Comminuted Metaphyseal–Diaphyseal Fractures

Comminuted Metaphyseal–Diaphyseal Fractures 11

Fig. 11.1 (a–c) Traditionally metaphyseal–diaphyseal comminution has been considered a contraindication for arthroscopy. However, no single good reason for this has been put forward. The only problem we have seen is that loss of reduction may occur because the wires may cut through the comminuted metaphyseal fragments during the arthroscopic part of the operation. (d) A paradigmatic example of this problem, a case of mine.

Fig. 11.2 The way to overcome this hindrance is a truism: Create a stable platform that maintains reduction while you do your arthroscopic work. In some cases the surgery has to be planned as shown here when the radial fragments are the larger ones. (© del Piñal 2014.)

Fig. 11.3 However, the operation is preferably planned the other way around, stabilizing the ulnar part of the radius first. In such cases the procedure is easier, because the scope can be advanced on a stable platform. In a nutshell, the surgeon has to use the larger fragment as the guide from which to build the joint.

Fig. 11.4 This 60-year-old woman suffered, in an accidental fall, a C33 fracture of the AO classification (articular comminuted and metaphyseal–diaphyseal comminution). Initial treatment was a cast, but the patient was not totally satisfied and sought a second opinion.

Fig. 11.5 Her case predated the use of the image processor that we currently use, and only axial views and some computed tomography (CT) coronal slices were available. However, it is clear that a major derangement of the joint existed in the axial images. Nevertheless, there were two major ulnar fragments.

Fig. 11.6 The only available coronal view demonstrates that the large cortical fragment missing (asterisk) on the radial cortex is abutting the lunate. This was confirmed at arthroscopy. The scope is in 6R. A flap of scapholunate interosseous membrane (SLIOM) can also be seen.

Fig. 11.7 The case was managed as follows: through a volar-radial approach, the length of the radius was restored and the joint temporarily reduced with K-wires. Once the surgeon was satisfied with the image intensifier controls, the most proximal screw was inserted in one of the elliptical holes of the extra-long DVR™ plate; this allows some fine tuning of the relationship with the ulna once the next step is completed. Two locking screws were inserted in the larger ulnar fragments, thus creating a stable strut that would not collapse during the rest of the operation. Notice that the screw in the stem of the plate allows ± 0.5-cm variance adjustments. The construct in such cases is so unstable that this part of the operation was performed without arthroscopy. Once the surgeon was satisfied with the radioulnar relationship, another screw was inserted in the stem of the plate, thus creating an unyielding platform.

Fig. 11.8 Now that a solid platform has been built, the scope can be advanced and the scaphoid fossa taken care of without risk of losing the reduction. First, a grasper is introduced through the 3–4 portal, unjamming the cortical fragment and removing it from the joint.

Fig. 11.9 Attention was then directed to the radial scaphoid fossa. (a) Here there were three main fragments, and all had been pushed distally into the joint by the spike (the step-off highlighted by arrows). The styloid K-wire was retracted and the scaphoid fossa fragments reduced with a Freer introduced from the 3–4 portal. (b) The step-off is now corrected.

Fig. 11.10 The summary of the maneuvers is as follows: the K-wire was retracted slightly (1); the fragment was reduced with a Freer (2); and the surgeon compressed the fragment toward the plate (3). Then, the assistant pushed in the K-wire (4) and drilled for the locking screws (5).

Fig. 11.11 The operation is terminated with the hand laying on the table and the rest of screws inserted. If I have the least concern about healing (because of the amount of devascularization), I pack cancellous bone graft from the olecranon in the fracture. However, in this patient I believed it was unnecessary. Range-of-motion exercises were begun immediately.

Fig. 11.12 Note in the radiographs at 1 year that in this case I had clearly dropped my guard and some radial translocation of the distal fragment persisted. This was not a hindrance to achieving a full range of motion and an excellent result in this patient.

Fig. 11.13 In Video 11.1 the maneuvers for reduction and the final result are shown.

Fig. 11.14 When there is massive metaphyseal–diaphyseal comminution, I use an indirect reduction technique, much the same as Lanz’s technique for extra-articular malunion. The technique is, however, more difficult because the shaft is unstable and the surgeon has to rely on fluoroscopy to place the plate at the appropriate angle of correction. The plate is attached to the distal fragment (first with K-wires, which are changed to locking screws when their position is satisfactory), and this combined construct is used for the reduction.