu n ate acet ragm en ts
be too sm all or screw pu rch ase. In th is in stan ce, 1.1 or can n ot be redu ced solely by ligam en totaxis or dorsal
1.2 m m K-w ires sh ou ld be u sed to redu ce an d stabilize bridge platin g. In th ese cases, an addition al palm ar
th ese ragm en ts. Th is is o ten th e case w ith radial styloid approach is recom m en ded, an d a sm all bu ttress plate is
an d in term ediate colu m n ragm en ts. u sed or su pplem en tal xation o th e ragm en t.
349
Pa rt II Case s
a b a b
A ter xation , th e DRUJ sh ou ld be

Fig 4.10 -21 a – b Fig 4.10 -22 a – bFollow in g xation o th e bridgin g plate
assessed or both orearm rotation an d stability. Th e on to th e patien t’s th ird m etacarpal, an d w ith a screw
m eth ods or determ in in g i DRUJ in stability exists are su pportin g th e lu n ate acet th rou gh th e m idsection o th e
sh ow n in th e xation topic in ch apter 4.1 Radial styloid— plate, in traoperative im ages w ere u sed to con rm good
ractu re treated w ith a radial colu m n plate. align m en t an d redu ction o th e radial ractu re.

Fig 4.10 -23 Wh ile th e patien t is in bed, u se pillow s to

keep th e h an d elevated above th e level o th e h eart to
redu ce sw ellin g.
4 Distal radius
8 Re h a b ilit a t io n (co n t )
Im m o b iliza t io n Im p la n t re m o va l
Th e K-w ires m ay be rem oved at approxim ately 6 w eeks,

bu t th e plate is le t in place u n til bon e h ealin g h as been
radiologically con rm ed, u su ally betw een 3–4 m on th s. At
tim e o rem oval, exten sor ten olysis is recom m en ded
ollow ed by an active reh abilitation program .
Fig 4.10 -24 Th e type an d du ration o postoperative

im m obilization depen ds on a n u m ber o actors in clu din g
th e qu ality o th e in tern al xation as w ell as patien t
activity an d reliability. It m ay be n ecessary to rest th e
w rist or several w eeks in a plaster or rem ovable splin t.
Fu n ct io n a l e xe rcis e s a n d p a t ie n t m o b iliza t io n
Fig 4.10 -25 Follow in g su rgery, begin active con trolled

ran ge o m otion exercises. Weigh tbearin g is perm itted on
th e orearm an d elbow a ter su rgery. Addition ally, a ter
th e patien t is stabilized, a plat orm cru tch can be u sed.
Th ree to 4 w eeks ollow in g th e su rgery, th e plat orm is
rem oved an d w eigh tbearin g is allow ed th rou gh th e h an d
grip o regu lar cru tch es. It is recom m en ded to restrict
li tin g an d carryin g to n o m ore th an 5 kg u n til th e
ractu re h as h ealed.
Th e protocol w ill be di eren t w h en th ere is associated

DRUJ in stability. A lon g arm splin t is applied or 3 w eeks
ollow in g su rgery, a ter w h ich DRUJ stability an d active
su pin ation o th e orearm is assessed. I th e patien t’s arm
can be u lly su pin ated, splin tin g is discon tin u ed. Axial
loadin g th rou gh th e extrem ity is allow ed or tran s ers an d
all w eigh tbearin g n eeds. How ever, i su pin ation is
di cu lt or i th e DRUJ requ ired recon stru ction , th en a
rem ovable lon g arm splin t is provided. I th e DRUJ w as
tran s xed w ith K-w ires, th en th e w ires are rem oved a ter
6 w eeks an d DRUJ stability is reassessed.
351
Pa rt II Case s
9 Ou t co m e
a b a b
Fig 4.10-26a –b At th e 2-week ollow-u p th e Fig 4.10-27a –b At a u rth er ollow-u p 5

postoperative im ages o th e bridgin g plate sh owed m on th s a ter plate rem oval, PA an d lateral
m ain tain ed align m en t an d redu ction . Th e bridgin g x-rays sh owed h ealin g o th e ractu re an d
plate was rem oved 12 weeks a ter su rgery. per ect con gru en cy an d align m en t o th e join t.
Fig 4.10 -28 Th e patien t h ad ach ieved a n ear u ll ran ge o

m otion an d w as able to recon tin u e h is m otorbike ridin g
activities w ith ou t di cu lties.
4 Distal radius
Us in g a 2 -in cis io n t e ch n iq u e
Fig 4.10 -29 As an altern ative, th e approach can be m ade Fig 4.10 -30 In sert a drill gu ide in to on e o th e distal screw
u sin g proxim al an d distal in cision s on ly. Th e 2-in cision h oles or u se as a h an dle. On ce th e plate h as been
approach m igh t be con sidered w h en th ere is gross in serted an d is in position over th e radiu s proxim al to th e
com m in u tion an d m u ltiple sm all bon e ragm en ts. A ter ractu re, a secon d in cision m easu rin g approxim ately 3 cm
closed redu ction , u se th e im age in ten si er to determ in e is m ade over th e dorsal aspect o th e radiu s ju st proxim al
w h ich m etacarpal to u se or xation . With th e plate to th e m u scle bellies o th e APL an d EPB, in lin e w ith th e
sittin g on th e skin , m ark th e skin at th e level o th e ECRL an d ECRB ten don s.
proxim al an d distal screw h oles. Make a 3 cm distal
in cision an d in sert th e plate.
Fig 4.10 -31 By blu n t dissection , th e in terval betw een th e Fig 4.10 -32 A drill gu ide, u sed as a secon d h an dle, is
ECRL/ ECRB an d th e APL/ EPB is developed, an d th e plate in serted in to on e o th e proxim al h oles o th e plate to
can be seen over th e diaph ysis o th e radiu s. Care m u st be acilitate th e align m en t o th e plate over th e radiu s.
taken to avoid in ju ry to th e su per cial bran ch o th e Fixation is com pleted in th e stan dard w ay.
radial n erve.
353
Pa rt II Case s
4.11 Distal radius—radiocarpal fracture
dislocation treated with double plating
a b c d
Fig 4.11 -1a –d A 30-year-old bu ildin g su pervisor w as seen in th e em ergen cy departm en t in

severe pain 2 h ou rs a ter allin g rom a h eigh t. On clin ical exam in ation th ere w as eviden ce o
gross de orm ity an d sw ellin g o th e h an d an d w rist exten din g to th e orearm ( a –b ). Th e PA
an d lateral x-rays revealed a com plex radiocarpal ractu re dislocation o h is righ t w rist ( c–d ).
a b c
Fig 4.11 -2a –cSagittal 2-D CT scan s dem on strated com plete dislocation
dorsally o th e carpu s as w ell as a sm all sh earin g ractu re o th e dorsal
aspect o th e distal radiu s.
355
Pa rt II Case s
a b c d
Mu ltiple 3-D CT scan s sh ow th e dorsal sh earin g ractu re ragm en ts bu t th e

Fig 4.11 -3a –d
palm ar rim o th e radiu s w as still in tact.
2 In d ica t io n s
Ra d io ca rp a l fra ct u re d is lo ca t io n s
a b
Fig 4.11 -4a –b Radiocarpal ractu re dislocation s are th e resu lt o h igh er-en ergy trau m a, can h ave associated so t-tissu e
in ju ries, an d are o ten ou n d in polytrau m a cases. Th e in ju ry is ch aracterized by m u lti ragm en tary dorsal rim ractu res
an d dorsal dislocation o th e carpu s. In th ese ractu res, th e ractu re o th e dorsal rim is associated w ith a radial styloid
ractu re as well, w ith greater m arked in stability. As th ese are partial in traarticu lar in ju ries, w ith an existin g or a h igh
risk o later radiocarpal su blu xation , th ey sh ou ld n orm ally be treated w ith open redu ction an d in tern al xation .
I th e distal radial ragm en ts are predom in an tly dorsal, redu ction an d xation is per orm ed u sin g dorsally applied plates
bu t i th ere is a sign i can t radial styloid ragm en t th is is h elped m ore e ectively w ith a radial colu m n plate. Large
ragm en ts can be treated w ith platin g or even lag screw s w h ile sm aller ragm en ts m ay requ ire xation w ith K-w ires or
su tu re an ch ors, alth ou gh redu ction an d stabilization by extern al xation m ay be n eeded in itially becau se o m arked
sw ellin g.
4 Distal radius
4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating
In it ia l a s s e s s m e n t Me d ia n n e r ve co m p re s s io n
Dorsal lunate facet
Median nerve
Fig 4.11 -5 Un der direct vision , approach th e radial styloid Fig 4.11 -6I th ere is den se sen sory loss or oth er sign s o
an d dorsal lu n ate acet ragm en ts. Usu ally th e dorsal m edian n erve com pression , th e m edian n erve sh ou ld be
capsu le is torn , bu t i it is in tact, a dorsal arth rotom y is decom pressed.
m ade parallel to th e dorsal rim to in spect th e articu lar
su r ace an d look or an y associated carpal in ju ries.
As s o cia t e d ca rp a l in ju rie s Im a gin g
Usin g CT scan s can be h elp u l or treatm en t decision s

w ith th is in ju ry.
Fig 4.11 -7 Th ese in ju ries m ay be associated w ith sh earin g

in ju ries o th e articu lar cartilage, scaph oid ractu res, an d
ru ptu res o th e scaph olu n ate ligam en t. Every patien t
a b c
Dorsal plates
Fig 4.11 -8a –c A selection o plates can be u sed to stabilize

dorsal radiocarpal ractu re dislocation s by stabilizin g th e
radial an d in term ediate colu m n s. Plates w ith variable
an gle (VA) lockin g screw option s can be u se u l. For th is
patien t, VA straigh t an d L-plates w ere u sed, w ith th e
in term ediate colu m n bein g treated rst.
357
Pa rt II Case s

Fig 4.11 -9 Position th e patien t su pin e an d place th e

option al.
Ap p ro a ch
Th e su rgical approach u sed w as a dorsal

Fig 4.11 -10
approach (see ch apter 1.8 Dorsal approach to th e distal
radiu s).
4 Distal radius
a b
Fig 4.11 -11 a – bTh e dorsal su rgical approach w as m arked. A ter th e in cision , th e exten sor
pollicis lon gu s w as elevated rom th e exten sor retin acu lu m .
a b
Th e sm all dorsal rim ractu res th en becam e visible. Th e

Fig 4.11 -12 a – b
approach allow ed access to both th e radial an d in term ediate colu m n s.
Ar t h ro t o m y
I direct vision o th e articu lar su r ace is n eeded, a lim ited

tran sverse radiocarpal arth rotom y is per orm ed.
359
Pa rt II Case s
5 Re d u ct io n
traction eith er m an u ally or u sin g n ger traps. Th e redu ction a b c
is m ain tain ed by a tem porary splin t. I de n itive su rgery is
plan n ed bu t can n ot be per orm ed with in a reason able tim e Fig 4.11 -14 a – cIn traoperative redu ction w as ch ecked
scale a tem porary extern al xator m ay be h elp u l. u sin g th e im age in ten si er.
Pro vis io n a l fixa t io n
Fig 4.11 -15I th e dorsal rim ragm en ts are large en ou gh , Fig 4.11 -16 I th ey are too sm all th ey can be h eld w ith
obtain provision al xation w ith K-w ires. su tu re an ch ors or tran sosseou s su tu res.
4 Distal radius
Pro vis io n a l ra d ia l s t ylo id fixa t io n
Superficial
branch of
radial nerve
Fig 4.11 -17 Th e radial styloid ragm en ts are redu ced Fig 4.11-18 Th e radial styloid ractu re com pon en t w as
u n der direct vision w ith eith er a K-w ire on th e dorsora- redu ced an d h eld w ith a K-wire. A dorsal w rist arth rotom y
dial aspect or percu tan eou sly. In th e latter case, in order h ad been per orm ed or direct vision o th e articu lar
n ot to in ju re th e sen sory bran ch o th e radial n erve, m ake redu ction .
a sm all in cision over th e tip o th e radial styloid an d u se a
protective drill gu ide to in sert tw o K-w ires. Con rm u sin g
a b
Fig 4.11 -19 a – bTh e articu lar redu ction w as con rm ed

u sin g in traoperative im agin g.
361
Pa rt II Case s
6 Fixa t io n
Fig 4.11 -20 Plates u sed in treatin g radial an d in term ediate

colu m n in ju ries are available precon tou red. How ever,
becau se o th e sh ape o th e dorsal distal m etaph ysis, th e
plate m ay n eed to be con tou red to t th e bon e su r ace
an d th e proxim al lim b m ay requ ire som e torsion al Fig 4.11-21 Variable an gle lockin g plates en able precise
adaptation . I th e distal tran sverse lim b o th e plate does position in g o th e distal screws in desired direction s becau se
n ot exert su cien t com pression on th e distal ragm en ts, th ere is 30 degrees o reedom or each screw in side th e
rem ove th e plate an d overben d th e tran sverse distal lim b. plate h ole to address th e in dividu al ractu re pattern s.
Pit fa ll: s cre w h o le d is t o r t io n Fixa t io n o f in t e rm e d ia t e co lu m n

a b
Avoid con tou rin g th e plate th rou gh th e

Fig 4.11 -22 a – b
lockin g h oles oth erw ise th e lockin g h ead screw m igh t n o
lon ger t.
a b
Fig 4.11 -23 a – bTh e appropriate plate is selected accordin g
to th e ractu re con gu ration . Th e plate sh ou ld be applied
as distally as possible over th e dorsal rim ragm en ts ( a ). I
th e provision al K-w ires con f ict w ith th e optim al plate
position , th e plate can be slipped over th e w ires, or th e
w ires can be reposition ed ( b ).
4 Distal radius
a b
Fig 4.11 -24 a – b Fix th e plate provision ally to th e bon e

w ith a stan dard cortex screw in serted th rou gh th e oblon g
plate h ole ( a ). Be ore u lly tigh ten in g it, ch eck th e plate
position u sin g in traoperative im agin g, adju stin g th e
position o th e plate as n ecessary. On ce th e plate position
is satis actory, it sh ou ld be secu red w ith a lockin g screw
in th e proxim al screw h oles ( b ).
In s e r t d is t a l s cre w s
20°
X-ray beam
a b
Screw s are in serted th rou gh th e distal plate h oles be ore or

Fig 4.11 -25 a – b
a ter rem oval o th e K-w ire(s), as appropriate ( a ). With im age in ten si cation ,
con rm th at th e distal screw s h ave n ot pen etrated th e articu lar su r ace. To
h ave a view in lin e w ith th e articu lar su r ace, th e beam sh ou ld be an gled 20
degrees rom th e tru e lateral ( b ).
363
Pa rt II Case s
Fixa t io n o f ra d ia l co lu m n St a b ilize t h e ra d ia l co lu m n
EPL
ECRB
Fig 4.5-2 6 Th e appropriate plate is selected accordin g to Fig 4.11-27 Ideally, wh ile applyin g th e plate th e n otch in
th e ractu re con gu ration an d con tou red i n ecessary. th e distal tip o th e im plan t is placed again st th e tem porary
Slide th e plate u n dern eath th e rst com partm en t an d K-wire.
apply it on to th e radial colu m n . Exten sor carpi radialis
brevis (ECRB); exten sor pollicis lon gu s (EPL).
Pit fa ll: in co rre ct p la ce m e n t In s e r t t h e firs t s cre w in t h e ra d ia l co lu m n p la t e
a b
Fig 4.11-28a –b Avoid placem en t o th e radial plate on th e Fig 4.11 -29 In sert a stan dard cortex screw th rou gh th e
dorsal aspect o th e radial colu m n as it will n ot bu ttress th e oblon g plate h ole proxim al to th e ractu re. Th e screw
redu ction adequ ately again st axial sh ear orces. sh ou ld en gage th e ar cortex. Th e position o th e plate
m ay be adju sted be ore th e screw is tigh ten ed. Tigh ten in g
th is screw w ill redu ce th e radial styloid.
4 Distal radius
In s e r t firs t lo ck in g h e a d s cre w In s e r t d is t a l lo ck in g h e a d s cre w s
Fig 4.11 -30 To preven t rotation o th e plate du rin g distal Fig 4.11 -31 I a K-w ire w as u sed, it is n ow rem oved.
lockin g screw xation , th e plate sh ou ld be secu red to th e Distal lockin g h ead screw (s) are in serted to su pport th e
bon e by in sertin g th e m ost proxim al screw . radial styloid. Usin g VA screw s allow optim al direction o
xation . Th e position o th e m ost distal screw sh ou ld be
ju st u n der th e su bch on dral bon e.
Pit fa ll: p e n e t ra t io n o f s igm o id n o t ch
20°
X-ray beam
Fig 4.11-32 Con rm th at th e screw does n ot protru de in to Fig 4.11 -33 Bew are o th e tip o th e screw pen etratin g
th e join t u n der direct vision an d u sin g an im age in ten si er, in to th e sigm oid n otch . It is sa er to leave th e screw a
with th e beam an gled 20 degrees rom th e tru e lateral. Th is little sh ort an d it sh ou ld n ot be drilled in to th e opposite
projection will pro le th e radial articu lar su r ace an d visu al- cortex.
ize an y en croach m en t o th e screw in to th e join t.
365
Pa rt II Case s
Fig 4.11 -34 I n ecessary, in sert addition al screw s an d Fig 4.11 -35 Th e de n itive xation w as
com plete th e xation . ach ieved u sin g a radial colu m n plate an d
a dorsal L-plate 2.4.
Pa lm a r liga m e n t o u s a vu ls io n re a t t a ch m e n t
a b a b
In traoperative im agin g con rm ed th e

Fig 4.11 -36 a – b Fig 4.11 -37 a – b Radiocarpal ractu re dislocation s m ay be
plate position an d th e an atom ical redu ction o th e associated w ith avu lsion o th e palm ar w rist capsu le rom
ractu re dislocation . th e distal radiu s. A ter dorsal xation , ch eck th e carpal
position an d stability u n der im age in ten si cation . I th ere
is carpal u ln ar an d/ or palm ar tran slation , con sider an
addition al palm ar approach to repair so t tissu es. Th e
capsu le can be reattach ed u sin g m u ltiple su tu re an ch ors
or tran sosseou s su tu res.
4 Distal radius
Ad d it io n a l e xt e rn a l fixa t io n
Fig 4.11-38 I th e dorsal rim ragm en ts are large en ou gh ,

th ey m ay be h eld in place with a bu ttress plate. I th ey are
too sm all, K-wires m ay be th e de n itive xation , in wh ich
case, a n eu tralization extern al xation sh ou ld be applied.

colu m n plate.
367
Pa rt II Case s
8 Ou t co m e
a b a b
Th e ollow -u p x-rays at
Fig 4.11 -40 a – b Th e 12-m on th ollow -u p x-rays
Fig 4.11 -41 a – b
6 w eeks sh ow ed th ere w as m ain tain ed sh ow ed good h ealin g.
redu ction an d early bon e h ealin g.
a b
c d
e f a b
Th e patien t h ad close to n orm al ran ge o

Fig 4.11 -42 a – f Th ere w as an excellen t overall
Fig 4 .1 1 -4 3 a – b
m otion com pared w ith th e u n in ju red side. u n ction al resu lt.
5 Reconstructions and
treatment of complications
Pa rt II Case s

