Marc Gracia-Elias, MD
Institut Kaplan, Hand and Upper Extremity.
Passeig de la Bonanova, 9, 2nd floor, 2nd door
08022 Barcelona, Spain.

(case submitted May 29, 1999)

The patient is a 35-year-old professional sailor. On May 1997 while jumping from the boat to the deck, he fell onto his outstretched right, dominant wrist. He had immediate substantial pain, swelling and the usual dorsal fork-like deformity, and he saw a local physician. (No initial fracture X-rays are available. Believe it or not; they disappeared from the files!) The xrays were interpreted as a three-part intraarticular fracture of the distal radius, with proximal impaction (die-punch) of the dorso-ulnar fragment, with dorsal metaphyseal comminution, and stability of the distal radioulnar joint (AO type C.2.2, or Mayo type III).

According to the initial treating physician charts, because of the irreducibility of the impacted portion of joint articular surface and the metaphyseal comminution, a surgical intervention was decided. As shown in figures 1A and 1B, a unilateral Orthofix external fixator was applied. Through a small dorsal incision, and without opening the joint, the dorsomedial fragment was elevated and fixed with two K-wires. The empty space created in the metaphysis was filled with cancellous bone from the iliac crest. No intraarticular arthroscopic examination was attempted. After this, the DRUJ stability was checked and considered adequate.

Figure 1a and 1b

Wounds healed adequately, and post-operative X-rays while with the EF in place showed good alignment. The wrist was kept immobilized for 3 months with the External Fixator (!), at which point consolidation was certain and both the EF and one K-wire were removed (for some reason the second K-wire was not palpable under the skin so it was not removed.)

Just after the EF was removed, the patient felt that something was wrong in his wrist. A dorsoradial protrusion appeared, associated to pain at any attempt of passively moving the wrist. No X-rays were obtained, and an intensive rehabilitation regime was initiated.

On February 1998, 9 months after the injury, the patient's wrist was still very painful, with a dorsally protruding bone at his dorsoradial aspect of the wrist. His arc of motion was very limited (flexion 18º; ext 25º; rad dev 0º; ulnar dev 5º; supination 65º; pronation 85º), and his grip strength almost absent (3 kgrs vs 48 kgrs the contralateral side). He was referred to my office and these xrays were obtained.

Figure 2a and 2b

Question 1: What associated problem had been missed, making an adequate recovery impossible?

Question 2: What three examination tools would have been useful to recognize this problem?

Question 3: In case this complication would have been recognized initially, would your treatment had been different?

Question 4: Assuming integrity of the cartilage at the head of the capitate, and a badly damaged radioscaphoid and radiolunate joint cartilages, what options do you consider?

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