Presentation
Bricklayer falled from height an outstretched arm with pain, tenderness, swelling and decreased range of motion. Deformity at wrist joint.
Patient Data
Rx right wrist
Fracture of the distal radius, volar type or reverse Barton fracture, with wedge shaped fragment and subluxation of radiocarpal joint. There’s also ulnar styloid fracture.
Rx right wrist
Radiographs postoperatively of displaced distal radius fracture after plate fixation with screws. Radial inclination and radial tilt are normal 22.58° (V.N. 21°-25°).
Rx right wrist (a month later)
The long axis of the radius, lunate, capitate and the third metacarpal bone should be align. This lateral wrist view show slight dislocation of the carpus with the radial styloid fragment in anterior side of the lunate (yellow arrow)
Rx right wrist (two month later)
Late avascular necrosis of volar marginal fragments that appear healed at eight weeks postoperatively can ultimately lead to late carpal subluxation when other intrasubstance ruptures of extrinsic ligaments fail to heal well.
Case Discussion
Complication rates for plate fixation show a very large variety, but it seems possible to prevent many of these complication if correct plate position is observed and special attention is given to avoid penetrating screws. Radiocarpal fracture-dislocations can occur with a larger radial styloid fragment controlling the origins of the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments with midsubstance rupture of the remaining volar extrinsics: short radiolunate (SRL), ulnolunate (UL), ulnocapitate (UC), and ulnotriquetral (UT). The volar extrinsic ligaments are the most important stabilizers resisting translation both dorsally and volarly. The dorsal extrinsic ligaments contribute very little to restraining translation both dorsally and volarly. These are high-energy traumas typically associated with high falls, violent sports impact, or vehicular accidents.