5.1 Distal radius—dorsal extraarticular malunion
treated with osteotomy and double plating
a b
Fig 5.1-1a – b A 54-year-old m an su ered a dorsally displaced distal radial

ractu re o th e righ t h an d w ith a sm all dorsal lu n ate in traarticu lar com po-
n en t, or wh ich h e received n on operative treatm en t. Th e PA an d lateral
x-rays taken in th e plaster cast sh ow ed th e in itial displaced ractu re.
a b c
Fig 5.1-2a – c At th e 4-m on th ollow -u p a ter th e in ju ry, 2-D CT scan s sh ow ed a m arked de orm ity existed
w h ile also in dicatin g im m atu re callu s.
371
Pa rt II Case s
a b
c d
Fig 5.1-3a –d Addition al 3-D CT scan s clearly sh owed th e eviden t

de orm ity. Th e de orm ity in volved con siderable sh orten in g o th e
radiu s, loss o th e wrist’s n orm al radial an d palm ar in clin ation , an d
dorsal displacem en t o th e distal ragm en t with dorsal ragm en tation .
5 Re constructions and tre atment of complications
5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating
2 In d ica t io n s
Do rs a l e xt ra a r t icu la r ra d iu s m a lu n io n
a b c
Loss of radial inclination Dorsal angulation Supination of distal fragm e nt
d e
Oblique vie w with norm al angulation Oblique vie w with dorsal angulation
Fig 5.1-4 a – e Malu n ion is a com m on com plication o distal radial ractu res an d occu rs w h en th e h ealed distal radiu s
deviates rom its origin al an atom ical align m en t. Th e m ost com m on de orm ity type in volves dorsal extraarticu lar
an gu lation , w ith radial sh orten in g an d su pin ation o th e distal ragm en t. Th e alteration o radial orien tation can m odi y
th e loads tran sm itted in th e carpu s an d th e distal radiou ln ar join t (DRUJ), possibly cau sin g th em to ch an ge an d adapt,
an d greatly in creasin g th e risk o developin g posttrau m atic osteoarth ritis.
Co rre ct ive o s t e o t o m y fo r m a lu n io n
A corrective osteotom y, in volvin g bon e len gth en in g or sh orten in g or to ch an ge align m en t, can o ten be ch osen to treat
a m alu n ited distal radial ractu re. Wh en con siderin g th is, th e ollow in g tw o qu estion s m u st be an sw ered:
• How m u ch de orm ity can actu ally be tolerated?
• Wh en is th e optim al tim e to per orm an osteotom y?
Th e qu estion o h ow m u ch de orm ity can be tolerated is n ot alw ays easy to an sw er as it can be di cu lt to qu an ti y an

acceptable m alalign m en t an d depen ds on th e n eeds o th e in dividu al. Wh ile som e patien ts rem ain sym ptom ree
despite th e de orm ity, oth ers can presen t w ith pain or u n ction al lim itation . Th e exten t o disability m ay depen d on th e
am ou n t o radial sh orten in g, th e loss o radial in clin ation , th e am ou n t o dorsal an gu lation , an d an y DRUJ in stability.
373
Pa rt II Case s
22° normal
1 mm
10°
5 mm
10°
a b c d
Fig 5.1-5 a – dHow m u ch de orm ity in th e distal radiu s can be accepted? Wh ile eviden ce o adaptive carpal in stability
(ch an ge in capitolu n ate or scaph olu n ate align m en t) is in creasin gly seen as an accu rate predictor o ou tcom e, as a
gen eral gu ide, th e ollow in g m easu rem en ts h ave been recogn ized as providin g acceptable levels o dorsal de orm ity:
a Not greater th an 5 m m o radial sh orten in g
b Not less th an 10 degrees o radial in clin ation
c Not greater th an 10 degrees o dorsal an gu lation
d Not greater th an 1 m m o step-o o th e articu lar su r ace.
As or th e m ost optim al tim e to per orm th e osteotom y, it is recom m en ded to operate wh en th e so t tissu es dem on strate
absen ce o troph ic ch an ges, wh en th e x-rays reveal lim ited or n o appearan ce o low bon e den sity (osteopen ia), an d wh en
wrist m obility is adequ ate. Regardless, th ere are advan tages to early operative treatm en t su ch as decreased likelih ood o
de orm ity or wh en th e correction is th rou gh an im m atu rely h ealed ractu re site, wh ich is always easier. Th is early approach
can lim it th e problem o so t-tissu e con tractu res an d can m in im ize th e econ om ic an d social im pact to th e patien t.
Besides u n acceptable de orm ities o th e distal radiu s, oth er in dication s or corrective osteotom y are carpal m alalign m en t,
in con gru en ce o th e DRUJ, decreased ran ge o m otion , decreased grip stren gth , th e presen ce o pain with m otion an d
activity, an d an u n acceptable clin ical appearan ce by th e patien t.
Im a gin g
Wh en dealin g w ith m alu n ion s, th e correct len gth o th e radiu s in relation to th e u ln a sh ou ld alw ays be establish ed
preoperatively by takin g x-rays o th e opposite w rist.
• Variable an gle (VA) lockin g com pression plate (LCP)

distal radiu s set
• 2.7 m m Sch an z pin s or 1.4 m m to 1.6 m m K-w ires
• Con ical drill gu ide
• Gon iom eter
• Osteotom e
• Au togen ou s bon e gra t or bon e su bstitu te
• Sm all extern al xation set
• Lam in ar spreader

Ap p ro a ch
a b
Fig 5.1-7 Th e su rgical approach u sed was a dorsal approach Fig 5.1-8 a – bDu rin g th e approach , th e exten sor pollicis
(see ch apter 1.8 Dorsal approach to th e distal radiu s). lon gu s (EPL) w as elevated rom th e th ird exten sor
com partm en t an d protected.
375
Pa rt II Case s
Pla n t h e o s t e o t o m y
1
4 3 2
a b
c
Plan Oste otom y line Re duction
Fig 5.1-9 a – c In preparin g or an osteotom y procedu re th ree types o osteotom ies can be con sidered:
a In com plete (open in g w edge)
b Rockin g
c Com plete ( u ll th ickn ess in terposition al).
To determ in e th e type o osteotom y requ ired, su perim pose th e x-ray o th e de orm ity side on to th e x-ray o th e
u n in ju red side. In th e sagittal view , draw a lin e betw een th e m ost dorsal poin t o th e n orm al x-ray ( 1 ) to th e dorsal
poin t o th e m alu n ion ( 2 ). Create a perpen dicu lar lin e at th e cen ter o th e lin e. Th is is ollow ed by a lin e draw n rom
th e m ost palm ar aspect o th e n orm al side ( 3 ) to th e m ost palm ar aspect o th e m alu n ion side ( 4 ) an d a perpen dicu lar
lin e is draw n in th e m iddle o th is lin e to con n ect to th e perpen dicu lar lin e draw n rom th e dorsal side. Wh ere th ese
tw o perpen dicu lar lin es in tersect w ill de n e w h at type o osteotom y w ill be requ ired.
In som e in stan ces, th e perpen dicu lar lin es in tersect directly on or n ear th e palm ar cortex (bu t still w ith in th e radiu s),
w h ich dem on strates th at th e osteotom y on ce created does n ot n eed len gth en in g o th e distal ragm en t an d requ ires an
in com plete osteotom y or a rockin g m eth od osteotom y.
How ever, I th e lin es in tersect beyon d th e palm ar cortex, as w ith th is patien t, it in dicates th at ollow in g th e osteotom y
o th e m alu n ion th e distal ragm en t w ill requ ire len gth en in g, creatin g a de ect o both th e dorsal an d palm ar aspects o
th e distal radiu s. A com plete osteotom y w ill th ere ore be requ ired ( c ).
De t e rm in e d e gre e o f d e fo rm it y
10°
a b c
Fig 5.1-10a –c A Sch an z pin is placed perpen dicu larly to th e radiu s bu t proxim al o th e osteotom y site wh ile a secon d pin is
placed distally in lin e with th e exten sion de orm ity o th e distal radiu s ( a –b ). A h an dh eld gon iom eter can be u sed to ju dge
th e degree o de orm ity an d an ticipated correction ( c). A sm all h ypoderm ic n eedle was placed in th e radiocarpal join t or
better orien tation .
Pe r fo rm t h e o s t e o t o m y
Fig 5.1-11a –b Th e osteotom y is per orm ed by u sin g an osteotom e

at th e site o th e de orm ity. Th e m alu n ion with dorsal an gu lation is
corrected by a dorsal open wedge osteotom y an d appropriate
a b len gth en in g o th e radiu s.
377
Pa rt II Case s
Op t io n : e xt e rn a l fixa t o r
a b
Fig 5.1-12a –b Th e lateral in traoperative im ages Fig 5.1-1 3 As an option , an d as u sed in th is case, th e
dem on strate th e position o th e Sch an z pin s an d th e osteotom y an d redu ction can be aided w ith an extern al
in ten ded osteotom y site ( a ). Th e osteotom y was xator. Attach an extern al xation pin h oldin g clam p to
per orm ed by u se o th e osteotom e ( b ). In teroperative each Sch an z pin . Th en place an addition al Sch an z pin
im agin g is u sed to determ in e th e exact location o th e in to th e distal ragm en t rom th e radial direction . Th is is
osteotom y an d to avoid dam agin g th e m edian n erve u sed to h elp regain th e an ticipated radial len gth an d
an d f exor ten don s. an gu lation o th e distal ragm en t.
a b a b
Fig 5.1-1 4a –b In traoperative im ages sh ow th e extern al xation Fig 5.1-15a –b Th e correction ollowin g th e osteotom y
an d th e osteotom y site. is seen in th e lateral in traoperative im ages, precorrec-
tion ( a ) an d a ter correction with a m ore appropriate
align m en t ( b ).
Fixa t io n o f in t e rm e d ia t e co lu m n
a b
Fig 5.1-16a –b For xation o th e distal radiu s, two con tou red
VA LCP dorsal plates 2.4 were sequ en tially applied, startin g
with th e plate or th e in term ediate colu m n .
Fixa t io n o f ra d ia l co lu m n
a b c
Fig 5.1-1 7a –cTh is w as ollow ed by xation o th e radial colu m n . Note th e u se o th e con ical drill
gu ide to allow variable direction s or th e lockin g h ead screw s.
Th e dou ble platin g xation procedu re ollow s th e u su al steps o selectin g, preparin g an d applyin g
th e plates, stabilizin g th e radial colu m n , en su rin g correct plate position in g, an d in sertin g th e
screw s. For u rth er in orm ation on th ese steps see ch apter 4.5 Distal radiu s—dorsally displaced
in traarticu lar ractu re treated w ith dou ble platin g.
379
Pa rt II Case s
a b
Fig 5.1-1 8a –bIn traoperative im ages ollow in g plate xation

en su red correct plate placem en t. Note th at th e de ect created
by th e osteotom y is still clearly eviden t.
Bo n e gra ft Ha r ve s t in g
2–4 cm
Iliac crest
Fig 5.1-1 9 Harvest corticocan cellou s gra t m aterial rom Fig 5.1-2 0 Make a lon gitu din al in cision over th e lateral
th e iliac crest. aspect o th e palpable iliac crest avoidin g th e an terior
aspect an d th e ilio em oral n erve. Mark ou t th e pre-
plan n ed gra t size to be h arvested con siderin g th e sh ape
an d size o th e de ect in th e distal radiu s. Harvest th e
selected gra t u sin g a sh arp osteotom e.
a b c
Fig 5.1-2 1a –c Th e de ect created by th e osteotom y w as lled w ith th e iliac crest gra t.
a b
Fig 5.1-2 2a –b On ce th e bon e gra t w as in place, th e

exten sor retin acu lu m w as reapproxim ated an d th e
w ou n d irrigated an d closed. Th e EPL ten don is le t above
th e retin acu lu m .
381
Pa rt II Case s

colu m n plate.
7 Ou t co m e
a b
Fig 5.1-24a –bAt th e 4-m on th ollow-u p th e postoperative x-rays

sh owed th e in tegration o th e bon e gra t an d th e com pleted xation .
a b
c d
Fig 5.1-2 5a –d Th e patien t sh ow ed som e lim itation o w rist f exion bu t th e exten sion ,
pron ation , an d su pin ation w ere good an d th e patien t w as w ith ou t pain .
Vid e o
Vid e o 5.1-1Th is video dem on strates a

corrective osteotom y on a distal radiu s with
xation with a m in icon dylar plate 2.0.
383
Pa rt II Case s
Do rs a l m a lu n io n t re a t e d t h ro u gh a p a lm a r a p p ro a ch
a b
c d
Fig 5.1-26a –d Occasion ally, plates placed on th e dorsal aspect o th e radiu s can resu lt in ten don irritation an d ru ptu re
becau se o th e in tim ate con tact between th e ten don s an d th e plate. As an altern ative, i th e xation is per orm ed with a
plate on th e palm ar aspect o th e radiu s (as sh own , applyin g a palm ar plate to assist with th e osteotom y ( a –b ), correctin g
align m en t ( c), an d even tu al xation ( d )), th en th e ten don s an d m edian n erve are protected by th e pron ator qu adratu s.
With th e u se o an gu lar stable im plan ts su ch as an LCP lockin g plate, m ost corrective osteotom ies can be per orm ed
th rou gh th e palm ar approach u sin g can cellou s bon e gra t in stead o a m ore com plex au togen ou s corticocan cellou s
gra t. Man y osteotom ies can n ow be per orm ed palm arly, an d in stead o scu lptu red bon e gra t, w h ich is a dem an din g
tech n iqu e, su rgeon s can u se can cellou s ch opped ch ips.
a b c
Fig 5.1-2 7a –c As an illu stration , th ese x-rays sh ow a dorsally displaced m alu n ion on a righ t-h an ded patien t
( a –b ). Th e in traoperative im age sh ow s th at th rou gh a palm ar approach th e an gu lar stable im plan t is applied
w ith th e proxim al lim b placed o th e palm ar cortex based on th e plan n ed an gu lar correction ( c ).
a b c
Fig 5.1-2 8a –c In traoperative im agin g sh ow s th e strategic placem en t o th e

im plan t ( a ) ollow ed by th e osteotom y an d th e plate th en applied to th e sh a t to
correct th e de orm ity ( b ) w ith placem en t o can cellou s bon e gra t to com plete
th e xation ( c ).
385
Pa rt II Case s
5.2 Distal radius—palmar extraarticular malunion
treated with osteotomy and plate
a b c d
Fig 5.2-1a –d A 15-year-old m ale sch ool stu den t su stain ed a displaced ractu re o th e righ t distal radiu s in a m otorcycle
in ju ry, or wh ich h e received treatm en t in a region al h ospital with closed redu ction an d percu tan eou s K-wire xation .
Th e patien t was in itially im m obilized in a sh ort arm plaster cast, wh ich was rem oved alon g with th e K-wires 15 days a ter
su rgery. Th e PA an d lateral x-rays sh ow th e in itial ractu re an d K-wire xation .
387
Pa rt II Case s
a b a b
Fig 5.2-2a –b At th e 5-week ollow-u p, n ew PA an d lateral Fig 5.2-3 a – b Th e patien t retu rn ed 6 m on th s a ter th e
x-rays sh owed a m alu n ited ractu re o th e distal radiu s. in itial trau m a h avin g a m atu re sym ptom atic m alu n ited
Th ere was sh orten in g o th e radiu s by 5 m m , radial ractu re o th e distal radiu s. He com plain ed o pain ,
in clin ation o 15 degrees, an d palm ar an gu lation o de orm ity, an d u n ction al lim itation o th e orearm an d
40 degrees. On th e lateral view, a trian gle o callu s was w rist. Th e ph ysical exam in ation sh ow ed redu ction o
sh own on th e palm ar aspect o th e radiu s. Th e growth plate w rist exten sion an d in creased f exion com pared w ith th e
was open in th e u ln a an d partially closed in th e radiu s. opposite lim b. Lim itation o su pin ation o th e orearm
w as also dem on strated, an d th ere w as pain du rin g active
an d passive m ovem en t an d orearm rotation . Exam in a-
tion o radial in clin ation an d sh orten in g sh ow ed th ere
h ad been n o im provem en t. Th e grow th plate w as closed
in both th e u ln a an d th e radiu s. In th e lateral view , a
com pen satory exten sion o th e capitate w as eviden t
becau se o th e f exed position o th e lu n ate as a resu lt o
th e in crease in palm ar an gu lation o th e radiu s.
a b
Fig 5.2-4 a – bTh e sagittal view CT scan s sh ow ed th e exact

plan e o th e m alu n ited ractu re an d th e apex o th e
de orm ity, both elem en ts th at h elp w h en plan n in g an
osteotom y. Addition ally, an x-ray o th e n orm al con tra-
lateral w rist w as u sed or preoperative plan n in g.
5 .2 Distal radius—palmar e xtraarticular malunion tre ate d with oste otomy and plate
2 In d ica t io n s
Pa lm a r e xt ra a r t icu la r ra d iu s m a lu n io n
a b c
Loss of radial inclination Palmar angulation Pronation of distal fragm e nt
d e
Oblique vie w with norm al angulation Oblique vie w with palmar angulation
Alth ou gh less requ en t th an dorsally displaced m alu n ion s, m alu n ited extraarticu lar ractu res o th e distal
Fig 5.2-5 a – e
radiu s can also occu r w ith in creased palm ar an gu lation , radial sh orten in g, an d pron ation o th e distal ragm en t, w h ich
can m odi y th e loads tran sm itted in th e carpu s an d th e distal radiou ln ar join t (DRUJ) w ith in creased risk o developin g
posttrau m atic osteoarth ritis.
Co rre ct ive o s t e o t o m y fo r m a lu n io n
As discu ssed in th e previou s ch apter, con sideration or a corrective osteotom y to treat distal radial m alu n ion depen ds
on h ow m u ch de orm ity can be accepted an d w h en best to operate. Wh ile th ere m ay be som e con train dication s, it is
gen erally accepted th at th ere are advan tages to early operative treatm en t, su ch as decreased likelih ood o de orm ity, or
w h en th e correction is th rou gh an im m atu rely h ealed ractu re site, w h ich is alw ays easier.
389
Pa rt II Case s
22° normal
1 mm
10°
5 mm
20°
a b c d
Fig 5.2-6 a – dAs or th e qu estion o h ow m u ch de orm ity can be accepted, as w ith dorsal m alu n ion , th ere are broad
gu idelin es on w h at are acceptable levels o palm ar de orm ity. Th ese are as ollow s:
a Not greater th an 5 m m o radial sh orten in g
b Not less th an 10 degrees o radial in clin ation
c Not greater th an 20 degrees o palm ar an gu lation
d Not greater th an 1 m m o step-o o th e articu lar su r ace.
Regardless o th ese m easu rem en ts, or th e you n g patien t in th is case th e decreased ran ge o m otion , decreased grip
stren gth , presen ce o pain w ith m otion an d activity, an d th e u n acceptable clin ical appearan ce by th e patien t m ade or
stron g in dicators or a corrective osteotom y.
Im a gin g
Wh en dealin g w ith m alu n ion s, th e correct len gth o th e radiu s in relation to th e u ln a sh ou ld alw ays be establish ed
preoperatively by takin g x-rays o th e opposite w rist.

distal radiu s set
• Poten tial n eed or extern al xator

Ap p ro a ch
Fig 5.2-8 Th e su rgical approach u sed w as a m odi ed

Hen ry palm ar approach (see Ch apter 1.6 Modi ed Hen ry
palm ar approach to th e distal radiu s).
391
Pa rt II Case s
1
4 3 2
a b
c
Plan Oste otom y line Re duction
In preparin g or an osteotom y procedu re th ree types o osteotom ies can be con sidered:
Fig 5.2-9 a – c
• In com plete (open in g w edge) ( a )
• Rockin g ( b )
• Com plete ( u ll th ickn ess in terposition al) ( c ).
By an alyzin g th e perpen dicu lar lin es (o n orm al versu s th e m alu n ited align m en t) an d w h ere th ey in tersected it w as
determ in ed th at th e osteotom y on ce created did n ot n eed len gth en in g o th e distal ragm en t, th ere ore an in com plete
osteotom y tech n iqu e w as selected. Details on h ow to determ in e w h ich osteotom y to per orm are ou tlin ed in th e plan o
th e osteotom y topic in ch apter 5.1 Distal radiu s—dorsal extraarticu lar m alu n ion treated w ith osteotom y an d dou ble
platin g.
Pe r fo rm t h e o s t e o t o m y
Fig 5.2-10 With a distal radial ractu re m alu n ited w ith Fig 5.2-1 1 Th rou gh th e m odi ed Hen ry palm ar approach ,
palm ar an gu lation , th e recom m en ded su rgery is an open an open w edge osteotom y w as per orm ed th at adju sted
w edge osteotom y or correction o th e de orm ity, len gth radial len gth , corrected th e excessive palm ar an gu lation ,
adju stm en t o th e radiu s, bon e gra t or bon e su bstitu te to an d restored th e n orm al radial in clin ation . Th e osteotom y
ll th e de ect, an d xation u sin g a palm ar plate. I in stead is per orm ed at th e site o th e m axim u m de orm ity.
o a regu lar plate an an gu lar stable im plan t is u sed, su ch Provide provision al xation w ith a K-w ire. Th e correction
as th e LCP, th e su rgeon can u se can cellou s ch opped bon e o th e de orm ity is acilitated by u tilizin g th e an atom ical
gra t becau se th ose im plan ts provide m u ch better stability. sh ape o th e im plan t.
393
Pa rt II Case s
In s e r t t h e firs t s cre w De t e rm in e a n d co rre ct ra d ia l in clin a t io n
Fig 5.2-1 2 Th e rst screw is placed th rou gh th e im plan t Fig 5.2-13 Th e de orm ity in th e ron tal plan e is corrected
proxim al to th e osteotom y. By tigh ten in g th is screw an u sin g th e lam in ar spreader to correct th e radial in clin ation .
in direct redu ction o th e de orm ity w ill resu lt.
In s e r t a d d it io n a l s cre w s
a b
Fig 5.2-1 5a –b In traoperative im ages sh ow th e correction

obtain ed w ith th e per orm ed osteotom y in both th e
coron al an d sagittal plan e. Th ese im ages also sh ow th e
correct location o th e plate, w h ere care w as taken n ot to
Fig 5.2-1 4Addition al screw s proxim ally an d distally are exceed th e w atersh ed lin e n or to in ter ere w ith th e
u sed to com plete th e xation . provision al xation m ain tain ed by th e K-w ire.
In s e r t b o n e gra ft
a b c
Fig 5.2-16a –c Au togen ou s can cellou s bon e gra t was u sed to ll th e space le t by th e osteotom y. Th e bon e was
stabilized with an LCP volar colu m n plate 2.4.
a b a b
Fig 5.2-1 7a –bLater in traoperative im ages sh ow th e n al Fig 5.2-18a –b Th e skylin e view dem on strated n o protru sion
xation w ith th e de orm ities corrected. o th e tip o th e screws on th e dorsal aspect o th e radiu s.
395
Pa rt II Case s
Re d u ct io n : o p t io n
Fig 5.2-1 9Th e osteotom y is u su ally per orm ed at th e site Fig 5.2-20 As an altern ative, redu ction can be ach ieved
o th e m axim u m de orm ity. with h yperexten sion o th e wrist u sin g a rolled towel or
bolster.
Fig 5.2-2 1 Fixation an d bon e gra t o th e de orm ity.

