Fig. 20.1 These radiographs belong to a 36-year-old man who sustained a bike fall 4 months prior to presentation. He is a security guard and underwent a very extensive physical therapy program after his original surgery.

Fig. 20.3 This immediate postoperative picture was of great help, because it seems that the fracture was never reduced at all. The (bent) K-wire at the DRUJ also suggests an attempt to maintain the reduction under force.

Note: This highlights the fact that the DRUJ can only be stable when the radius anatomy is restored; otherwise, relapse and bending of the K-wires is the norm.

Fig. 20.4 Two screws (asterisks) can be seen penetrating a large anterior-ulnar fragment and actually eroding the lunate.

Fig. 20.5 This is confirmed in the sagittal slices. Note the enormous defect on the lunate in S4, where the screw can be seen penetrating the subchondral bone (dots).

Fig. 20.7 In these complex cases I spend time trying to figure out the nature of the original deformity, the way the previous surgeon has managed it, and the reasons for its failure. Thus thinking in reverse might provide the key to solving the case. Taking into account the preoperative images, I came up with this “sketch” of the deformity, which the highly talented Max Crespi has rendered.

Note: My drawing skills are (and have always been) nil. Thanks to this I am a surgeon rather than an architect.