A 40-year-old man fractured his left nondominant wrist in a skiing accident . A, Posteroanterior view at time of injury demonstrates complex metaphyseal and articular comminution with substantial displacement. B, Lateral view also demonstrates substantial metaphyseal comminution.

A, External fixation provides both continuous intraoperative traction as well as postoperative support and protection. A single large incision for insertion of both Schanz screws helps to protect the radial sensory nerve and prevent impaling underlying muscles and tendons. B, Volar access is most commonly obtained using Henry’s interval between the flexor carpi radialis (FCR) and the radial artery. The skin is incised in line with the FCR and crosses the transverse wrist creases obliquely. The superficial radial artery and the palmar cutaneous branch of the median nerve should be protected in the distal portion of the wound. The flexor carpi radialis tendon sheath is incised to gain access to the deeper structures. A second incision in the palm was used to release the carpal tunnel to prevent injury to the palmar cutaneous branch of the median nerve. C, The fat overlying the pronator quadratus and the flexor pollicis longus are swept ulnarward bluntly. For very proximal exposure, the most radial and distal portion of the flexor pollicis longus muscle is elevated from the radius (forceps). The radial edge of the radius is exposed (Hohmann retractors). The pronator quadratus is then incised on its radial margin and elevated subperiosteally. D, The brachioradialis tendon can be released or Z-lengthened to facilitate restoration of length and ulnarward inclination of the distal radius articular surface. E, This illustration demonstrates the difficulty in aligning and stabilizing these complex fractures. Direct cortical contact between the radial diaphysis and the distal radius is possible only in a very small area in the center. On the ulnar side (Freer elevator and left index finger), a large fragment of volar-ulnar cortex has been repositioned and provisionally stabilized with a smooth Kirschner wire to help judge restoration of length and alignment and perhaps provide additional stability. F, The dorsal incision is in line with the third metacarpal and the radial diaphysis (and Lister’s tubercle when palpable). A long incision is needed to provide for both dorsal and radial implants and dorsal capsulotomy. G, The development of full-thickness skin grafts protects the radial and ulnar sensory nerve branches and provides broad access to the dorsal surface of the distal radius. H, The extensor pollicis longus is identified, mobilized, and transposed dorsally and radially into the subcutaneous tissues, where it is left at the end of the procedure. I, The fourth dorsal compartment is elevated subperiosteally off the distal radius, but the attachment of the dorsal capsule to the dorsal fracture fragments is maintained. J, A longitudinal incision of the dorsal capsule has been created, and the dorsal ulnar distal radius fragments are elevated. One can see a piece of metaphyseal cortical bone that was removed from the joint (near the Hohmann retractor to the left) and impacted central articular fragments below the forceps under the dorsal-ulnar fragment. K, The forceps ( right hand ) are elevating the dorsal portion of the scapholunate interosseous ligament, which was avulsed from the scaphoid at the time of injury. A dorsal capsulotomy allows for identification and treatment of intercarpal injuries. L, The alignment of the volar articular fragments (at the tip of the suction) can be monitored and adjusted through this exposure. M , Impacted central articular fragments are identified, realigned, and supported. In complex fractures such as this one, these fragments are removed, replaced once the major volar fragments have been realigned and secured, and supported with both fixed-angle fixation devices and bone graft. N, The volar plate can assist with realignment of the volar articular fragments. The volar fragments tend to rotate on their volar capsular attachments into dorsal angulation. The distal screws are applied in anatomic position, with the proximal portion of the plate off the bone. O, When the proximal portion of the plate is brought down to bone, the alignment of the volar articular fragments is improved. The alignment of the volar cortex is checked and the plate secured proximally. P, The radial styloid fragment may benefit from a separate fixation device specifically to control it. Good access to the radial styloid is available between the first and second dorsal compartments. In this patient, a plate with angular stable screws was applied to the radial styloid in this area. Q, With the radial styloid and the volar fragments realigned and stabilized, the metaphyseal and articular defects are more obvious. R, The impacted central articular fragments are replaced and supported by the angular stable screws and by bone placed into the metaphyseal defect. If all of the bone fragments that are retrieved are saved and replaced at the end of the case, additional bone graft and substitutes are often unnecessary. S, Before repositioning and fixation of the dorsal ulnar fragments, the scapholunate ligament is reattached to the scaphoid using a suture anchor. T, The dorsal cortex with the dorsal articular margin is then repositioned and repaired with a dorsal plate. Angular stable screws in the distal limb provide additional support for the articular fragments. U, The wounds are closed. V, The traction across the external fixator is diminished so that the extrinsic extensor and flexor tendons are not excessively tight. The wrist is placed in a position of neutral or slight extension to facilitate motion and rehabilitation of the hand.