Fig. 21.1 As we near the final chapter, please allow me to digress with a light-hearted joke: Do you know the difference between a complex case and a painful complex case? The complex case has already been operated on by somebody else; the painful complex case has already been operated on by you!
Most hand surgeons are aware that the image intensifier is unreliable and that postoperative radiographs may reveal step-offs that were not appreciated on fluoroscopy. In these cases the blame often falls on the surgeon; however, what if the plate itself did not adequately hold the reduction as it is meant to? What if plates are not as good as we have been led to believe by the manufacturers?
The following is a painful complex case that I hope promotes some debate and provides some potential solutions.
Fig. 21.2 This 24-year-old patient sustained a displaced distal radius fracture, with persistent instability after reduction in the office (not a great start to the case!). The reduction was far from normal, with the radius tending to shift back toward the original deformity, which can be seen in the S4 and S5 images and in the preoperative photograph.
Fig. 21.3 The patient was operated on as described throughout this atlas. No complications ensued. A question of concomitant scapholunate dissociation was quickly answered at arthroscopy: a “baby-bum” sign indicated normality. There was a small articular step-off that required minimal twisting to achieve an anatomical reduction (scope in 6R; probe in 3–4).
Fig. 21.4 Final fluoroscopic views after fixation. Note the minimal widening of the S-L interval on the anteroposterior view and a normal S-L angle on the lateral view. (However, a normal S-L angle may later evolve into a true S-L dissociation; therefore arthroscopic findings provided peace of mind.)
Fig. 21.6 Despite formal physical therapy from the third week, little progress could be seen at the 8-week visit when compared to the previous image. The patient continued to complain of mild yet nagging pain. New radiographs were ordered at that visit. (Note: Same t-shirt but different day!)
Fig. 21.7 Despite the poor quality of the radiographs, the scaphoid fossa fragment has clearly sunk into the metaphysis. There are now two possible courses of action that may be taken: either disregard the problem and discharge the patient with the “nuisance,” assuring the patient that “it will improve in the next few years,” or accept that things went awry and attempt to fix it.
Fig. 21.8 The CT scan clearly demonstrates failure of the fixation, with the scaphoid fossa now depressed 4 mm—fairly concerning, given the perfect arthroscopic reduction (see Fig. 22.3).
Fig. 21.9 The sagittal slices are helpful to give a three-dimensional shape to the problem. S3 looks very unusual; however, the other slices appear quite normal. Notice in S4 and S5 the subchondral position of the ulnar-side screws but the much-too-proximal location of the radial-side hardware.
Fig. 21.10 The coronal cuts confirmed that the length of the radius had been maintained, as had the reduction of the lunate fossa fragment. However, it is evident that the scaphoid fossa fragment has sunk. It seems likely that the fragment slipped over the third screw in the distal row, and the remaining screws were unable to maintain the reduction. Note the radiolucency around the tip of the radial screws.
In summary, the plates had been designed to support the load and to allow immediate range of motion; thus this is a case of design failure, because the plate has not failed mechanically.
Fig. 21.11 Using the OsiriX and slanting the axis in the frontal plane, a true “fragment view” was obtained (see Fig. 1.14). This view offers a much better idea of the deformity (which is actually worse than the original deformity).
Fig. 21.12 From studying the CT images, a mental image of the deformity was formulated: Essentially the radial central screws have failed to support the reduced scaphoid fossa.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