colu m n plate.
7 Ou t co m e
a b
Fig 5.2-23a –b At th e 6-m on th ollow-u p, th e x-rays sh owed

th at th e u ln a an d radiu s were equ al in len gth , th ere was
15 degrees o palm ar an gu lation , an d 20 degrees o radial
in clin ation . Th e site o th e osteotom y h ad com pletely
h ealed.
397
Pa rt II Case s
a b
c d
e f
Fig 5.2-2 4a –f At th is stage, th ere w as good u ln ar an d radial deviation , an d

th e patien t cou ld ach ieve excellen t ran ge o m otion .
a b
Fig 5.2-2 5a –b At a later ollow -u p, th e plate w as rem oved

w ith ou t problem s or th e patien t.
5.3 Distal radius—intraarticular malunion treated
with osteotomy and palmar plate
Fig 5.3-1 a – b A 28-year-old salesm an su stain ed a

all on to h is ou tstretch ed h an d. Th e PA an d
lateral x-rays taken im m ediately a ter th e all
sh ow ed a palm ar articu lar sh earin g ractu re an d
palm ar displacem en t w ith an articu lar step-o o
3 m m an d in volvem en t o tw o-th irds o th e
articu lar su r ace. Th ere w as articu lar in con gru ity
at th e lu n ate acet, an d a distan ce betw een th e
palm ar an d dorsal rim o 9 m m , w ith palm ar
su blu xation o th e carpu s eviden t. He w as
in itially provided w ith n on operative treatm en t
a b o a sh ort cast or 6 w eeks.
a b c d
Fig 5.3-2a – d Fou r m on th s a ter th e in itial trau m a, h e presen ted com plain in g o pain , de orm ity, an d
n oticeable lim itation in ran ge o m otion . Th e x-rays taken at th at stage sh ow ed a m alu n ited in traarticu lar
ractu re o th e distal radiu s w ith palm ar su blu xation o th e carpu s an d still w ith articu lar step-o o 3 m m .
399
Pa rt II Case s
Fig 5 .3 -3In th e sagittal view CT scan , th e

palm ar carpal su blu xation w as eviden t.
Th e ractu re w as in com pletely h ealed
w ith both articu lar in con gru ity as w ell as
brou s u n ion at th e distal m argin .
a b c
Fig 5.3-4 a – cA set o 3-D CT scan s o ered en ou gh in orm ation abou t th e de orm ity to
in dicate th e n eed or an osteotom y an d xation .
5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate
2 In d ica t io n s
In t ra a r t icu la r ra d iu s m a lu n io n
Wh ile extraarticu lar m alu n ion o th e distal radiu s is m ore com m on , in traarticu lar m alu n ion in volvin g th e radiocarpal join t
or distal radiou ln ar join t (DRUJ) can also occu r. Articu lar in con gru ity on th e join t su r ace u ltim ately leads to cartilage
degen eration , an d residu al articu lar in con gru ity o greater th an 1 m m will predictably lead to posttrau m atic arth ritis. For
th is reason , a corrective osteotom y sh ou ld be con sidered or an y distal radiu s m alu n ion with join t in volvem en t an d
associated in con gru en ce.
In d ica t io n s fo r s u rge r y in m a lu n it e d in t ra a r t icu la r d is t a l ra d ia l fra ct u re s
Th e ollow in g are in dication s or su rgery:

• An y step-o greater th an 1 m m , as it cau ses articu lar in con gru ity
• Carpu s su blu xation , as it a ects carpal kin em atics an d overall w rist u n ction an d is di cu lt to tolerate by th e patien t
• Malu n ited ractu res th at h ave a relatively sim ple in traarticu lar com pon en t.
Note th at th e osteotom y sh ou ld be per orm ed as early as possible sin ce it can be m ade en tirely th rou gh th e im m atu re
callu s ollow in g th e plan es o th e de orm ity, th u s ach ievin g a m ore an atom ical redu ction o th e articu lar su r ace.
a b c d
Fig 5.3-5 a – d Exam ples o m alu n ited in traarticu lar distal radial ractu res am en able or corrective osteotom y in clu de:
a Malu n ited palm ar sh earin g ractu re w ith palm ar su blu xation o th e carpu s
b Malu n ited dorsal sh earin g ractu re w ith dorsal su blu xation o th e carpu s
c Dorsal die pu n ch ractu res w ith ran k in con gru ity betw een th e sigm oid n otch an d th e h ead o th e u ln a
d Malu n ited radial styloid ractu res w ith ran k radiocarpal in con gru ity.
401
Pa rt II Case s
Co n tra in d ica tio n s fo r su rge ry in m a lu n ite d in tra a rticu la r Im a gin g

d is t a l ra d ia l fra ctu re s
In an in traarticu lar distal radial racture m alun ion , obtainin g
Th e ollowin g are con train dication s or su rgery: th e x-ray o th e in itial in ju ry is especially h elp u l to both
• In volves advan ced posttrau m atic arth ritis u nderstan d th e articu lar in ju ry an d in th e preoperative
• Older patien ts with low dem an d an d/ or m in im al plan n in g o th e osteotom y. Also, a h igh -resolu tion CT with
sym ptom s mu ltiplan ar re ormattin g is help u l to identi y th e racture
• In volves less th an 1 m m articu lar displacem en t plan e, which is possible u pward o 8 to 12 weeks a ter th e
• In volves a com plex de orm ity with both distal radial an d in ju ry. An MRI or wrist arth roscopy m ay play a u se u l role
carpal in ju ries. in evalu atin g th e am ou n t o cartilage dam age.
Eq u ip m e n t

distal radiu s set
• Osteotom e
• Oscillatin g saw
• Poten tial n eed or au togen ou s bon e gra t
a b
Fig 5.3-6 a – b To begin , position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e
orearm ( a ). Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e
distal radiu s. Th e orearm is later placed in a pron ated position or th e dorsal approach ( b ). A n on sterile
pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.
Fig 5.3-7 Two su rgical approach es were u sed to treat th is Fig 5.3-8 Th e secon d su rgical approach u sed was a dorsal
patien t’s in ju ry. First, a m odi ed Hen ry palm ar approach approach (see ch apter 1.8 Dorsal approach to th e distal
was requ ired (see Ch apter 1.6 Modi ed Hen ry palm ar radiu s). With th is dorsal approach , on ly th e th ird exten sor
approach to th e distal radiu s). com partm en t was open ed. Th e in term ediate an d radial
colu m n s were approach ed separately u sin g a sin gle dorsal
skin in cision .
a b
Th rou gh th e m odi ed Hen ry approach , th e palm ar aspect o th e radiu s w as exposed an d th e m alu n ion
Fig 5.3-9 a – b
becam e eviden t ( a ). Th e dorsal approach , ollow ed by a dorsal capsu lotom y o th e join t su r ace, revealed th e exact
location o th e articu lar step ( b ).
403
Pa rt II Case s
5 Re d u ct io n
Os t e o t o m y
a b
c d
Fig 5.3-1 0a –d Th rou gh th e palm ar approach , th e osteotom y w as in itiated u sin g an osteotom e an d w as gu ided th rou gh
th e plan e o th e m alu n ion u sin g th e im age in ten si er.
a b
c d
Fig 5.3-1 1a –d Th e h an d is th en tu rn ed dow n in to pron ation an d th e w rist is f exed over a bolster or layer o tow els to
h elp determ in e th e exact location o th e step-o . Th e osteotom e is u sed to im plem en t th e osteotom y rom distal to
proxim al, an d is gu ided by th e im age in ten si er u n til th e palm ar an d dorsal cu ts m eet an d th e palm ar ragm en t
becom es ree to be redu ced. It is im portan t to leave th e radiocarpal ligam en ts attach ed to th e palm ar ragm en t to avoid
th e risk o carpal in stability. A palm ar capsu lotom y is proh ibited, oth erw ise carpal in stability can develop.
405
Pa rt II Case s
Fig 5.3-1 2 Th e dorsal view allow ed a clearer view o th e Fig 5.3-1 3 To assist in redu ction o th e osteotom y, place a
articu lar step, an d allow s precise placem en t o th e rolled tow el or bolster u n der th e w rist an d h yperexten d
osteotom e to create th e osteotom y. it. Per ect an atom ical redu ction can be ach ieved by direct
m an ipu lation u sin g a den tal pick or a n e h ook.
Alt e rn a t ive : re d u ct io n u s in g p la t e
a b
Fig 5.3-1 4a –b Th e plate can be u sed to pu sh th e palm ar ragm en t to ach ieve redu ction u sin g an appropriate screw
th rou gh th e oblon g plate h ole. Th e redu ction m u st be con rm ed w ith th e u se o im age in ten si cation .
6 Fixa t io n
a b
c d
Fig 5.3-1 5a –d Fixation o th e distal radiu s sh ou ld be per orm ed w ith an appropriate palm ar plate en su rin g it bu ttresses
th e articu lar ragm en ts an d avoids later displacem en t. For th is patien t, stable xation o th e osteotom ized palm ar
ragm en t w as ach ieved u sin g an LCP volar colu m n plate 2.4, w h ich allow ed or early reh abilitation o th e radiocarpal
an d radiou ln ar join ts.
Th e xation procedu re ollow s th e u su al steps o selectin g an d applyin g th e plate, in sertin g distal an d proxim al screw s,
an d in traoperative im agin g. For u rth er in orm ation on th ese steps see ch apter 4.6 Distal radiu s—m u lti ragm en tary
in traarticu lar ractu re treated w ith a palm ar plate.
407
Pa rt II Case s
a b
Fig 5 .3 -16Fin al screw s w ere in serted an d th e distal radiu s Fig 5.3-1 7a –bTh e n al in traoperative im ages sh ow ed th e
xation com pleted. In traoperative im ages sh ow ed correct an atom ical redu ction .
placem en t o th e plate.

colu m n plate.
8 Ou t co m e
a b
Fig 5.3-1 9a –b At th e 4-m on th ollow -u p, th e AP an d

lateral x-rays sh ow ed com plete h ealin g.
a b
c d
Fig 5.3-2 0a –d Th e clin ical ou tcom e resu lted in n o pain an d a good u n ction al resu lt.
409
Pa rt II Case s
In t ra a r t icu la r m a lu n io n t re a t e d w it h o s t e o t o m y a n d a
ra d ia l co lu m n p la t e a n d s cre w s
a b a b
Fig 5.3-2 1a –b A 22-year-old em ale m edical stu den t Fig 5.3-2 2a –b Th e radial CT scan s dem on strated a 2 m m
su ered a ractu re o th e distal radiu s, a pelvis ractu re, articu lar step-o an d displacem en t on su pin ation o th e
an d oth er in ju ries in a m otor veh icle acciden t. A ter radial styloid, both o w h ich w ere cau sin g radiocarpal
in itial treatm en t, sh e w as seen by m edical specialists in con gru ity.
2 m on th s a ter th e in ju ry, an d w h ile h ealin g h ad pro-
gressed w ith h er oth er in ju ries, sh e con tin u ed to h ave
w rist pain an d lim itation in ran ge o m otion . Th e PA an d
lateral x-rays sh ow ed a displaced partially h ealed ractu re
o th e radial styloid h avin g an eviden t displacem en t w ith
radiocarpal in con gru ity.
In d ica t io n s
2 mm
Fig 5.3-23 In con gru en cy on th e join t su r ace o th e radiu s u ltim ately leads
to cartilage degen eration an d th is is especially so wh en th ere is a m alu n ited
radial styloid with a step-o o 2 m m or m ore an d ran k radiocarpal
in con gru ity. For th is reason , a corrective osteotom y an d radial colu m n
plate xation with addition al h eadless com pression screws was con sidered
or th is patien t.
Su rgica l a p p ro a ch

(see ch apter 1.8 Dorsal approach to th e distal radiu s). With
th is dorsal approach , on ly th e th ird exten sor com partm en t
was open ed. Th e in term ediate an d radial colu m n s were
approach ed separately u sin g a sin gle dorsal skin in cision .
a b
Fig 5.3-25a –b Th rou gh a dorsal approach , th e th ird com partm en t was open ed
in lin e with th e exten sor pollicis lon gu s (EPL) ten don in th e exten sor retin acu -
lu m . Th e EPL ten don is reed, protected, an d retracted to th e radial side o th e
wrist. Th e ou rth an d secon d com partm en ts were elevated su bperiosteally,
leavin g both com partm en ts in tact. Th e ou rth com partm en t was retracted
u ln arly an d th e secon d com partm en t radially. Th e lateral colu m n an d part o
th e in term ediate colu m n were exposed. Th e dorsal capsu le was in cised to
expose th e join t, m akin g th e step-o o th e join t su r ace clearly visible. Th e lin e
o th e ractu re was iden ti ed u sin g th e m agn i yin g lou pes.
411
Pa rt II Case s
Re d u ct io n
a b
Fig 5.3-2 6a –b With th e de orm ity n ow in clear view ( a ), u sin g a n arrow osteotom e
an d a sm all cu rette, an osteotom y is per orm ed th rou gh th e im m atu re callu s ( b ).
a b
Fig 5.3-2 7a –b Redu ce th e osteotom ized ragm en t u sin g poin ted redu ction orceps ( a ).
Th en in sert a gu ide w ire rom th e radiu s m etaph ysis in to th e styloid ragm en t as
perpen dicu lar as possible to th e ractu re site ( b ).
Fig 5.3-2 8 Pass an addition al gu ide w ire Fig 5.3-29 Followin g th e osteotom y an d tem porary
across th e ractu re site, gain in g pu rch ase redu ction , provision al xation was per orm ed u sin g th e
in to th e cortex o th e radial styloid. gu ide wires. Redu ction was ch ecked u sin g th e im age
in ten si er an d by direct vision o th e join t su r ace.
Fixa t io n w it h ra d ia l co lu m n p la t e
Fig 5.3-30 An LCP radial colu m n plate 2.4 was placed over
th e radial colu m n . Th e appropriate plate is selected accord-
in g to th e ractu re con gu ration an d con tou red i n eces-
sary. Slide th e plate u n dern eath th e rst com partm en t an d
apply it on to th e radial colu m n . In sert a stan dard cortex
screw in to th e oblon g plate h ole proxim al to th e m alu n ion .
Tigh ten in g th is screw will redu ce th e radial styloid.
413
Pa rt II Case s
In s e r t t h e a d d it io n a l la g s cre w s
a b
Fig 5.3-3 1a –b Usin g gu ide w ires, tw o 3 m m h eadless com pression screw s are in serted
exertin g in ter ragm en tary com pression on th e osteotom y lin e.
In s e r t p ro xim a l a n d d is t a l s cre w s
a b
Fig 5.3-3 2a –b Com plete th e radial colu m n plate xation by

in sertin g proxim al an d distal screw s in to th e plate h oles. Th e
plate in creases stability an d allow s u n restricted early m obility.
Fig 5.3-3 3 In traoperative im ages

sh ow ed th e an atom ical redu ction
an d th e correct placem en t o th e
plates an d screw s.
Fig 5.3-3 4Tw o bon e an ch ors w ere placed on th e dorsal Fig 5.3-3 5Th e dorsal capsu le w as su tu red back on to th e
rim o th e radiu s. dorsal rim o th e radiu s u sin g th e an ch or’s su tu res.
415
Pa rt II Case s
Ou t co m e
a b
Fig 5.3-3 6a –b At th e 3-m on th ollow -u p, th e radiological

im ages in dicated good h ealin g.
a b
c d
Fig 5.3-3 7a –d Th ere w as also an excellen t clin ical ou tcom e or th is aspirin g m edical
pro ession al.
5.4 Distal radius—extraarticular and intraarticular
malunion treated with osteotomy and dorsal
double plating
Fig 5 .4 -1a –b A 27-year-old h ou se clean er h ad a all

w h ile w orkin g yet did n ot presen t or m edical advice
u n til 6 m on th s later. Sh e h ad su ered a com plex
ractu re o h er righ t distal radiu s an d h ad lim ited w rist
an d orearm m otion . Sh e com plain ed o persisten t pain
w ith both w ork-speci c an d n orm al activities o daily
livin g. Th e PA an d lateral x-rays revealed a com bin ed
in traarticu lar an d extraarticu lar distal radial ractu re
a b m alu n ion .
6 mm
a b
Fig 5.4-2a –b Th e axial CT scan sh owed an im paction o th e lu n ate acet with a

6 m m step-o an d gap, an d in traarticu lar in con gru en cy o th e distal radiou ln ar
join t (DRUJ).
417
Pa rt II Case s
35°
a b c
Th e sagittal CT scan sh ow ed 35 degrees dorsal an gu lation du e to th e extraarticu lar

Fig 5.4-3 a – c
m etaph yseal de orm ity. Radial sh orten in g an d su pin ation o th e distal ragm en t w ere also eviden t.
5 .4 Distal radius—e xtraarticular and intraarticular malunion tre ate d with oste otomy and dorsal double plating
2 In d ica t io n s
Co m b in e d in t ra a r t icu la r a n d e xt ra a r t icu la r m a lu n io n
In som e in stan ces ollow in g a distal radial ractu re, a com bin ed in traarticu lar an d extraarticu lar m alu n ion can occu r,
w h ich can adversely a ect both th e radiocarpal an d radiou ln ar join t u n ction s. As discu ssed in th e previou s ch apters in
th is section , de orm ity in volvin g greater th an 1 m m step-o at th e articu lar su r ace, or greater th an 10 degrees o dorsal
an gu lation as a resu lt o extraarticu lar m alu n ion , are in dication s or treatm en t by osteotom y. Both th ese levels o
de orm ity w ere greatly exceeded in th is patien t. Care u l u n derstan din g o th e com pon en t parts o th e m alu n ion is
cru cial to plan n in g th e type an d location o th e osteotom ies.
Im a gin g
1
1
3
2
3
a b
Fig 5.4-4a –c Axial 2-D CT an d 3-D CT scan s

provide a clearer u n derstan din g o th e
1 articu lar in con gru ity an d th e act th at th e
3 articu lar m alu n ion in th is case con sisted o
th ree m ajor com pon en ts. Th ese in clu de both
2 th e dorsal an d lu n ate acets an d th e radial
c styloid.
419
Pa rt II Case s

distal radiu s set
• VA LCP dorsal plates 2.4
• 2.0 m m cortex screw
• Osteotom e

option al.
Ap p ro a ch

(see ch apter 1.8 Dorsal approach to th e distal radiu s).
a b
Fig 5.4-7a –b Th e dorsal exposu re isolated th e exten sor pollicis lon gu s.

Th e posterior in terosseou s n erve was iden ti ed an d section ed.
5 Re d u ct io n
Fig 5.4-8 Osteotom y lin es are plan n ed on to th e bon e

ollow in g th e variou s ractu re pattern s. On ce per orm ed,
th e osteotom ies separate th e dorsou ln ar com pon en t an d
th e m etaph ysis.
421
Pa rt II Case s
Pe r fo rm t h e a r t icu la r co m p o n e n t o s t e o t o m y
a b
Fig 5.4-9 a – bAn osteotom y is rst per orm ed at th e articu lar site. Th e dorsal lu n ate
acet is osteotom ized an d retracted distally. Th is w ill n ow expose th e back o th e
palm ar lu n ate acet an d displaced radial styloid ( a ). K-w ires are in trodu ced in to th e
palm ar lu n ate acet an d radial styloid com pon en ts to be later u sed as joysticks ( b ).
Pe r fo rm t h e m e t a p h ys e a l co m p o n e n t o s t e o t o m y
a b
Fig 5.4-1 0a –b An osteotom y is th en per orm ed at th e site o th e m etaph yseal m alu n ion ( a ). Note th at it is
im portan t to release th e attach m en t o th e brach ioradialis to gain realign m en t or adequ ate len gth o th e
articu lar com pon en t. Th e osteotom y is open ed u sin g a lam in ar spreader an d th e dorsal m etaph yseal de orm ity
redu ced leavin g a gap in th e m etaph yseal area o th e bon e ( b ).
Bo n e gra ft
Iliac crest
Fig 5.4-11 Th e K-wire is rem oved rom th e palm ar lu n ate Fig 5.4-1 2 Harvest th e corticocan cellou s gra t m aterial
acet an d th e dorsal lu n ate acet is reposition ed an d h eld rom th e iliac crest.
with a K-wire th rou gh both lu n ate acet ragm en ts. Th e
redu ction o both th e articu lar an d m etaph yseal de orm ities
are tem porarily h eld with K-wires.
Ha r ve s t in g b o n e w e d ge
2–4 cm
a b
Fig 5.4-1 3a –b Expose th e crest over a 2–4 cm segm en t an d m ark ou t th e preplan n ed gra t
size to be h arvested ( a ). Con sider th e sh ape an d size o th e de ect in th e distal radiu s an d
h ow th e gra t w ill ll th e de ect created by th e osteotom y ( b ). Harvest th e selected gra t
u sin g a sh arp osteotom e. Con trol bleedin g w ith a w ou n d pack an d u se a sm all su ction
drain i n ecessary. Close th e skin an d apply a pressu re dressin g.
423
Pa rt II Case s
a b
Fig 5.4-1 4 On ce th e optim al an atom ical position is Fig 5.4-1 5a –b In traoperative im ages sh ow th e correction
ach ieved, th e parts are tem porarily xated an d th e iliac o both th e in traarticu lar an d extraarticu lar m alu n ion s
crest bon e w edge is in trodu ced in to th e m etaph yseal an d th eir tem porarily stabilization w ith K-w ires.
osteotom y site.
6 Fixa t io n
Fixa t io n o f a r t icu la r co m p o n e n t s
Fig 5.4-1 6It m ay be n ecessary to x th e articu lar

com pon en ts w ith a radially in serted 2.0 m m lag screw .
Fixa t io n o f in t e rm e d ia t e co lu m n Fixa t io n o f ra d ia l co lu m n
Fig 5.4-1 7 To xate th e m etaph ysis, tw o plates are placed Fig 5.4-1 8 To com plete th e xation , a straigh t plate w as
on th e dorsal side. First, th e in term ediate colu m n m u st be u sed or th e radial colu m n .
su pported by a su itable in term ediate colu m n dorsal plate.
For th is patien t, a straigh t plate w as u sed. Th e xation procedu re ollow s th e u su al steps o select-
in g, con tou rin g, an d applyin g th e plate, an d in sertin g
Th e xation procedu re ollow s th e u su al steps o selectin g, proxim al an d distal screw s; h ow ever on th is occasion , th e
con tou rin g, an d applyin g th e plate, an d in sertin g proxim al plate w as placed m ore adjacen t to th e in term ediate
an d distal screw s. For u rth er in orm ation on th ese steps colu m n plate on th e dorsal side.
see th e xation o in term ediate colu m n topic in ch apter
4.5 Distal radiu s—dorsally displaced in traarticu lar ractu re
treated with dou ble platin g.

colu m n plate.
425
Pa rt II Case s
8 Ou t co m e
a b
Fig 5.4-2 0a –bAt th e 1-year ollow -u p th e

osteotom ies w ere sh ow n to be h ealed.
a b c d
Fig 5.4-2 1a –d At an 11-year ollow -u p th e im plan ts w ere electively rem oved.
a b
c d
e f
Fig 5.4-2 2a –f Th e patien t h ad excellen t u n ction an d ran ge o m otion , w ith n o w rist arth ritis.
427
Pa rt II Case s
5.5 Rheumatoid arthritis treated with radiolunate
arthrodesis
a b a b c
Fig 5.5-1a –b A 60-year-old em ale beau ty Fig 5.5-2a –c Th e CT scan s dem on strated on goin g arth ritis
th erapist presen ted com plain in g o progressive with radiolu n ate join t space n arrowin g, u ln ar tran slation
pain an d u n ction al lim itation in h er le t wrist (displacem en t in an u ln ar direction ) o th e carpu s, an d
a ter su erin g rh eu m atoid arth ritis or 15 years. cystic ch an ges at th e radiolu n ate articu lation .
Th e PA an d lateral x-rays revealed join t space
n arrowin g at th e radiolu n ate join t an d th e distal
radiou ln ar join t (DRUJ).
Fig 5.5-3 Th e 3-D CT scan s u rth er

in dicated th e u ln ar tran slation o
th e carpu s.
429
Pa rt II Case s
2 In d ica t io n s
Wris t d ys fu n ct io n fro m rh e u m a t o id a r t h rit is
a b
Norm al joints Arthritic joints
Fig 5.5-4a –b Rh eu m atoid arth ritis is a w ell-recogn ized problem w h ere th e body’s ow n im m u n e system starts to attack
th e join ts. O ten a ectin g th e h an d an d w rist, it resu lts in in f am m ation , pain , an d sti n ess an d th icken in g in th e
a ected join ts, an d m ay even even tu ally a ect th e m ajor organ s. In itial treatm en t can in clu de m edication s, steroids, an d
su pport braces or im m obilization , bu t severe cases can be treated w ith su rgical treatm en t to repair or u se th e join ts.
Sym ptom atic w rist dys u n ction o an y etiology can requ ire recon stru ction , an d salvage procedu res are requ en tly th e
on ly w ay to o er th e patien t a stable pain - ree w rist. A n u m ber o su rgical option s th at ideally preserve m otion an d
avoid com plication s in th e lon g term can be con sidered:
• Lim ited w rist arth rodesis
• Proxim al row carpectom y (w h ich is con train dicated in th is case becau se th e rh eu m atoid arth ritis a ects th e lu n ate
acet o th e distal radiu s)
• Arth roplasty (in volvin g replacem en t o th e w rist join t)
• Total w rist arth rodesis.
Lim it e d w ris t a r t h ro d e s is
A lim ited w rist arth rodesis in volves th e su rgical u sion o a selection o bon es in th e w rist depen din g on th e exten t o
th e a ected area. Th e u ltim ate goals o a lim ited w rist arth rodesis in clu de elim in atin g pain th at is related to th e join ts
th at h ave ocal arth ritis w h ile sim u ltan eou sly preservin g as m u ch m otion as possible th rou gh th e rem ain in g articu lar
su r aces. Frequ en tly, th e radiolu n ate or radioscaph oid join ts are in volved an d sign i can t pain an d de orm ity are n oted.
In som e cases (as w ill be seen in th e altern ative tech n iqu es later in th is ch apter) th e partial or u ll rem oval o an
a ected carpal is n ecessary in an attem pt to preserve u n ction al m otion .
5 .5 Rheumatoid arthritis tre ate d with radiolunate arthrode sis
Ra d io lu n a t e a r t h ro d e s is Im a gin g
X-rays an d CT scan s an d laboratory testin g m ay su pport

an in itial diagn osis o rh eu m atoid arth ritis. Th ey m ay also
h elp to exclu de oth er diseases w ith sim ilar sym ptom s.
a b c
Fig 5.5-5a –c A radiolu n ate arth rodesis is a lim ited wrist

arth rodesis procedu re in dicated wh en th ere is palm ar or
u ln ar tran slation o th e carpu s or localized radiolu n ate
arth ritis ( a ), com m on ly seen in patien ts with rh eu m atoid
arth ritis bu t also n oted in th ose with die pu n ch ractu res
with in th e lu n ate ossa. For th is patien t, a lockin g com pres-
sion plate (LCP) distal u ln a (h ook) plate was placed in to th e
dorsal rim o th e lu n ate at on e en d an d to th e radiu s at th e
oth er, u sin g th e segm en ts togeth er ( b –c ).
• LCP distal u ln a plate 2.0

• Bon e n ibbler/ ron geu r

431
Pa rt II Case s
Ap p ro a ch
Fig 5.5-7 Th e su rgical approach u sed w as a dorsal Fig 5.5-8 Th e dorsal capsu le o th e le t w rist
approach (see ch apter 1.8 Dorsal approach to th e distal w as open ed in a T- ash ion , exposin g th e
radiu s). Th e in cision w as th rou gh th e th ird exten sor radiolu n ate join t. Note th e absen ce o
com partm en t. h yalin e cartilage on th e lu n ate.
5 Re d u ct io n
Bo n e gra ft
Lister tubercle
a b
Fig 5.5-9 Harvest gra t m aterial rom th e distal radiu s or Fig 5.5-10a –b Th rou gh th e existin g dorsal approach ,
later in sertion in to th e a ected w rist join ts. A good an d an d with th e exten sor ten don s retracted radially an d
sa e place is proxim al an d sligh tly radial to Lister tu bercle. u ln arly, th e Lister tu bercle was u sed as a sou rce o
Wh en h arvestin g, retract th e ten don s o th e secon d au togen ou s bon e gra t.
com partm en t radially an d th e exten sor pollicis lon gu s in
an u ln ar direction .
Re d u ce t h e lu n a t e a n d in s e r t t h e gra ft
Fig 5.5-11 A ter decortication o th e articu lar su r aces a b

o both th e lu n ate an d lu n ate ossa, an d placin g th e
au togen ou s bon e gra t betw een th e join t su r aces, th e Fig 5.5-1 2a –bTh e PA an d lateral in traoperative im ages
lu n ate is redu ced an d provision ally h eld with a sh ow th e placem en t o th e K-w ire. Th e lu n ate is
K-w ire. redu ced in n eu tral position .
6 Fixa t io n
a b c
Fig 5.5-1 3a –c In sert th e h ook plate. Th e plate adapts w ell to th e

radiolu n ate articu lation . Th e h ooks are placed in to th e dorsal
rim o th e lu n ate. On ce applied, th e h ook plate w ill be w ell
seated an d avoids th e lu n ocapitate join t. Take great care th at
th e h ooks o th e h ook plate do n ot orce th e lu n ate in to
exten sion . A tem porary radiolu n ate K-w ire can preven t th is.
433
Pa rt II Case s
In s e r t s cre w s
a b c
Fig 5.5-1 4a –cAn gu lar stable screw s are u sed to x th e plate to both th e lu n ate an d radiu s m etaph ysis. Th e m ost distal
screw is directed proxim ally in to th e distal radiu s an d placed u n der com pression .
a b
Fig 5.5-1 5a –b On e lockin g screw w as in serted in to

th e lu n ate an d a lag screw w as also placed th rou gh
th e lu n ate an d w as th readed on th e palm ar cortex
o th e radiu s.

colu m n plate.
8 Ou t co m e
a b
a b c d
Fig 5.5-17a –b At a ollow-u p approxim ately 6 m on th s a ter Fig 5.5-1 8a –d Fu ll orearm rotation w as ach ieved bu t
su rgery, th e AP an d lateral x-rays sh owed excellen t u sion . w ith som e lim itation o w rist f exion an d exten sion .
How ever, th e patien t w as com pletely pain ree.
435
Pa rt II Case s
9 Alt e rn a t ive t e ch n iq u e 1
Ra d io s ca p h o lu n a t e a r t h ro d e s is
a b c
Fig 5.5-1 9a –c A radioscaph olu n ate arth rodesis is a lim ited w rist arth rodesis procedu re in dicated or
patien ts w ith degen erative join t disease th rou gh ou t th e radiocarpal join t ( a ). It in volves th e en tire
join t su r ace. Th e x-ray an d CT scan s sh ow radiocarpal osteoarth ritis on a righ t h an d ollow in g a
m alu n ited in traarticu lar distal radial ractu re ( b – c ). Note th at th e cartilage o th e m idcarpal join t
w as n ot dam aged, w h ich is a prerequ isite to in dicate th is tech n iqu e.
Fixa t io n a n d o u t co m e
a b c
Fig 5.5-2 0a –c Th e radioscaph olu n ate arth rodesis in volved th e placem en t o tw o 3.0 m m
h eadless com pression screw s com in g rom th e radiu s, on e in to th e scaph oid an d on e
in to th e lu n ate. At th e 5-year ollow -u p, PA an d lateral x-rays sh ow ed excellen t u sion ,
an d th e patien t sh ow ed pain less u n ction al w rist m otion . Clin ical m otion (f exion an d
exten sion ) can be seen in th e lateral x-rays.
Ra d io s ca p h o lu n a t e a r t h ro d e s is w it h re s e ct io n o f t h e d is t a l h a lf o f t h e s ca p h o id
a b
Fig 5.5-21a –b Th e CT scan s o th is patien t dem on strate

arth ritic in volvem en t o both th e radiolu n ate an d radioscaph -
oid join t as sequ elae o a m alu n ited distal radial ractu re
in itially treated by closed redu ction an d percu tan eou s xation .
Th e cartilage o th e m idcarpal join t was n ot dam aged. Note th e
palm ar su blu xation o th e carpu s in th e lateral view an d a gap
o 4–5 m m in th e distal radial articu lar su r ace. Fu rth er
treatm en t with a radioscaph olu n ate arth rodesis was requ ired.
a b c
Fig 5.5-22a –c Wh en th e radiocarpal join t u n dergoes a u sion procedu re, th e wrist’s ran ge o m otion is
con siderably redu ced, o ten as m u ch as 50% . For th is reason , rem oval o th e distal h al o th e
scaph oid is som etim es recom m en ded to im prove m otion th rou gh th e m idcarpal join t ( a ). Fixation
can in volve screws in serted in a cross orm ation ( b ) or com in g parallel rom th e radial styloid ( c ).
437
Pa rt II Case s
Fixa t io n a n d o u t co m e
a b
Fig 5.5-2 4a –bA good ran ge o m otion w as ach ieved by

a b th e 7-year ollow -u p.
Fig 5.5-2 3a –b Treatm en t in volved rem oval o th e distal

h al o th e scaph oid alon g w ith in sertion o tw o 3.5 m m
screw s w ith w ash ers an d a K-w ire. Th e PA view x-ray
sh ow s total h ealin g o th e u sion 4 m on th s a ter su rgery
( a ). Note th at th e n orm al relation sh ip betw een th e
scaph oid an d lu n ate w as preserved in order to m ain tain
th e con gru en cy o th e m idcarpal join t. Solid u sion is
sh ow n at 6 m on th s ollow in g su rgery ( b ). Th e screw rom
th e radiu s in to th e scaph oid w as rem oved at th at tim e
becau se o ten don irritation .
5.6 Kienbock’s disease treated with total wrist
arthrodesis
a b c d
Fig 5.6-1a –d A 47-year-old righ t-h an d dom in an t taxi driver experien ced a m ildly pain u l wrist or 3 years u n til h e
su ered a torsion al in ju ry li tin g a h eavy object (car wh eel). His wrist pain becam e extrem e. Th e PA an d lateral x-rays
sh owed Kien bock´s disease stage IIIB with severe lu n ate collapse an d osteoporosis ( a –b ). Th e MRIs con rm ed th e
diagn osis, with loss o vascu larization an d collapse o th e lu n ate bein g eviden t ( c–d ).
Th e clin ical exam in ation revealed n oticeable swellin g o th e wrist an d lim ited m otion . He h ad on ly 10 degrees o wrist
exten sion an d 5 degrees o f exion , with on ly 10 degrees o u ln ar deviation an d absen ce o radial deviation . Grip
stren gth in th e a ected h an d h ad allen m arkedly to ju st 15.5 kg (average grip stren gth or th e n orm al popu lation at
th e sam e age was 52 kg).
439
Pa rt II Case s
2 In d ica t io n s
Kie n b o ck ’s d is e a s e (a va s cu la r n e cro s is o f t h e lu n a t e )
a b c
Stage I Stage II Stage IIIA
d e
Stage IIIB Stage IV
Fig 5.6-2 a – e Kien bock’s disease is a disorder th at in volves n ecrosis o th e lu n ate an d its poten tial even tu al collapse. It
resu lts rom an in terru ption o blood su pply to th e lu n ate cau sed by an y n u m ber o actors, bu t typically in volvin g an
in itial trau m a to th e w rist. Th e exten t o collapse an d ragm en tation o th e lu n ate can be u sed to h elp classi y th e
disorder, as ollow s:
• Stage I: Norm al lu n ate ractu re
• Stage II: Sclerosis o th e lu n ate w ith ou t collapse
• Stage IIIA: Lu n ate collapse an d ragm en tation in addition to proxim al m igration o th e capitate
• Stage IIIB: Lu n ate collapse an d ragm en tation in addition to proxim al m igration o th e capitate plu s xed f exion
de orm ity o th e scaph oid
• Stage IV: Degen eration arou n d th e lu n ate w ith radiocarpal an d m idcarpal arth ritic ch an ges.
Sym ptom atic w rist dys u n ction o an y etiology can requ ire recon stru ction , an d salvage procedu res are requ en tly th e
on ly w ay to o er th e patien t a stable pain - ree w rist. A n u m ber o su rgical option s th at ideally preserve m otion an d
avoid com plication s in th e lon g term can be con sidered:
• Lim ited w rist arth rodesis
• Proxim al row carpectom y
• Arth roplasty
• Total w rist arth rodesis.
5 .6 Kie nbock’s dise ase tre ate d with total wrist arthrode sis
To t a l w ris t a r t h ro d e s is Ch o ice o f im p la n t
Short curvature
a
Standard curvature
b
Straight
c
Optional
Fig 5.6-4a –c A wrist u sion plate with sh ort or stan dard
Mandatory cu rvatu re (or in som e in dication s n o ben d at all) is th e
im plan t o ch oice. Th e precon tou red cu rved plates redu ce
Fig 5.6-3 A total w rist arth rodesis in volves th e total th e n eed or in traoperative ben din g to ollow th e n atu ral
u sion o th e radiocarpal an d m idcarpal join ts. Th is is a con tou rs o th e wrist. Th e plate also places th e h an d in an
salvage procedu re w h ere th e patien t h as lost u n ction al optim al position . Th e design o th e cu rved wrist u sion
w rist m otion or su ers persisten t an d u n relen tin g pain plates places th e radiu s in 10 degrees exten sion , wh ich is
an d exten sive in tercarpal arth ritis. Th e u ltim ate goal is a ideal as th e goal is to ach ieve th e arth rodesis with th e wrist
pain - ree an d stable w rist w ith restoration o u n ction al in 10 degrees o exten sion an d 15 degrees o u ln ar devia-
grip stren gth . tion . For th is patien t, th e sh ort cu rved plate was selected.
• Lockin g com pression plate (LCP) w rist u sion set

• Wrist u sion plate 2.7/ 3.5
• Osteotom e

441
Pa rt II Case s
Ap p ro a ch
Fig 5.6-6 Th e su rgical approach u sed w as a dorsal approach

(see ch apter 1.8 Dorsal approach to th e distal radiu s). With
th is dorsal approach , th ere w as a straigh t lon gitu din al in cision
betw een th e th ird an d ou rth exten sor com partm en ts.
Fig 5.6-7a –b A straigh t dorsal

lon gitu din al in cision was m ade
( a ). Th e dorsal side o th e wrist
a ter lon gitu din al capsu lar
a b open in g ( b ).
Fig 5.6 -8 Ch on dral debridem en t

o th e radiocarpal an d m idcarpal
join ts w as u n dertaken u n til
reach in g bleedin g su r aces.
5 Re d u ct io n
Bo n e gra ft
Lister tubercle
a b
Fig 5.6-9 a – b Harvest gra t m aterial rom th e distal radiu s or later in sertion in to th e a ected
w rist join ts. On th is occasion , Lister tu bercle an d th e dorsal h al o th e distal radiu s w ere
rem oved or u se as bon e gra t m aterial.
H
M L
R
S
Optional
a Mandatory b
Join ts to u se (below ):
R: Radiu s
L: Lu n ate
S: Scaph oid
C: Capitate
H: Ham ate
M: Th ird m etacarpal
Fig 5.6-1 0a –b Expose an d prepare th e join t su r aces to be in clu ded in th e u sion . Th en distribu te th e
can cellou s bon e gra t th rou gh ou t th e radiocarpal an d m idcarpal join ts to en h an ce th e u sion procedu re.
443
Pa rt II Case s
6 Fixa t io n
Fig 5.6-1 1In sert th e w rist u sion plate th rou gh th e

approach an d position th e plate directly over th e th ird
m etacarpal distally an d th e radiu s proxim ally.
Me a s u re s cre w d e p t h
a b
Fig 5.6-12a –c Place th e drill gu ide in th e rst

(m ost distal) h ole an d drill with a 2.0 m m drill
bit to th e desired len gth . Rem ove th e drill an d
c drill gu ide an d m easu re or screw len gth .
In s e r t d is t a l s cre w s
1 3 2
Fig 5.6-1 3 In th is procedu re, 2.7 m m com pression or a

lockin g screw s are u sed or th e distal en d o th e plate,
goin g in to th e capitate or m etacarpals. Larger 3.5 m m
com pression or lockin g screw s are u sed or th e radiu s.
In sert th e 2.7 m m distal screw s rst (w ith recom m en ded
sequ en ce o screw in sertion sh ow n ).
Fig 5.6-1 4a –b In traoperative im ages sh ow th e 2.7 m m

lockin g screw s bein g placed in to th e th ird m etacarpal.
Me a s u re a n d in s e r t s cre w in t o t h e ca p it a t e
a b
Fig 5.6-15a –b Determ in e screw len gth an d in sert a 2.7 m m lockin g screw th rou gh th e cen tral plate h ole in to th e capitate.
445
Pa rt II Case s
6 Fixa t io n
Align p la t e a n d m e a s u re p ro xim a l s cre w d e p t h
Fig 5.6-1 6 Th e distal xation in to th e th ird m etacarpal Fig 5.6-17 Align th e plate over th e radiu s. Place th e
an d capitate is sh ow n . drill gu ide in th e th ird m ost proxim al h ole an d drill
with a 2.5 m m drill bit to th e desired len gth . Th is will
becom e screw n u m ber 5. Rem ove th e drill an d drill
gu ide an d m easu re or screw len gth . Veri y with
6 5 7 8
Fig 5.6-18 Th e 3.5 m m com pression or lockin g screws are

n ow u sed or in sertion in to th e radiu s (with recom m en ded
sequ en ce o screw in sertion sh own ). Th e th screw can be
Fig 5.6-1 9 Th e in traoperative im age sh ow s a 3.5 m m
applied as a com pression screw in order to apply th e plate
lockin g screw bein g placed in to th e radiu s.
toward th e dorsal cortex o th e radiu s.
a b
Fig 5.6-2 0a –b Local bon e gra t rom th e earlier debridem en t w as in serted in to th e area to com plete th e xation .

colu m n plate.
447
Pa rt II Case s
8 Ou t co m e
a b b
Fig 5.6-22a –b At th e 13-week ollow-u p, Fig 5.6-23a –b A ter a period o 6 m on th s ollowin g

th e x-rays sh owed th e total wrist wrist u sion su rgery, th e patien t retu rn ed to h is job
arth rodesis was com plete with u ll as a taxi driver. At th e 5-year ollow-u p, h e n oted
in tegration o th e bon e gra t. occasion al discom ort with stren u ou s activity, bu t
gen erally good ran ge o m otion ( a –b ), an d grip
stren gth th at h ad im proved to 46.5 kg. He h ad a
patien t satis action ratin g o 9 (VAS: 0-10).
Vid e o
Vid e o 5.6-1Th is video dem on strates a wrist

arth rodesis with a wrist u sion plate.
5.7 Malunited fracture with associated ulnar
abutment syndrome treated with an ulnar
shortening osteotomy
a b c
Fig 5.7-1a – c A 64-year-old m an su stain ed a closed ractu re o h is n on dom in an t le t distal radiu s a ter a all. Th e
ractu re w as m an aged n on operatively in a sh ort arm cast or 6 w eeks an d h ealed w ith a m in or loss o radial len gth .
Follow in g n on operative treatm en t, n ew PA x-rays sh ow ed positive u ln ar varian ce o 2 m m an d an avu lsion o th e tip

o th e u ln ar styloid ( a ). Forearm rotation becam e in creasin gly pain u l an d lim ited h is ability to u lly pron ate. New
MRI scan s revealed edem atou s ch an ges in th e u ln ar corn er o th e lu n ate an d th e opposin g part o th e u ln ar h ead
( b – c ), w h ich w ere th e resu lt o on goin g im pact betw een th e u ln a an d th e lu n ate.
449
Pa rt II Case s
2 In d ica t io n s
Ra d io u ln a r le n g t h d is cre p a n c y a n d u ln a r a b u t m e n t s yn d ro m e
A m in or degree o radiou ln ar len gth discrepan cy is n ot u n com m on a ter a h ealed distal radial ractu re, h owever, en du rin g
sym ptom s are u n u su al. In th is case, relative len gth en in g o th e u ln a (as a con sequ en ce o radial sh orten in g) h as resu lted in
redu ced orearm rotation (du e to distal radiou ln ar join t [DRUJ] su blu xation ), an d u ln ar sided wrist pain . Patien ts com plain
th at u ln ar sided wrist pain is worse in u ll pron ation an d f exion . Th ere is o ten a redu ced ran ge o total orearm rotation
com pared with th e n orm al side. For th is patien t, in itial m an agem en t with rest, splin t im m obilization , an d steroid in jection s
h ad ailed to resolve th e sym ptom s, so an u ln ar sh orten in g osteotom y was recom m en ded.
Uln ar abu tm en t (or u ln ar im paction ) syn drom e is cau sed by excessive im pact betw een th e u ln a an d its closest carpals,
typically th e lu n ate, an d o ten as a resu lt o positive u ln ar varian ce. Th e con dition can ran ge rom sim ple w ear pattern s,
to trian gu lar brocartilage com plex per oration , to advan ced cases w ith u ln ocarpal osteoarth ritis.
Uln a r va ria n ce Im a gin g
2 mm
- 2 mm
a b
Positive variance Ne gative variance
Fig 5.7-2a –b Variation in relative len gth o th e distal Fig 5.7-3 Plain x-rays in a stan dardized position sh ou ld
articu lar su r aces o th e u ln a an d radiu s is described as be taken . For best resu lts, seat th e patien t an d place th e
u ln ar varian ce. Wh en th e articu lar su r ace o th e u ln a is a ected arm w ith 90 degrees o abdu ction at th e sh ou l-
m ore distal com pared with th e articu lar su r ace o th e der, f exed 90 degrees at th e elbow , w ith th e arm lyin g in
radiu s th ere is positive u ln ar varian ce ( a ), an d a m ore n eu tral orearm rotation .
proxim al u ln ar len gth resu lts in n egative u ln ar varian ce ( b ).
Varian ce o 2 m m or greater typically requ ires operative
treatm en t. Th e varian ce can be assessed in a variety o ways
radiologically bu t it is m an datory to obtain a com parison
x-ray o th e u n in ju red side to ju dge th e relevan ce o th e
radiological m easu rem en ts.
5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy
Ach ie vin g s h o r t e n in g
a b c
Wh en treatin g radiou ln ar len gth discrepan cies th rou gh u ln ar sh orten in g, th e procedu re can be ach ieved by:
Fig 5.7-4a –c
• Rem ovin g a portion o bon e rom th e u ln ar h ead (w a er resection ) via open or arth roscopic su rgery
• Or by sh orten in g th e bon e th rou gh a distal diaph yseal osteotom y (u ln ar sh orten in g osteotom y).
A w a er resection does n ot address su blu xation o th e DRUJ an d is in dicated in prim ary u ln ocarpal abu tm en t rath er th an
secon dary abu tm en t created by radial sh orten in g. A w a er resection rem oves th e term in al portion o th e u ln ar h ead bu t
accu rate resection o a preplan n ed am ou n t is di cu lt to ach ieve. How ever, th e DRUJ is n ot distu rbed ( a ).
An u ln ar sh orten in g osteotom y can be per orm ed precisely an d allow s an exact resection , produ cin g an accu rate am ou n t
o sh orten in g ( b ). In appropriate cases, th e DRUJ can be realign ed. A straigh t plate is u sed to stabilize th e osteotom y.
Altern atively, an obliqu e osteotom y creates a larger su r ace area or bon e u n ion an d also stabilizes rotation o th e
ragm en ts, preven tin g a rotation al m alu n ion ( c ). An obliqu e osteotom y also h as advan tages in applyin g in tern al xation .
A straigh t plate is again u sed to stabilize th e osteotom y bu t w ith a lag screw bein g passed perpen dicu larly across th e
osteotom y site. An obliqu e osteotom y w as ch osen or th is patien t.
A lockin g com pression plate (LCP) u ln a osteotom y system 2.7 an d a straigh t plate can be u sed to create an exact
preplan n ed am ou n t o sh orten in g an d to produ ce stable xation .
451
Pa rt II Case s
• LCP u ln a osteotom y set

• LCP u ln a osteotom y plate 2.7

ron tal an d sagittal plan e o th e distal u ln a an d radiu s. A
Ap p ro a ch
Fig 5.7-6 Th e su rgical approach u sed w as an u ln ar Fig 5.7-7 Th e approach w as m ade via a lon gitu din al
approach (see ch apter 1.10 Uln ar approach to th e in cision over th e distal su bcu tan eou s border o th e u ln a.
distal u ln a).
Fig 5.7-8 Th e f exor carpi u ln aris (FCU) is retracted toward

th e radial side. Th is protects th e u ln ar n eu rovascu lar bu n dle
an d reveals th e f at su r ace o th e distal u ln ar diaph ysis.
453
Pa rt II Case s
5 Re d u ct io n
In s e r t t h e s h o r t e n in g gu id e
a b
c d
Fig 5.7-9a –d Th e correct sh orten in g gu ide is selected based on th e plan n ed am ou n t o sh orten in g (2 m m in th is case).
Th e sh orten in g block is placed on th e f attest part o th e distal u ln a ( a –b ). Th e gu ide is attach ed to th e distal u ln a u sin g
K-wires th at m u st pen etrate both cortices ( c–d ). In traoperative x-rays are taken to en su re correct align m en t.
Se le ct t h e cu t t in g b lo ck a n d a n gle a n d p e r fo rm t h e o s t e o t o m y
a b
c d
Fig 5.7-1 0a –d Th e appropriate cu ttin g block is selected (in th is case, an obliqu e osteotom y h ad been plan n ed) an d
applied to th e sh orten in g gu ide ( a – b ). Th e preplan n ed osteotom y is m ade u sin g parallel saw blades o th e preselected
size (2 m m ) ( c– d ). Th e saw blades m u st cu t th e ar cortex u lly to en able a n eat apposition o th e osteotom y su r aces.
Fig 5.7-1 1 Th e slice o resected bon e w as excised an d th e

gu ide block w as th en rem oved.
455
Pa rt II Case s
6 Fixa t io n
Se le ct a n d in s e r t t h e p la t e
a b c
Fig 5.7-1 2a –c Th e plate is selected an d in trodu ced over th e K-w ires an d pu sh ed dow n on to th e su r ace o th e
bon e ( a –b ). Rotation al align m en t is m ain tain ed by virtu e o th e K-w ires ( c ).
In s e r t s cre w s
a b
Fig 5.7-13a –b Th e im plan t m u st be stabilized by sequ en tially rem ovin g each K-wire an d replacin g it with a cortex screw.
a b
Fig 5.7-1 4a –b Tw o distal screw s w ere in serted rst, w h ich secu red th e align m en t o th e plate on to th e
bon e su r ace ( a ). Be ore rem ovin g th e proxim al K-w ire, a plate redu ction clam p w as applied to
tem porarily stabilize th e position o th e im plan t on th e proxim al part o th e osteotom y ( b ).
Fig 5.7-1 5 Th e proxim al screw w as in serted an d

tigh ten ed an d th e osteotom y gap closes in to
com pression . It is critical to com press in to th e
axilla o th e obliqu e osteotom y or stability.
457
Pa rt II Case s
In s e r t la g s cre w
b c
Fig 5.7-16a –c A cortex screw is in serted th rou gh th e plate as a lag screw to u rth er com press th e osteotom y
an d im prove its stability.
In s e r t lo ck in g s cre w s
a b
Fig 5.7-1 7a –b Lockin g screw s are in serted at each en d o th e im plan t on ce u ll com pression h as been ach ieved.
a b c
Intraoperative images con rmed th e correct placemen t o th e implan t and correct len gth o th e lag screw.
Fig 5.7-18a –c
Veri cation o the amou n t o u ln ar sh orten ing ach ieved sh ould be per ormed.
a b

459
Pa rt II Case s

colu m n plate.
8 Ou t co m e
a b
a b c d
Fig 5.7-21a –b At th e 6-m on th ollow-u p, th e Fig 5.7-22a –d Th e patien t h ad obtain ed excellen t ran ge o m otion ,
x-ray an d CT scan im ages con rm ed radio- an d with th e u ln a/ lu n ate abu tm en t resolved, was pain ree.
logical u n ion .
Th is video dem on strates an u ln ar sh a t

Vid e o 5 .7 -1
treated w ith an obliqu e sh orten in g osteotom y u sin g th e
LCP u ln a osteotom y system 2.7.
Uln a r s h o r t e n in g u s in g a s t a n d a rd d yn a m ic
co m p re s s io n p la t e
a b
Fig 5.7-2 3a –b A stan dard dyn am ic com pression plate

(DCP) or lim ited con tact LC-DCP 3.5 can be u sed in stead
o th e u ln ar sh orten in g system . Th e osteotom y is created
reeh an d, eith er tran sverse or (as sh ow n h ere) obliqu ely.
Th e im plan t m u st be preben t to produ ce com pression on
th e ar cortex an d an obliqu e osteotom y m u st be plan n ed
so th at com pression can occu r in to th e axilla.
461
Pa rt II Case s
Me t a p h ys e a l u ln a r s h o r t e n in g u s in g a d is t a l u ln a p la t e
a b c d
Fig 5.7-24a –d Th e prin ciple an d altern ative tech n iqu es described in th is ch apter so ar h ave in volved osteotom ies in th e
diaph ysis, wh ere cortical bon e is th ick an d can cellou s su r ace area is lim ited. Con sequ en tly, h ealin g can be slow. Yet, th e
distal u ln ar m etaph ysis h as a large can cellou s su r ace area with th in cortical bon e, an d so a m ore distally placed osteotom y
sh ou ld h eal m ore qu ickly as a resu lt.
A 39-year-old m ach in e operator with lon g stan din g pain at th e u ln ar side o th e le t wrist h ad u n dergon e u n su ccess u l
n on operative treatm en t. Th e 2-D an d 3-D CT scan s sh owed th e in con gru ity o th e distal u ln ar join t ( a –b ). Bon e scan s
sh owed in creased u ptake o tech n etiu m n u cleotide (an d th ere ore abn orm alities) arou n d th e DRUJ ( c–d ).
10 Alt e rn a t ive t e ch n iq u e 2 (co n t )
Se le ct t h e p la t e De t e rm in e t h e le ve l o f va ria n ce
2 mm
a b
Fig 5.7-25a –b As selected or th is patien t, th e distal u ln a Fig 5.7-2 6 Th e rst step is to assess an d determ in e th e
(h ook) plate, with its lockin g screws on both sides o th e level o varian ce. For th is patien t th ere w as 2 m m o
osteotom y (wh ich is created reeh an d in eith er a tran sverse positive u ln ar varian ce.
or obliqu e ash ion ), provides excellen t stability or th is
m ore distally placed procedu re.
Ap p ly t h e p la t e Pe r fo rm t h e o s t e o t o m y
2 mm
Fig 5.7-2 7 Th e plate is applied w ith th e h ook over th e Fig 5.7-28Th e plate an d screws are rem oved an d a 2 m m
u ln ar styloid, an d tem porary xation is m ade w ith tw o wa er o bon e is resected rom th e distal u ln ar m etaph ysis.
screw s in to th e u ln ar h ead.
463
Pa rt II Case s
Re a p p ly t h e p la t e
a b
Fig 5.7-2 9a –b In traoperative im ages sh ow th e 2 m m Fig 5.7-3 0 Th e plate an d distal screw s are reapplied.
w a er bein g created an d rem oved, revealin g th e site o th e
osteotom y.
a b
Fig 5.7-3 1a –bUsin g a drill gu ide as a h an dle, th e plate can be m oved

proxim ally an d th e osteotom y site an d u ln a, redu ced.
a b
Fig 5.7-3 2Th e proxim al screw s are placed, w ith axial Fig 5.7-33a –b Th e u ln a plate an d screws are n ow secu red
com pression applied th rou gh th e plate. with th e osteotom y site placed u n der com pression .
Op t io n : o b liq u e o s t e o t o m y Ou t co m e
a b a b
Fig 5.7-34a –b As a u rth er option , th e procedu re can be Fig 5.7-35a –b By th e 3-m on th ollow-u p a ter
per orm ed with an obliqu e osteotom y ( a ), allowin g or th e su rgery, com plete u n ion h ad been ach ieved.
placem en t o a lag screw to provide addition al su pport ( b ).
465
Pa rt II Case s
a b
c d
Fig 5.7-36a –d Th e patien t h ad ach ieved a u lly u n ction al recovery with ou t pain .
5.8 Long-standing nonunion treated with
resection of the distal ulna and double
plating of the radius
a b c
Fig 5 .8 -1a –cA 67-year-old retired m an h ad a lon g-stan din g extraarticu lar n on u n ion o h is righ t distal
radiu s, w ith obviou s de orm ity. Clin ical im ages an d x-rays dem on strated sh orten in g, an gu lation , an d
th e su ggestion o syn ovial pseu darth rosis. Th e patien t w as previou sly told n oth in g cou ld be don e, yet
on goin g in stability, de orm ity, an d pain orced h im to con tin u e to seek m edical advice.
467
Pa rt II Case s
2 In d ica t io n s
No n u n io n o f t h e d is t a l ra d iu s
a b
PA vie w AP vie w
Fig 5.8-2a –b Failu re to ach ieve u n ion ollow in g a distal radial ractu re is exceedin gly u n com m on . Failed
in tern al xation , in ection , or Ch arcot arth ropath y are am on g th e m ost likely cau ses. I u n treated, du e to its
proxim ity to th e radiocarpal join t, th ere is a poten tial or th e n on u n ion to develop in to a m obile pseu darth rosis
addin g to th e com plexity o an y recon stru ction . Fu rth erm ore, th e lim ited size o th e distal m etaph yseal an d
articu lar com pon en t as w ell as th e likelih ood o associated disu se osteoporosis presen ts a de n ite ch allen ge to
ach ievin g stable in tern al xation an d u ltim ate u n ion .
Dis t a l u ln a re s e ctio n
Wh ile preservation o th e distal radiou ln ar join t (DRUJ) is h elp u l or both m otion an d stability, w ith
lon g-stan din g n on u n ion s su ch as w ith th is low -dem an d patien t, len gth discrepan cy an d posttrau m atic DRUJ
arth rosis m ay requ ire resection o th e distal u ln a, w h ich can provide local bon e gra t m aterial.
5 .8 Long-standing nonunion tre ate d with re se ction of the distal ulna and double plating of the radius
a b c d
Palmar plate 2-column plate Volar column plate Radial column plate
Fig 5.8-3a –d Given a n on u n ion to su ch an exten t alon g a patien t’s

distal radial sh a t, lon ger an gu lar stable plates an d plates with larger
m u ltiple-h ole h eads an d variable an gle (VA) lockin g screw option s
sh ou ld be con sidered to h elp with stability. For added stability,
in sertion o a radial colu m n plate is also recom m en ded.
• A palm ar lockin g plate w ith lon ger sh a t

• Radial colu m n plate 2.4
• Sm all extern al distractor

469
Pa rt II Case s
Ap p ro a ch e s
a b a b
Th e in itial su rgical approach u sed w as a

Fig 5 .8 -5 a –b Th e distal radiu s w as approach ed th rou gh
Fig 5.8-6 a – b
m odi ed Hen ry palm ar approach (see Ch apter 1.6 th e m odi ed Hen ry palm ar in cision . Th e f exor carpi
Modi ed Hen ry palm ar approach to th e distal radiu s). radialis (FCR) ten don w as iden ti ed ( a ). Th e con tracted
Th is w as ollow ed by an u ln ar approach to th e u ln a (see FCR ten don w as section ed ollow ed by th e ten don o th e
ch apter 1.10 Uln ar approach to th e distal u ln a). brach ioradialis ( b ).
Fig 5.8-7 Th e secon d in cision w as th en

per orm ed based alon g th e u ln a. Th is
allow ed th e u ln a to be osteotom ized.
Uln a r o s t e o t o m y
a b
Fig 5.8-8 a – b Measu re an d rem ove a section o u ln a to create equ al len gth alon g
th e radiu s an d u ln a. Th e resected bon e m aterial is th en able to be u sed or bon e
gra t m aterial later on .
5 Re d u ct io n
In s e r t e xt e rn a l fixa t io n p in s
a b
Tw o sm all th readed extern al distractor pin s/ K-w ires are in serted to be u sed
Fig 5.8-9 a – b
as joysticks, w ith on e pin in th e distal radial m etaph ysis an d on e in th e proxim al sh a t.
471
Pa rt II Case s
a b
Fig 5.8-1 0a –b Th e n on u n ion is th en realign ed an d th e position secu red w ith th e sm all

distractor ( a ). Debridem en t o th e n on u n ion requ ired rem oval o th e syn ovial
m em bran e ( b ).
Fig 5.8-1 1 On ce realign ed, prepare an d in sert th e

bon e gra t obtain ed rom th e u ln ar osteotom y.
6 Fixa t io n
a b
Fig 5.8-12a –b Fixation o th e distal radiu s sh ou ld be per orm ed with an appropriate palm ar
plate. Th e u su al steps in volve selectin g an appropriate plate based on th e con gu ration o th e
n on u n ion , in sertin g distal screws, in sertin g proxim al screws, an d in traoperative im agin g.
Ra d ia l co lu m n p la t e fixa t io n
Fig 5.8-1 3 Th is is ollow ed by in sertion o a radial colu m n

plate or u rth er stability. Th e steps in volve selectin g,
con tou rin g, an d applyin g th e plate, stabilizin g th e radial
colu m n , an d in sertin g proxim al an d distal screw s.
473
Pa rt II Case s

colu m n plate.
8 Ou t co m e
a b
Fig 5.8-15a –b At th e 6-m on th ollow-u p, x-rays Fig 5.8-1 6Th e x-ray at

sh owed u n ion o th e distal radiu s with restoration 3 years postoperatively
o a m ore n orm al align m en t. sh ow ed com plete h ealin g.
a b
Fig 5.8-17a –b Th e resu lt was th at th e patien t h ad a stable an d well-align ed orearm an d wrist. Despite m an y
previou s years o dys u n ction , h is h an d u n ction h ad n ow retu rn ed with good stren gth an d n orm al sen sation .
5.9 Chronic intercarpal arthritis treated with
scaphoid resection and 4 -corner fusion
a b a b
Fig 5.9-1a – b A 42-year-old m ale jew elry sh op ow n er Fig 5.9-2 a – bTh e sagittal CT scan s sh ow ed carpal
an d design er ell on h is ou tstretch ed w rist bu t did n ot collapse, de orm ity, an d sh orten in g o th e scaph oid,
seek treatm en t u n til 1 year later, w h en h e h ad persisten t w h ile osteoarth ritic ch an ges w ere also eviden t.
pain an d lim itation o w rist m obility. Th e x-rays sh ow ed
eviden ce o osteoarth ritic ch an ges in th e radioscaph oid
join t an d a scaph oid ractu re n on u n ion .
a b a b
Fig 5.9-3a –b Coron al view CT scan s revealed lon g-stan d- Th e MRI sh ow ed cartilage loss at th e
Fig 5.9-4 a – b
in g scaph oid n on u n ion with in tercarpal an d radiocarpal radioscaph oid join t. Treatm en t in volvin g ou r-corn er
arth ritis, or “SNAC” wrist. u sion w as o ered as a salvage procedu re.
475
Pa rt II Case s
2 In d ica t io n s
In t e rca rp a l o s t e o a r t h rit is a n d t h e SLAC/ SNAC w ris t
SNAC
SLAC
a b c
Norm al SLAC SNAC
Fig 5.9-5 a – cIt h as already been sh ow n in th is pu blication th at scaph oid ractu res an d su rrou n din g ligam en t dam age
are com m on , an d du e to a w ide variety o actors, can ail to h eal. Th e resu lt can be especially problem atic w h en th e
scaph oid in ju ry is n ot in itially diagn osed or w h en th e patien t ails to seek im m ediate m edical treatm en t. Poten tial
resu lts rom su ch situ ation s in clu de n ecrosis an d n on u n ion , bu t it can also lead to con dition s su ch as scaph olu n ate
advan ced collapse (SLAC) an d scaph oid n on u n ion advan ced collapse (SNAC), w h ich are orm s o osteoarth ritis greatly
a ectin g w rist u n ction . Typically, both con dition s resu lt in loss o w rist m obility, sw ellin g in th e in tercarpal join ts,
distortion o th e sh ape o th e scaph oid, ch an ge to join t kin em atics, an d pain . For m an y patien ts, su rgical salvage
procedu res provide an e ective treatm en t option .
5 .9 Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion
Cla s s ifica t io n o f s ca p h o id n o n u n io n a d va n ce d co lla p s e
a b
c d
Fig 5.9-6a –d Th e ou r stages o scaph oid n on u n ion advan ced collapse are as ollows:
a Stage I: Arth ritis at th e radial styloid
b Stage II: Arth ritis o th e scaph oid ossa
c Stage III: Arth ritis o th e capitolu n ate/ m idcarpal join t
d Stage IV: Di u se arth ritis o th e carpu s.
Sym ptom atic wrist dys u n ction o an y etiology can requ ire recon stru ction an d salvage
procedu res are requ en tly th e on ly way to o er th e patien t a stable pain - ree wrist. A
n u m ber o su rgical option s th at ideally preserve m otion an d avoid com plication s in th e
lon g term can be con sidered:
• Lim ited wrist arth rodesis
• Proxim al row carpectom y
• Arth roplasty
• Total wrist arth rodesis.
477
Pa rt II Case s
Lim it e d w ris t a r t h ro d e s is w it h fo u r-co rn e r fu s io n Ch o ice o f im p la n t
Fig 5.9-8 Fou r-corn er u sion is per orm ed w ith an

in tercarpal u sion plate (dorsal circu lar plate or spider
plate). It allow s variable an gle (VA) screw in sertion an d
can be adapted to th e speci c an atom y o th e patien t.
Fig 5.9-7 Fou r-corn er u sion is a lim ited w rist arth rodesis
treatm en t provided to th ose w ith advan ced degen erative
ch an ges in th e w rist w h ere th e carpals are u sed (eg, th e
lu n ate, capitate, triqu etru m , an d h am ate bon es). As it
in volves on ly partial u sion , it preserves lim ited m otion
w h ile allow in g pain redu ction rom th e a ected join ts.
Th e “ ou r corn ers” o th e carpal bon es are attach ed by an
in tercarpal u sion plate, w h ile th e scaph oid is partially or
u lly resected.
Eq u ip m e n t lis t Pa t ie n t p o s it io n in g
• VA lockin g in tercarpal u sion system

• In tercarpal u sion plate
• Osteotom e

Ap p ro a ch
a b
Du e to th e speci c n atu re o th e in ju ry, th e su rgical approach u sed w as a dorsal approach to

Fig 5 .9 -1 0 a – b
th e carpu s (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries, h ow ever in th is case,
on ly th e dorsal approach w as requ ired). Th is approach in volves a radially based capsu lar ligam en tou s f ap to
be elevated an d a capsu lotom y in cision .
479
Pa rt II Case s
a b
Fig 5.9-11a –b Th e approach was m ade over th e th ird Fig 5.9-12 Th e posterior in terosseou s n erve was iden ti ed
com partm en t by in cisin g th e exten sor retin acu lu m an d resected to partially den ervate th is area o th e wrist to
over th e exten sor pollicis lon gu s (EPL) ten don . Th e h elp lim it postoperative pain .
EPL ten don was released an d retracted radially,
togeth er with th e exten sor ten don s o th e secon d
com partm en t.
a b
Fig 5.9-13a –b In traoperative ph otos sh ow th e radially based capsu lar ligam en tou s f ap preservin g th e radiolu -
n otriqu etal ligam en t ( a ). Th e capsu lar f ap was elevated by sh arp dissection in an u ln ar to radial direction ( b ).
R
L C
H
T
Fig 5.9-14 Th e carpal bon es were th en exposed

an d iden ti ed (S=scaph oid, C=capitate,
H=h am ate, T=triqu etru m , L=lu n ate; with
R=radiu s).
Excis e t h e s ca p h o id
a b
Becau se o th e ch ron ic n on u n ion an d su rrou n din g arth ritic ch an ges th e rst part
Fig 5.9-1 5a – b
o th is procedu re w as to com pletely rem ove th e scaph oid. Particu lar care m u st be taken to
preserve th e palm ar radioscaph ocapitate ligam en t. In som e in stan ces, th e excised scaph oid can
provide som e au togen ou s bon e gra t m aterial.
481
Pa rt II Case s
5 Re d u ct io n
Re d u ce ro t a t io n a l d e fo rm it y a n d p ro vis io n a lly fix t h e ca rp a l b o n e s
a b
Fig 5.9-16a –c Usin g a th icker joystick K-w ire, th e

dorsif exion o th e lu n ate is corrected an d stabilized by
bein g in trodu ced th rou gh th e capitate to align th e radiu s,
c th e lu n ate, an d th e capitate in n eu tral position .
a b
Fig 5.9-17a –b In traoperative im ages sh ow th e K-wire in place.
De b rid e t h e m id ca rp a l jo in t
a b
Fig 5.9-1 8a –b Usin g a sm all ron geu r an d osteotom e, th e cartilage o th e m idcarpal join t is rem oved to expose th e
su bch on dral bon e (debride th e m idcarpal join t) ( a ). Make su re th at sclerotic an d den se su bch on dral bon e is rem oved
dow n to can cellou s bon e ( b ). Preparation o th e join t su r aces betw een th e capitate/ h am ate an d lu n ate/ triqu etru m is
option al or m ay be carried ou t a ter provision al xation . Excessive rem oval o bon e sh ou ld be avoided oth erw ise th e
sh ape o th e carpu s w ill be m odi ed.
6 Fixa t io n
Se le ct fixa t io n m e t h o d a n d p la t e
Fig 5.9-19 To ach ieve u sion o th e m idcarpal join t, th e VA

lockin g in tercarpal u sion system was u sed (sh own with th e
plate in serted), wh ich is a variable an gle lockin g tech n ology
or m idcarpal lim ited arth rodesis. Appropriate plate size is
ch osen u sin g th e im age in ten si er an d it can also be u sed to
veri y correct align m en t o th e carpal bon es.
483
Pa rt II Case s
Po s it io n re a m in g gu id e
a b
Fig 5.9-2 0a –b To begin , ch oose th e ream in g gu ide accordin g to th e selected plate an d x it

tem porarily w ith at least on e 1.1 m m / 1.2 m m K-w ire per carpal bon e over th e cen ter o th e
ou r-bon e ju n ction ( a ). I n ecessary, rem ove th e palm ar lu n ocapitate K-w ire to avoid later
in ter eren ce w ith th e ream er ( b ).
a b
Th e h an dle o th e ream in g gu ide sh ou ld be in lin e w ith th e radial sh a t ( a ). Th e ream in g gu ide w as

Fig 5.9-2 1a –b
tem porarily xed w ith K-w ires over th e cen ter o th e ou r-bon e ju n ction ( b ).
Op t io n a l in s t ru m e n t : re d u ct io n re a m in g gu id e Re a m p la t e re ce s s
Fig 5.9-2 2 Use th e redu ction ream in g gu ide i redu ction Fig 5.9-2 3 Ch oose th e ream er correspon din g to th e
o th e carpal bon es is requ ired. Th is particu lar ream in g (redu ction ) ream in g gu ide. Ream th rou gh th e ream in g
gu ide h as o set eet to allow it to sit com ortably on th e gu ide to th e rst laser m arkin g lin e.
carpu s. I th is gu ide is u sed, its h an dle m u st be located on
th e radial side o th e carpu s w h en , as in th is case, a righ t
w rist is bein g treated an d on th e u ln ar side o th e carpu s
w h en a le t w rist is bein g treated.
Ap p ly t h e p la t e
Fig 5.9-24 Use th e plate h older to pick u p th e appropriately

sized plate. Position th e plate th rou gh th e redu ction
ream in g gu ide.
485
Pa rt II Case s
Fix p la t e w it h lo ck in g s cre w s
Fig 5.9-2 5 Th e plate w as in serted as sh ow n . Ch eck or Fig 5.9-2 6 Start plate xation w ith th e placem en t o VA
su cien t ream in g depth by trial placem en t o th e plate, lockin g screw s in th e lu n ate. Use th e variable an gle part
en su rin g th at th e plate edge does n ot project beyon d th e o th e drill gu ide 1.8 (see m arkin g “VARIABLE ANGLE”)
bon e at an y poin t. It is critically im portan t to en su re th e an d u lly in sert it in to th e lockin g h ole. Drill th e h ole
plate edge does n ot project beyon d th e proxim al m argin w ith th e 1.8 m m drill bit at th e desired an gle.
o th e ream ed de ect oth erw ise w rist exten sion w ill be
blocked by im plan t im pin gem en t.
Me a s u re s cre w le n g t h u s in g t h e d e p t h ga u ge
a b
Fig 5.9-2 7a –b In sert lockin g screw s u sin g th e T8 screw driver sh a t w ith stardrive attach ed to th e h an dle w ith qu ick
cou plin g. At least tw o screw s sh ou ld be placed in th e lu n ate.
Bo n e gra ft
Fig 5.9-28 Fill th e space between th e ou r bon es with

au togen ou s bon e gra t taken rom th e excised scaph oid, or
rom th e iliac crest or Lister tu bercle. As an altern ative,
bon e gra t can be placed be ore th e plate is in serted.

colu m n plate.
487
Pa rt II Case s
8 Ou t co m e
a b
Fig 5.9-3 0a –b Th e 3-m on th ollow -u p x-rays

sh ow ed th at u sion w as ach ieved.
a b
c d
Fig 5.9-3 1a –dAt th e 1-year ollow -u p th ere w as com plete resolu tion o pain an d a u n ction al
ran ge o m otion bu t w ith som e lim itation o f exion an d exten sion .
8 Ou t co m e
Vid e o
Vid e o 5 .9 -1Th is video dem on strates a m idcarpal w rist

u sion u sin g th e VA lockin g in tercarpal u sion system .
489
Pa rt II Case s
Appendix
Furthe r re ading
Further reading
Ca rp a l in ju rie s In o u e G, Ku w a h a t a Y. Man agem en t o Min a m i A, Ka n e d a K. Repair an d/or
acu te perilu n ate d islocation s w ith ou t recon stru ction o scaph olu n ate
Ad k is o n JW, Ch a p m a n MW. Treatm en t o ractu re o th e scaph oid. J Hand Surg. in terosseou s ligam en t in lu n ate an d
acu te lu n ate an d perilu n ate d islocation s. 1997;22:6 47–652. perilu n ate dislocation s. J Hand Surg Am.
Clin Orthop Relat Res. 1982;199 –207. In o u e G, Sh io n o ya K. Herbert screw 1993;18:1099 –1106.
Ba in GI, McLe a n JM, Tu rn e r PC, e t a l . xation by lim ited access or acu te Na ka m u ra R, Ho rii E, Wa t a n a b e K, e t a l .
Tran slu n ate ractu re w ith associated ractu res o th e scaph oid. J Bone Joint Surg. Prox im al row car pectom y versu s lim ited
perilu n ate in ju ry: 3 case reports w ith 1997;79:418 –421. w rist arth rodesis or advan ced Kien bock’s
in trodu ction o th e tran slu n ate arc con cept. In o u e G, Sh io n o ya K, Ku w a h a t a Y. Herbert d isease. J Hand Surg. 1998;23:741–745.
J Hand Surg Am. 2008;33:1770 –1776. screw xation or scaph oid n on u n ion s. An Nu n e z FA Jr, Lu o TD, Ju p it e r JB, e t a l .
Bla za r PE, Mu rra y P. Treatm en t o an alysis o actors in f u en cin g ou tcom e. Scaph ocapitate syn d rom e w ith associated
perilu n ate d islocation s by com bin ed dorsal Clin Orthop Relat Res. 1997 Oct;343:99 –106. tran s-scaph oid, tran s-h am ate perilu n ate
an d palm ar approach es. Tech Hand Up Jira n e k WA, Ru b y LK, Mille n d e r LB, e t a l . d islocation . Hand. 2016;12(2):27-31.
Extrem Surg. 2001;5:2–7. Lon g-term resu lts a ter Ru sse bon e- Ro b b in s RR, Ca r t e r PR. Iliac crest bon e
Ca p o JT, Co rt i SJ, Sh a m ia n B, e t a l . gra tin g: th e e ect o m alu n ion o th e gra tin g an d Herbert screw xation o
Treatm en t o dorsal perilu n ate d islocation s scaph oid. J Bone Joint Surg Am. n onu n ion s o th e scaph oid w ith avascu lar
an d ractu re-d islocation s u sin g a 1992;74:1217–1228. prox im al poles. J Hand Surg Am.
stan dardized protocol. Hand N Y. Jo h n s o n RP. Th e acu tely in ju red w rist an d 1995;20:818 –831.
2012;7:380 –387. its residu als. Clin Orthop Relat Res. Ru s s e O . Fractu res o th e car pal n avicu lar.
Fe n t o n RL. Th e n avicu lo-capitate ractu re 1980;33 –4 4. J Bone Joint Surg Am. 1960;42:759 –768.
syn drom e. J Bone Joint Surg Am. 1956;38- Jo n e s DB Jr, Bü rge r H, Bis h o p AT, e t a l . Sca lcio n e LR, Gim b e r LH, Ho AM, e t a l .
A:681–68 4. Treatm en t o scaph oid waist n on u n ion s Spectru m o car pal dislocation s an d
Fo rli A, Co u r vo is ie r A, Wim s e y S, e t a l . w ith an avascu lar prox im al pole an d car pal ractu re-dislocation s: im agin g an d
Perilu n ate d islocation s an d tran sscaph oid collapse. A com parison o two vascu larized m an agem en t. Am J Roentgenol.
perilu n ate ractu re-d islocation s: a bon e gra ts. J Bone Joint Surg Am. 2014;203:541–550.
retrospective stu dy w ith m in im u m 2008;90:2616 –2625. Sch u in d F, Ha e n t je n s P, Va n In n is F, e t a l .
ten -year ollow-u p. J Hand Surg Am. Ju p it e r JB, Nu n e z FA Jr, Nu n e z F, e t a l . Progn ostic actors in th e treatm en t o
2010;35:62 –68. Cu rren t perspective on com plex w rist car pal scaph oid n on u n ion s. J Hand Surg
Gilu la LA, De s t o u e t JM, We e k s PM, e t a l . ractu re-d islocation . Instr Course Lect. Am. 1999;24:761–776.
Roen tgen ograph ic d iagn osis o th e pain u l 2018;67:155 –174. Sh e e t z KK, Bis h o p AT, Be rge r RA. Th e
w rist. Clin Orthop Relat Res. 198 4;52 –64. Ka rd a s h ia n G, Ch ris t o fo ro u DC, Le e SK. arterial blood su pply o th e distal rad iu s
Gra h a m TJ. Th e in erior arc in ju ry: an Perilu n ate dislocation s. Bull N Y U Hosp Jt an d u ln a an d its poten tial u se in
add ition to th e am ily o com plex car pal Dis. 2011;69:87–96. vascu larized ped icled bon e gra ts. J Hand
ractu re-d islocation pattern s. Am J Orthop Kn o ll VD, Alla n C, Tru m b le TE. Tran s- Surg Am. 1995;20:902 –914.
(Belle Mead NJ). 20 03;32:10 –19. scaph oid perilu n ate ractu re d islocation s: So t e re a n o s DG, Mit s io n is GJ,
Gre e n DP. Th e e ect o avascu lar n ecrosis resu lts o screw xation o th e scaph oid Gia n n a ko p o u lo s PN, e t a l . Perilu n ate
on Ru sse bon e gra tin g or scaph oid an d lu n otr iqu etral repair w ith a dorsal d islocation an d ractu re dislocation : a
n onu n ion . J Hand Surg Am. approach . J Hand Surg Am. 2005; critical an alysis o th e volar-dorsal
1985;10:597–605. 30:1145 –1152. approach . J Hand Surg Am. 1997;22:49 –56.
Ha d d a d FS, Go d d a rd NJ. Acu te Ko m u rcu M, Ku rk lu M, Ozt u ra n KE, e t a l . So u e r JS, Ru t ge rs M, An d e rm a h r J, e t a l .
percu tan eou s scaph oid xation : a pilot Early an d delayed treatm en t o dorsal Perilu n ate ractu re-d islocation s o th e
stu dy. J Bone Joint Surg. 1998;80:95 –99. tran sscaph oid perilu n ate ractu re- w rist: com parison o tem porar y screw
He rb e rt TJ, Fis h e r WE. Man agem en t o th e d islocation s. J Orthop Trauma. versu s K-w ire xation . J Hand Surg Am.
ractu red scaph oid u sin g a n ew bon e screw. 2008;22:535 –54 0. 2007;32:318 –325.
J Bone Joint Surg. 1984;66(1):114 –123. Kre m e r T, We n d t M, Rie d e l K, e t a l . Open St ra w RG, Da vis TR, Dia s JJ. Scaph oid
He rzb e rg G . Acu te dorsal tran s-scaph oid redu ction or perilu n ate in ju ries—clin ical n on u n ion : treatm en t w ith a pedicled
perilu n ate dislocation s: Open redu ction ou tcom e an d patien t satis action . J Hand vascu larized bon e gra t based on th e 1,2
an d in tern al xation . Tech Hand Up Extrem Surg Am. 2010;35:1599 –1606. in tercom partm en tal su praretin acu lar
Surg. 2000;4:2–13. Krie f E, Ap p y-Fe d id a B, Ro t a ri V, e t a l . bran ch o th e rad ial arter y. J Hand Surg.
He rzb e rg G, Co m t e t JJ, Lin s ch e id RL, e t a l . Resu lts o perilu n ate d islocation s an d 2002;27:413 –416.
Perilu n ate d islocation s an d ractu re- perilu n ate ractu re d islocation s w ith a Te is e n H, Hja rb a e k J. Classi cation o resh
dislocation s: a mu lticen ter stu dy. m in im u m 15-year ollow-u p. J Hand Surg ractu res o th e lu n ate. J Hand Surg.
J Hand Surg Am. 1993;18:768 –779. Am. 2015;40:2191–2197. 1988;13:458 –462.
He rzb e rg G, Fo ris s ie r D. Acu te dorsal Ma ck GR, Bo s s e MJ, Ge lb e rm a n RH, e t a l . Tru m b le T. Fractu res an d d islocation s o th e
tran s-scaph oid perilu n ate ractu re- Th e n atu ral h istory o scaph oid n on -u n ion . car pu s. In : Tru m ble T, ed. Principles of Hand
dislocation s: m ed iu m -term resu lts. J Bone Joint Surg Am. 198 4;66:50 4 –509. Surgery and Therapy. Ph iladelph ia:
J Hand Surg. 2002;27:498 –502. Ma y e ld JK, Jo h n s o n RP, Kilco yn e RK. Sau n ders;2000:90 –125.
Hild e b ra n d KA, Ro s s DC, Pa t t e rs o n SD, Car pal d islocation s: path om ech an ics an d Tru m b le T, Ve rh e yd e n J. Treatm en t o
e t a l . Dorsal perilu n ate d islocation s an d progressive perilu n ar in stability. J Hand isolated perilu n ate an d lu n ate d islocation s
ractu re-d islocation s: qu estion n aire, Surg Am. 1980;5:226 –241. w ith com bin ed dorsal an d volar approach
clin ical, an d rad iograph ic evalu ation . Me rre ll GA, Wo lfe SW, Sla d e JF III. an d in traosseou s cerclage w ire. J Hand Surg
J Hand Surg Am. 2000;25:1069 –1079. Treatm en t o scaph oid n on u n ion s: Am. 200 4;29:412 –417.
qu an titative m eta-an alysis o th e literatu re.
J Hand Surg Am. 2002;27:685 –691.
493
Appendix
Wo za s e k GE, Mo s e r KD. Percu tan eou s Lin s ch e id RL, Do b yn s JH, Be a b o u t JW, e t a l . Dista l ra d ia l inju rie s
screw xation or ractu res o th e scaph oid. Trau m atic in stability o th e w rist:
J Bone Joint Surg. 1991;73;138 –142. d iagn osis, classi cation , an d Co h e n MD, Ju p it e r JB. Fractu res o th e
Za id e m b e rg C, Sie b e rt JW, An grigia n i C. path om ech an ics. J Bone Joint Surg Am. d istal rad iu s. In : Brow n er BD, ed. Skeletal
A n ew vascu larized bon e gra t or scaph oid 1972;54:1612 –1632. Trauma: Basic Science, Management, and
n onu n ion . J Hand Surg Am. Ma y e ld JK, Jo h n s o n RP, Kilco yn e RK. Reconstruction.
1991;16:474 –478. Car pal d islocation s: path om ech an ics an d 4th ed. Ph iladelph ia: W B Sau n ders,
progressive perilu n ar in stability. J Hand 2009:1405 –1458.
Surg Am. 1980;5:226 –241. Du m o n t ie r C, Me ye r zu Re xke n d o rf G,
Ca rp a l in sta b ilit y Min a m i A, Ka n e d a K. Repair an d/or Sa u t e t A, e t a l . Radiocar pal dislocation s:
recon stru ction o scaph olu n ate classi cation an d proposal or treatm en t. A
Allie u Y, Bra h in B, As ce n cio G . Car pal in terosseou s ligam en t in lu n ate an d review o twen ty-seven cases. J Bone Joint
in stabilities: radiological an d clin ico- perilu n ate d islocation s. J Hand Surg Am. Surg Am. 2001;83:212 –218.
path ological classi cation . Ann Radiol. 1993 Nov;18(6):1099 –1106. Fe rn a n d e z DL. Correction o post-trau m atic
1982;25:275 –287. Mit s u ya s u H, Pa t t e rs o n RM, Sh a h MA, w rist de orm ity in adu lts by osteotom y,
Be rge r RA. Th e ligam en ts o th e w rist: a e t a l . Th e role o th e dorsal in tercar pal bon e-gra tin g, an d in tern al xation . J Bone
cu rren t overview o an atom y w ith ligam en t in dyn am ic an d static Joint Surg Am. 1982;64:1164 –1178.
con sideration s o th eir poten tial u n ction s. scaph olu n ate in stability. J Hand Surg Am. Fe rn a n d e z DL. Fractu res o th e d istal
Hand Clin. 1997;13:63 –82. 200 4;29:279 –288. rad iu s: operative treatm en t. Instr Course
Bru n e lli GA, Bru n e lli GA. Car pal in stability Re t t ig ME, Ra s k in KB. Lon g-term Lect. 1993;42:73 –88.
w ith scaph o-lu n ate d issociation treated assessm en t o proxim al row car pectom y or Fe rn a n d e z DL, Rin g D, Ju p it e r JB. Su rgical
u sin g th e f exor car pi rad ialis an d ch ron ic perilu n ate d islocation s. J Hand m an agem en t o delayed u n ion an d
scaph o-trapezoid ligam en t repair: Surg Am. 1999;24:1231–1236. n onu n ion o distal radiu s ractu res. J Hand
ou n dation s, tech n iqu e an d resu lts o Rikli DA, Ho n igm a n n P, Ba b s t R, e t a l . Surg Am. 2001;26A:201–209.
prelim in ary series. Rev Chir Orthop In tra-articu lar pressu re m easu rem en t in Go n g HS, Ch o HE, Kim J, e t a l . Su rgical
Reparatrice Appar Mot. 2003;89:152 –157. th e rad iou ln ocar pal join t u sin g a n ovel treatm en t o acu te d istal radiou ln ar join t
Co o n e y WP, Bu s s e y R, Do b yn s JH, e t a l . sen sor: in vitro an d in vivo resu lts. J Hand in stability associated w ith distal rad iu s
Di cu lt w rist ractu res: perilu n ate Surg Am. 2007;32:67–75. ractu res. J Hand Surg Eur. 2015;
ractu re-d islocation s o th e w rist. Clin Rit t MJPF, Lin s ch e id RL, Co o n e y WP, e t a l . 4 0:783 –789.
Orthop Rel Res. 1987;214:136 –147. Th e lu n otriqu etral join t: k in em atic e ects Ha n e l DP, Lu TS, We il WM . Bridge platin g o
Fe n t o n RL. Th e n avicu lo-capitate ractu re o sequ en tial ligam en t section in g, ligam en t d istal radiu s ractu res: th e Harbor view
syn drom e. J Bone Joint Surg Am. repair, an d arth rodesis. J Hand Surg Am. m eth od. Clin Orthop Relat Res. 2006;4 45:91–
1956;38:681–68 4. 1998;23:432 –4 45. 99.
Ga rcia -Elia s M, Llu ch AL, St a n le y JK. Sa ffa r P. Classi cation o car pal Ja ko b M, Rik li DA, Re ga zzo n i P. Fractu res
Th ree-ligam en t ten odesis or th e treatm en t in stabilities. In : Bü ch ler U, ed. Wrist o th e d istal rad iu s treated by in tern al
o scaph olu n ate d issociation : in d ication s Instability. Lon don : Martin xation an d early u n ction . A prospective
an d su rgical tech n iqu e. J Hand Surg Am. Du n itz;1996:29 –34. stu dy o 73 con secu tive patien ts. J Bone
20 06;31:125 –134. Sh in AY, We in s t e in LP, Be rge r RA, e t a l . Joint Surg. 2000;82:340 –34 4.
Ge is s le r WB, Fre e la n d AE, Sa vo ie FH, e t a l . Treatm en t o isolated in ju ries o th e Ju p it e r JB, Rin g D. A com parison o early
In tracar pal so t-tissu e lesion s associated lu n otriqu etral ligam en t: a com parison o an d late recon stru ction o m alu n ited
w ith an in tra-articu lar ractu re o th e arth rodesis, ligam en t recon stru ction an d ractu res o th e distal en d o th e rad iu s. J
distal en d o th e rad iu s. J Bone Joint Surg ligam en t repair. J Bone Joint Surg. Bone Joint Surg Am. 1996;78:739 –74 8.
Am. 1996;78:357–365. 2001;83:1023 –1028. Ka rn e zis IA, Pa n a gio t o p o u lo s E,
Go ld fa rb CA, St e rn PJ, Kie fh a b e r TR. Sie ge l JM, Ru b y LK. A critical look at Tyllia n a k is , e t a l . Correlation between
Palm ar m idcar pal in stability: th e resu lts o in tercar pal arth rodesis: review o th e radiological param eters an d patien t-rated
treatm en t w ith 4 -corn er arth rodesis. literatu re. J Hand Surg Am. 1996; w rist dys u n ction ollow in g ractu res o th e
J Hand Surg Am. 2004;29:258 –263. 21:717–723. d istal radiu s. Injury. 2005;36:1435 –1439.
Jo h n s o n RP. Th e evolu tion o car pal Ta le is n ik J. The Wrist. New York: Chu rch ill Krä m e r S, Me ye r H, O’Lo u gh lin PF, e t a l .
n om en clatu re: a sh ort review. J Hand Surg Livin gston e;1985. Th e in ciden ce o u ln ocar pal com plain ts
Am. 1990;15:834 –838. Vie ga s SF. Ligam en tou s repair ollow in g a ter d istal rad ial ractu re in relation to th e
La rs e n CF, Am a d io PC, Gilu la LA, e t a l . acu te scaph olu n ate d issociation . In : ractu re o th e u ln ar styloid. J Hand
An alysis o car pal in stability, I: description Gelberm an RH, ed. Master Techniques in Surg Eur. 2013;38:710 –717.
o th e sch em e. J Hand Surg Am. Orthopedic Surgery: The Wrist. New York: La fo n t a in e M, Ha rd y D, De lin ce PH .
1995;20:757–764. Raven Press;1994:135 –146. Stability assessm en t o d istal rad iu s
Lich t m a n DM, Bru ck n e r JD, Cu lp RW, e t a l . Wa ls h JJ, Be rge r RA, Co o n e y WP. Cu rren t ractu res. Injury. 1989;20:208 –210.
Palm ar m idcar pal in stability: resu lts o statu s o scaph olu n ate in terosseou s Le s lie BM, Me d o ff RJ. Fractu re speci c
su rgical recon stru ction . J Hand Surg Am. ligam en t in ju ries. J Am Acad Orthop Surg. xation o distal rad iu s ractu res. Tech
1993;18:307–315. 2002;10:32 –42. Orthop. 2000;15:336 –352.
Lich t m a n DM, Wro t e n ES . Un derstan din g Wa t s o n HK, As h m e a d D IV, Ma k h lo u f MV. Lo za n o -Ca ld e ró n SA, Do o rn b e rg J, Rin g D.
m idcar pal in stability. J Hand Surg Am. Exam in ation o th e scaph oid. J Hand Surg Fractu res o th e dorsal articu lar m argin o
20 06;31:491–498. Am. 1988;13:657–660. th e d istal part o th e rad iu s w ith dorsal
Lin s ch e id RL, Do b yn s JH . Treatm en t o Wa t s o n HK, We in zw e ig J, Ze p p ie ri J. Th e radiocar pal su blu xation . J Bone Joint Surg
scaph olu n ate d issociation . Hand Clin. n atu ral progression o scaph oid in stability. Am. 2006;88:14 86 –1493.
1992;8:6 45 –652. Hand Clin. 1997;13:39 –49. Ma cKe n n e y PJ, McQu e e n MM, Elt o n R.
Zd ra vko vic V, Se n n w a ld GR. A n ew Pred iction o in stability in d istal rad iu s
rad iograph ic m eth od o m easu r in g car pal ractu res. J Bone Joint Surg Am.
collapse. J Bone Joint Surg. 1997; 20 06;88:194 4 –1951.
79:167–169.
Furthe r re ading
Me lo n e CP Jr. Articu lar ractu res o th e Co n s t a n t in e KJ, To m a in o MM, He rn d o n JH, Ju p it e r JB, Rin g D. A com parison o early
distal rad iu s. Orthop Clin North Am. e t a l . Com parison o u ln ar sh orten in g an d late recon stru ction o m alu n ited
198 4;15:217–236. osteotom y an d th e wa er resection ractu res o th e distal en d o th e rad iu s.
Nu n e z FA Jr, Zh o n g yu L, Ca m p b e ll D, e t a l . procedu re as treatm en t or u ln ar im paction J Bone Joint Surg Am. 1996;78A:739 –74 8.
Distal u ln a h ook plate: an gu lar stable syn drom e. J Hand Surg Am. 2000;25:55 –60. Kn irk JL, Ju p it e r JB. In tra-articu lar
im plan t or xation o d istal u ln a. J Wrist Da rro w JC Jr, Lin s ch e id RL, Do b yn s JH, ractu res o th e distal en d o th e rad iu s in
Surg. 2013 Feb;2(1):87–92. e t a l . Distal u ln ar recession or disorders o you n g adu lts. J Bone Joint Surg Am.
Orb a y JL, Fe rn a n d e z DL. Volar xed-an gle th e distal rad iou ln ar join t. J Hand Surg Am. 1986;68A:647–659.
plate xation or u n stable d istal rad iu s 1985;10:4 82-491. Lo za n o -Ca ld e ro n SA, Bro u w e r KM,
ractu res in th e elderly patien t. J Hand Eke n s t a m F, Ha ge rt CG . An atom ical stu d ies Do o rn b e rg JN, e t a l . Lon g-term ou tcom es
Surg Am. 2004;29:96 –102. on th e geom etr y an d stability o th e d istal o corrective osteotom y or th e treatm en t o
Rik li DA, Re ga zzo n i P. Fractu res o th e rad iou ln ar join t. Scand J Plast Reconstr Surg. d istal rad iu s m alu n ion . J Hand Surg Am.
distal en d o th e rad iu s treated by in tern al 1985;19:17–25. 2010;35E:370 –380.
xation an d early u n ction . A prelim in ary Frie d m a n SL, Pa lm e r AK. Th e u ln ar Pro m m e rs b e rge r KJ, Va n Sch o o n h o ve n J,
report o 20 cases. J Bone Joint Surg. im paction syn drom e. Hand Clin. La n z UB. Ou tcom e a ter corrective
1996;78(4):588 –592. 1991;7:295 –310. osteotomy or m alu n ited ractu res o th e
Rin g D, Pro m m e rs b e rge r KJ, Go n zá le z d e l Ge is s le r WB, Fe rn a n d e z DL, La m e y DM . d istal end o th e rad iu s. J Hand Surg.
Pin o J, e t a l . Corrective osteotom y or Distal rad iou ln ar join t in ju ries associated 2002;27B:55 –60.
in tra-articu lar m alu n ion o th e distal part w ith ractu res o th e d istal radiu s. Clin Rikli DA, Re ga zzo n i P. Fractu res o th e
o th e rad iu s. J Bone Joint Surg Am. Orthop Relat Res. 1996 Ju n ;327:135 –146. d istal en d o th e rad iu s treated by in tern al
20 05;87:1503 –1509. Hu ls ize r D, We is s AP, Ake lm a n E. Uln ar- xation an d early u n ction . A prelim in ary
So u e r JS, Rin g D, Ma t s ch ke S, e t a l . E ect sh orten in g osteotom y a ter ailed report o 20 cases. J Bone Joint Surg.
o an u n repaired ractu re o th e u ln ar arth roscopic débridem en t o th e trian gu lar 1996;78(4):588 –592.
styloid base on ou tcom e a ter plate- brocartilage com plex. J Hand Surg Am. Rin g D, Ro b e rge C, Mo rga n T, e t a l .
an dscrew xation o a d istal radial 1997;22:694 –698. Osteotom y or m alu n ited ractu res o th e
ractu re. J Bone Joint Surg Am. 2009; Ka p a n d ji IA. Th e Kapan dji-Sau ve d istal radiu s: a com par ison o stru ctu ral
91:830 –838. procedu re. J Hand Surg. 1992;17:125 –126. an d n on stru ctu ral au togen ou s bon e gra ts.
Ta le is n ik J, Wa t s o n HK. M idcar pal Nu n e z FA Jr, Ba rn w e ll J, Li Z, e t a l . J Hand Surg Am. 2002;27A:216 –222.
in stability cau sed by m alu n ited ractu res o Metaph yseal u ln ar sh orten in g osteotom y Rin g D, Pro m m e rs b e rge r KJ, Go n za le z d e l
th e distal radiu s. J Hand Surg Am. or th e treatm en t o u ln ocar pal abu tm en t Pin o J, e t a l . Corrective osteotom y or
198 4;9:350 –357. syn drom e u sin g distal u ln a h ook plate: in tra-articu lar m alu n ion o th e d istal part
Ze n ke Y, Sa ka i A, Os h ige T, e t a l . Th e e ect Case series. J Hand Surg Am. o th e rad iu s. J Bone Joint Surg Am.
o an associated u ln ar styloid ractu re on 2012;37A:1574 –1579. 2005;87A:1503 –1509.
th e ou tcom e a ter xation o a ractu re o Pa lm e r AK, We rn e r FW. Biom ech an ics o
th e distal radiu s. J Bone Joint Surg. 2009; th e d istal rad iou ln ar join t. Clin Orthop Relat
91:102–107. Res. 198 4;187:26 –35. Arth ro de sis o f th e wrist
Ba in GI, Wa t t s AC. Th e ou tcom e o scaph oid

Dista l ra dio uln a r jo int inju rie s Ma lun ion of d ista l ra d ia l fra ctu re s excision an d ou rcorn er arth rodesis or
advan ced car pal collapse at a m in imu m o
Ad a m s BD, Be rge r RA. An an atom ic Am a d io PC, Bo t t e MJ. Treatm en t o ten years. J Hand Surg Am. 2010;
recon stru ction o th e d istal rad iou ln ar m alu n ion o th e distal rad iu s. Hand Clin. 35(5):719 –725.
ligam en ts or posttrau m atic distal 1987;3:541–561. Bo la n o LE, Gre e n DP. Wrist arth rodesis in
radiou ln ar join t in stability. J Hand Surg Fe rn a n d e z DL. Correction o post-trau m atic post-trau m atic arth ritis: A com parison o
Am. 2002;27:243 –251. w rist de orm ity in adu lts by osteotom y, two m eth ods. J Hand Surg Am.
Alla n CH, Jo s h i A, Lich t m a n DM . Kien böck’s bon e-gra tin g, an d in tern al xation . J Bone 1993;18:786 –791.
disease: diagn osis an d treatm en t. J Am Acad Joint Surg. 1982;6 4 A:116 4 –1178 an d Bo ris ch BN, Ha u s s m a n n P. Rad io-lu n ate
Orthop Surg. 2001;9:128 –136. 200 0;120:23 –26. arth rodesis in th e rh eu m atoid w rist: a
Be d n a r MS, Arn o czk y SP, e t a l . Th e Fe rn a n d e z DL. Malu n ion o th e distal retrospective clin ical an d rad iological
m icrovascu latu re o th e trian gu lar rad iu s: cu rren t approach to m an agem en t. lon g-term ollow-u p. J Hand Surg.
brocartilage com plex: its clin ical Instr Course Lect. 1993;42:99 –113. 2002;27:61–72.
sign i can ce. J Hand Surg Am. 1991;16:1101– Fe rn a n d e z DL, Ju p it e r B. Fractures of the Ch a m a y A, De lla Sa n t a D, Vila s e ca A.
1105. Distal Radius: A Practical Approach to Rad iolu n ate arth rodesis actor o stability
Bilo s ZJ, Ch a m b e rla n d D. Distal u ln ar h ead Management. New York: Sprin ger;1996. or th e rh eu m atoid w rist. Ann Chir Main.
sh orten in g or treatm en t o trian gu lar Go n zá le z d e l Pin o J, Na g y L, Go n zá le z E, 1983;2:5 –17.
brocartilage com plex tears w ith u ln a e t a l . Com plex in tra-articu lar osteotom y Co h e n MS, Ko zin SH . Degen erative arth ritis
positive varian ce. J Hand Surg Am. or m alu n ion o th e distal rad iu s. o th e w rist: prox im al row car pectom y
1991;16:1115 –1119. In d ication s an d su rgical tech n iqu e. Rev versu s scaph oid excision an d ou r-corn er
Bre e n TF, Ju p it e r JB. Exten sor car pi u ln aris Orthop Traumatol. 2000;4 4:406 –417. arth rodesis. J Hand Surg Am. 2001;26:94 –
an d f exor car pi u ln aris ten odesis o th e Je n k in s NH, Min t o w t-Czyz WJ. Mal-u n ion 104.
u n stable d istal u ln a. J Hand Surg Am. an d dys u n ction in Colles’ ractu re. J Hand Co o n e y WP, Lin s ch e id RL, Do b yn s JH .
1989;14:612 –617. Surg. 1988;13B:291–293. Scaph oid ractu res: problem s associated
Ch e n NC, Wo lfe SW. Uln a sh orten in g Ju p it e r JB, Fe rn a n d e z DL. Com plication s w ith n onu n ion an d avascu lar n ecrosis.
osteotom y u sin g a com pression device. ollow in g distal radial ractu res. Instr Orthop Clin North Am. 198 4;15:381–391.
J Hand Surg Am. 2003;28:88 –93. Course Lect. 2002;51:203 –219. Frie d m a n S, Pa lm e r A. Th e u ln ar im paction
Ch u n S, Pa lm e r AK. Th e u ln ar im paction syn drom e. Hand Clin. 1991;7:295-310.
syn drom e: ollow-u p o u ln ar sh orten in g
osteotom y. J Hand Surg Am. 1993;18:4 6 –53.
495
Appendix
Ga rcia -Elia s M, Co o n e y WP, An KN, e t a l . Krim m e r H, Wie m e r P, Ka lb K. Com parative Sh in EK, Ju p it e r JB. Rad ioscaph olu n ate
Wrist k in em atics a ter lim ited in tercar pal ou tcom e assessm en t o th e w rist join t— arth rodesis or advan ced degen erative
arth rodesis. J Hand Surg Am. 1989;14:791– m ed iocar pal partial arth rodesis an d total radiocar pal osteoarth ritis. Tech Hand Up
799. arth rodesis. Handchir Mikrochir Plast Chir. Extrem Surg. 2007;11:180 –183.
Go n zá le z d e l Pin o J, Ca m p b e ll D, Fis ch e r T, 200 0;32:369 –374. St ra u ch RJ. Scaph olu n ate advan ced collapse
e t a l . Variable an gle lock in g in tercar pal Mu lfo rd JS, Ce u le m a n s LJ, Na m D, e t a l . an d scaph oid n onu n ion advan ced collapse
u sion system or ou r-corn er arth rodesis: Prox im al row car pectom y vs ou r corn er arth ritis—u pdate on evalu ation an d
In d ication s an d su rgical tech n iqu e. J Wrist u sion or scaph olu n ate (SLAC) or scaph oid treatm en t. J Hand Surg Am. 2011;
Surg. 2012 Au g;1(1):73 –78. n onu n ion advan ced collapse (SNAC) 36(4):729 –735.
Ha s t in gs H . Arth rodesis o th e w rists: a system atic review o ou tcom es. J Wa t s o n HK, Ba lle t FL. Th e SLAC w rist:
osteoarth ritic w rist. In : Gelberm an RH, ed. Hand Surg Eur. 2009;34(2):256 –263. scaph olu n ate advan ced collapse pattern o
Master Techniques in Orthopaedic Surgery. The Na g y L, Bü ch le r U. Lon g-term resu lts o degen erative arth ritis. J Hand Surg Am.
Wrist. New York: Raven rad ioscaph olu n ate u sion ollow in g 1984;9:358 –365.
Press;1994:345 –350. ractu res o th e d istal rad iu s. J Hand Surg. We is s APC, Ha s t in gs H . Wrist arth rodesis
Ha s t in gs H, We is s APC, Qu e n ze r D, e t a l . 1997;22:705 –710. or trau m atic con d ition s: a stu dy o plate
Arth rodesis o th e w rist or post-trau m atic Ozyu re ko glu T, Tu rke r T. Resu lts o a an d local bon e gra t application . J Hand
disorders. J Bone Joint Surg Am. m eth od o 4 -corn er arth rodesis u sin g Surg Am. 1995;20:50 –56.
1996;78:897–902. h ead less com pression screw s. J Hand Surg Wyrick JD, St e rn PJ, Kie fh a b e r TR.
Kra ka u e r JD, Bis h o p AT, Co o n e y WP. Am. 2012;37(3):486 –492. Motion -preser vin g procedu res in th e
Su rgical treatm en t o scaph olu n ate Pa lm e r AK, Do b yn s JH, Lin s ch e id RL. treatm en t o scaph olu n ate advan ced
advan ced collapse. J Hand Surg Am. Man agem en t o post-trau m atic in stability collapse w rist: prox im al row car pectom y
1994;19:751–759. o th e w rist secon dar y to ligam en t ru ptu re. versu s ou r-corn er arth rodesis. J Hand
J Hand Surg Am. 1978;3:507–532. Surg Am. 1995;20:965 –970.
Sh in AY. Fou r-corn er arth rodesis. J Am Soc
Surg Hand. 2001;1:93 –111.
Distal radius and ulna
AO/ OTA Fracture and Dislocation

Classi cation
Hand and carpus
For u rth er edu cation al m aterial abou t th e classi cation an d

access to th e com plete Fractu re an d Dislocation Classi cation
Com pen diu m , please u se th e QR code.
Appendix
2R3/ 2U3
Lo ca tio n: Radius/ Ulna, dista l e n d se gm e n t 2R3/ 2U3
U R
Type s:
Radius, distal end segment, Radius, distal end segment, Radius, distal end segment,
e xtra a rticu la r fra cture p a rtia l a rticu la r fra cture co m p le te a rticu la r fra ctu re
2R3A 2R3B 2R3C
Ulna, distal end segment, Ulna, distal end segment, Ulna, distal end segment,
e xtra a rticu la r fra cture pa rtia l a rticu la r fra cture co m p le te a rticu la r fra ctu re
2U3A 2U3B 2U3C
499
Appendix
2R3A
Typ e : Radius, distal end segment, e xtra a rticu la r fra cture 2R3A
Gro up :
Radius, distal end segment, extraarticular,
ra d ia l stylo id a vu lsion fra cture
2R3A1
Grou p : Radius, distal end segment, extraarticular, sim p le fra ctu re 2R3A2
Su b grou p s:
Tra nsve rse , n o disp la ce m e n t / tilt Do rsa l disp la ce m e n t / tilt (Co lle s) Vola r d ispla ce m e n t / tilt (Sm ith’s)
(m a y b e sh o rte n e d ) 2R3A2.2 2R3A2.3
2R3A2.1
Grou p : Radius, distal end segment, extraarticular, we d ge o r m u ltifra gm e n ta ry fra ctu re 2R3A3
Su b grou p s:
Inta ct we d ge fra ctu re Fra gm e n ta ry we d ge fra ctu re Mu ltifra gm e n ta ry fra ctu re
2R3A3.1 2R3A3.2 2R3A3.3
2U3A
Typ e : Ulna, distal end segment, e xtra a rticula r fra ctu re 2U3A
Gro u p: Ulna, distal end segment, extraarticular, stylo id p ro ce ss fra ctu re 2U3A1
Su bgro u ps:
Tip of st yloid fra ctu re Ba se o f st yloid fra ctu re
2U3A1.1 2U3A1.2
Gro u p: Ulna, distal end segment, extraarticular, sim p le fra ctu re 2U3A2
Su bgro up s:
Sp ira l fra ctu re Ob liqu e fra ctu re (>_30°) Tra n sve rse fra ctu re (< 30°)
2U3A2.1 2U3A2.2 2U3A2.3
> < 30°

− 30°
Gro u p: Ulna, distal end segment, extraarticular, m ultifra gm e n ta ry fra cture 2U3A3
501
Appendix
2R3B
Typ e : Radius, distal end segment, p a rtia l a rticu la r fra ctu re 2R3B
Grou p : Radius, distal end segment, partial articular, sa gitta l fra ctu re 2R3B1
Su b grou p s:
In volvin g sca p h oid fossa In volvin g lun a te fo ssa
2R3B1.1 2R3B1.3
Grou p : Radius, distal end segment, partial articular, d orsa l rim (Ba rto n’s) fra cture 2R3B2
Su b grou p s:
Sim ple fra cture Fra gm e n ta ry fra cture With d o rsa l d islo ca tio n
2R3B2.1 2R3B2.2 2R3B2.3
Grou p : Radius, distal end segment, partial articular, vo la r rim (re ve rse Ba rto n ’s , Go yra n d -Sm ith ’s II) fra ctu re 2R3B3
Su b grou p s:
Sim p le fra cture Fra gm e n ta ry fra ctu re
2R3B3.1 2R3B3.3
2R3C
Type : Radius, distal end segment, co m p le te a rticu la r fra ctu re 2R3C
Gro u p: Radius, distal end segment, complete, sim p le a rticu la r a n d m e ta p h yse a l fra ctu re 2R3C1
Su bgro u ps:
Dorsom e d ia l a rticu la r fra cture Sa gitta l a rticu la r fra ctu re Fro n ta l/ coro na l a rticu la r fra cture
2R3C1.1* 2R3C1.2* 2R3C1.3*
*Qualif cations:
t DRUJ stable
u DRUJ unstable
Grou p : Radius, distal end segment, complete, simple articular, m e ta ph yse a l m u ltifra gm e n ta ry fra ctu re 2R3C2
Su b grou p s:
Sa gitta l a rticu la r fra ctu re Fro n ta l/ co ro na l fra ctu re Exte n din g in to th e d ia p hysis
2R3C2.1* 2R3C2.2* 2R3C2.3*
*Qualif cations:
t DRUJ stable
u DRUJ unstable
Gro u p : Radius, distal end segment, complete, a rticu la r m ultifra gm e n ta ry fra ctu re , sim ple o r m u ltifra gm e n ta ry m e ta p h yse a l
fra cture 2R3C3
Su b grou p s:
Simple metaphyseal racture Metaphyseal multi ragmentary racture Extending into the diaphysis
2R3C3.1* 2R3C3.2* 2R3C3.3*
*Qualif cations:
t DRUJ stable
u DRUJ unstable
Qu a lif ca tio n s are optional and applied to the racture code where the asterisk is located as a lower-case letter within rounded brackets. More than one
qualif cation can be applied or a given racture classif cation, separated by a comma. For a more detailed explanation, see the compendium introduction.
503
Appendix
Ha n d a n d ca rp u s 78
An a to m ica l re gio n : Ha n d a n d ca rpu s 7 78
78
78 78
78
78
78
78
78 78
78
78
78
77 77
77
*
77
77
76
74 75
73
76 72
71
76
Bo n e s:
Hand and carpus, Lu n a te 71
Hand and carpus, Sca p h o id 72
Hand and carpus, Ca p ita te 73
Hand and carpus, Ha m a te 74
Hand and carpus, Tra p e ziu m 75
Hand and carpus, Oth e r ca rp a l b o n e s 76
Hand and carpus, Me ta ca rp a l 77
Hand and carpus, Ph a la n x 78
Hand and carpus, Cru sh e d , m u ltip le fra ctu re s 79
Qu a lif ca tio n s are optional and applied to the racture code where the asterisk is located as a lower-case letter within rounded brackets. More than one
Hand and carpus
Lu n a te 71
Bo n e : Hand and carpus, lu n a te 71
Typ e s:
Hand and carpus, lunate, Hand and carpus, lunate, Hand and carpus, lunate,
a vu lsio n fra ctu re sim p le fra ctu re m u ltifra gm e n ta ry fra ctu re
71A 71B 71C
Sca p h o id 72
Bo n e : Hand and carpus, sca p h o id 72
Typ e s:
Hand and carpus, scaphoid, Hand and carpus, scaphoid, Hand and carpus, scaphoid,
72A 72B* 72C*
*Qualif cations:
a Proximal pole
b Waist
c Distal pole
Ca p ita te 73
Bo n e : Hand and carpus, ca p ita te 73
Typ e s:
Hand and carpus, capitate, Hand and carpus, capitate, Hand and carpus, capitate,
73A 73B 73C
Ha m a te 74
Bo n e : Hand and carpus, h a m a te 74
Typ e s:
Hand and carpus, hamate, Hand and carpus, hamate, Hand and carpus, hamate,
h o ok fra ctu re sim p le fra ctu re m u ltifra gm e n ta ry fra ctu re
74A 74B 74C
Tra p e ziu m 75
Bo n e : Hand and carpus, tra p e zium 75
Typ e s:
Hand and carpus, trapezium, Hand and carpus, trapezium, Hand and carpus, trapezium,
75A 75B 75C
505
Appendix
Oth e r 76 ._.
Bo n e : Hand and carpus, o the r 76.__.
Pisifo rm Triq u e trum Tra p e zo id

76.1. 76.2. 76.3.
→ The bone identi er (between two dots .__.) is added to the code after the anatomical region.
76 .1
Hand and carpus, p isiform 76.1.
Typ e :
Hand and carpus, other, pisiform, Hand and carpus, other, pisiform, Hand and carpus, other, pisiform,
76.1.A 76.1.B 76.1.C
76 .2
Hand and carpus, triq u e tru m 76.2.
Typ e :
Hand and carpus, other, triquetrum, Hand and carpus, other, triquetrum, Hand and carpus, other, triquetrum,
76.2.A 76.2.B 76.2.C
76 .3
Hand and carpus, tra p e zo id 76.3.
Typ e :
Hand and carpus, other, trapezoid, Hand and carpus, other, trapezoid, Hand and carpus, other, trapezoid,
76.3.A 76.3.B 76.3.C
Hand and carpus
Me ta ca rp a ls 77.__.
Bo n e : Hand and carpus, m e ta ca rp a l 77.__.
Metacarpal
identifiers
3 Distal
3 2
4
Bone 5
segment 2 Diaphyseal 1
location
1 Proximal
→ The metacarpal bones are identi ed as follows: Thumb = 1, index = 2, long or middle = 3, ring = 4, and little = 5.
→ The metacarpal identi er is added (between two dots .__.) after the bone code.
→ The bone segment location is then added.
→ Example: Hand, 3rd metacarpal, proximal end segment = 77.3.1
Lo ca tio n: Hand and carpus, metacarpal, p roxim a l e n d se gm e n t 77.__.1

→ Example code for the 3rd metacarpal is indicated with an underline 77.3.1
Typ e s:
Hand and carpus, metacarpal, proximal end Hand and carpus, metacarpal, proximal end Hand and carpus, metacarpal, proximal end
segment, e xtra a rticu la r fra cture segment, p a rtia l a rticu la r fra ctu re segment, co m p le te a rticu la r
77.3.1A 77.3.1B 77.3.1C
Lo ca tio n: Hand and carpus, metacarpal, d ia ph yse a l fra ctu re 77.__.2

Typ e s:
Hand and carpus, metacarpal, diaphyseal, Hand and carpus, metacarpal, diaphyseal, Hand and carpus, metacarpal, diaphyseal,
sim p le fra ctu re we d ge fra ctu re m u ltifra gm e n ta ry fra ctu re
77. 3.2A 77. 3.2B 77. 3.2C
Lo ca tio n: Hand and carpus, metacarpal, d ista l e n d se gm e n t 77.__.3

Typ e s:
Hand and carpus, metacarpal, distal end Hand and carpus, metacarpal, distal end Hand and carpus, metacarpal, distal end
segment, e xtra a rticu la r fra cture segment, p a rtia l a rticu la r fra ctu re segment, co m p le te a rticu la r fra ctu re
77. 3.3A 77. 3.3B 77. 3.3C
507
Appendix
Ph a la n x 78.__.__.
Bo n e : Hand and carpus, p h a la n x 78.__.__.
Finger
3
2
4
1
2
Phalanges
1 3 Distal
Bone
segment
2 Diaphyseal
location
1 Proximal
→ The ngers and phalanges are identi ed as follows:

Fingers: Thumb = 1, index = 2, long or middle = 3, ring = 4, and little = 5.
Phalanges: Proximal phalanx = 1, middle phalanx = 2, and distal phalanx = 3.
The nger identi er plus phalanx identi er are added (between dots .__.__.) after the bone code.
→ Example: Proximal thumb phalanx is 78.1.1.
→ The location is then added.
→ An a to m ica l re gio n + b o ne .Finge r.Pha la n x.Bo ne se gm e nt loca tio n
→ Example: Proximal thumb phalanx proximal end segment is 78.1.1.1
Loca tio n : Hand and carpus, phalanx, p roxim a l e n d se gm e n t 78.1.1.1

→ Example code for proximal thumb phalanx is indicated with an underline 78.1.1.1
Typ e s:
Hand and carpus, phalanx, proximal end Hand and carpus, phalanx, proximal end Hand and carpus, phalanx, proximal end
segment, e xtra a rticu la r fra ctu re segment, p a rtia l a rticula r fra ctu re segment, co m p le te a rticu la r fra ctu re
78.1.1.1A 78.1.1.1B 78.1.1.1C
Loca tio n : Hand and carpus, phalanx d ia ph yse a l fra ctu re 78.1.1.2
Typ e s:
Hand and carpus, phalanx, diaphyseal, Hand and carpus, phalanx, diaphyseal, Hand and carpus, phalanx, diaphyseal,
sim p le fra ctu re we dge fra cture m u ltifra gm e n ta ry fra ctu re
78.1.1.2A 78.1.1.2B 78.1.1.2C
Loca tio n : Hand and carpus, phalanx, d ista l e n d se gm e n t 78.1.1.3

Typ e s:
Hand and carpus, phalanx, distal end segment, Hand and carpus, phalanx, distal end segment, Hand and carpus, phalanx, distal end segment,
e xtra a rticu la r fra ctu re p a rtia l a rticu la r fra ctu re co m p le te a rticu la r fra ctu re
78.1.1.3A 78.1.1.3B 78.1.1.3C
Hand and carpus
Cru sh e d , m u ltip le fra ctu re s 79

Hand and carpus, cru sh , m u ltip le fra ctu re s h a n d 79
Qua lif ca tion s are optional and applied to the racture code where the asterisk is located as a lower-case letter within rounded brackets. More than one
509

Manual of Fracture Management - Wrist 1st Edition

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Je sse B Jupite r | Douglas A Cam pbe ll | Fie sky Nuñe z

Manual of Fracture Management

Manual of Fracture Management

Close to 2 ,0 0 0 illustrations and im age s and 15 vide os

Che ck hazards and le gal re strictions on www.aofoundation.org/ le gal

ISBN: 978 3132428 416 1 2 3 4 5 6

Now several decades an d th ou san ds o operation s later we

Drs Cam pbell, Ju piter, an d Nu n ez, th ree li elon g su rgeon

Renato Fricker, MD Jesse B Jupiter, MD Fiesky A Nuñez Jr, MD, PhD

A PL abdu ctor pollicis lon gu s

Online book content

Usin g a QR code scan n er on a m obile device, readers w ill

Fore word V 1.1 Palm ar approach to the scaphoid 5

Pre face VI 1.2 Dorsal approach to the scaphoid 13

Contributors VIII 1.4 Radiopalm ar approach to the thum b base 31

Abbre viations X 1.5 Dorsoradial approach to the distal radius 37

1.7 Ulnar palm ar approach to the distal radius 49

1.8 Dorsal approach to the distal radius 55

1.9 Exte nde d dorsal approach to the distal radius 65

1.10 Ulnar approach to the distal ulna 77

3 .1 Ulnar styloid—fracture tre ate d with te nsion band wiring 221

3 .2 Ulna, he ad and ne ck—m ultifragm e ntary fracture tre ate d 231

5 .1 Distal radius—dorsal e xtraarticular malunion treate d with 371 Furthe r re ading 4 93

5 .3 Distal radius—intraarticular malunion treate d with 39 9

5 .4 Distal radius—e xtraarticular and intraarticular m alunion 417

5 .5 Rheumatoid arthritis treate d with radiolunate arthrodesis 429

5 .6 Kienbock’s disease treate d with total wrist arthrode sis 439

5 .7 Malunite d fracture with associate d ulnar abutm e nt 44 9

5 .8 Long-standing nonunion tre ate d with re se ction of 467

5 .9 Chronic inte rcarpal arthritis tre ate d with scaphoid 475

2 Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d Je sse B Jupite r

4 Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d Je sse B Jupite r

Fig 1.1 -1 In ju ries in volvin g th e scaph oid can be treated

Fig 1.1-2 a – b Fractu res o th e scaph oid are typically

Fig 1.1-3 Th e palm ar approach also gives access to

Fig 1.1-6 a – b On th e palm ar side o th e w rist, th e

Fig 1.1-7 Im portan t an atom ical lan dm arks or th e an gled

Palmar cutaneous branch Flexor carpi

Fig 1.1-8 Th e in cision lin e can be m arked on th e skin in lin e

Fig 1.1-9 Altern atively, a zigzag palm ar in cision can be

Palmar cutaneous branch Flexor carpi

Fig 1.1-1 0 Th e su per cial palm ar bran ch o th e radial

Fig 1.1-1 1 Th e FCR sh eath is open ed as ar distally as

Superficial palmar branch

Fig 1.1-1 2 Th e capsu le is th en in cised obliqu ely rom

Fig 1.1-1 3 Altern atively, to preserve th e palm ar liga-

Long radiolunate ligament

Fig 1.1-1 4 Retract th e divided radioscaph ocapitate

Long radiolunate ligament

Fig 1.1-1 5 I it is n ecessary to expose th e proxim al part o

Fig 1.1-1 6 Th e scaph otrapezial join t m u st be exposed to

Fig 1.1-1 7 Th e scaph otrapezial join t is iden ti ed, th e

Fig 1.1-18 Th e divided palm ar ligam en ts (radioscaph ocapitate

Th is video dem on strates th e

Fig 1.2 -1 In ju ries in volvin g th e scaph oid can be treated

Fig 1.2-2 a – b Th e dorsal approach to th e scaph oid is

Fig 1.2-3 Th ere are ve exten sor com partm en ts on th e

Th e rst com partm en t con tain s th e abdu ctor pollicis

Fig 1.2-4 Th e su per cial radial n erve (1) an d th e dorsal

Make a straigh t dorsal skin in cision startin g

Fig 1.2-6 En su re to preserve an y parts o th e su per cial

Fig 1.2-7 In cise th e distal part o th e exten sor retin acu lu m

Superficial branch of Extensor retinaculum