Fig. 5.1 As stated in the previous chapter, the contour of the anterior metaphysis adapts to the plate and thus the anterior fragment is reduced automatically, whereas the dorsal fragment may remain unreduced. The surgeon should be aware that because of metaphyseal comminution (in which the K-wires may pull through the metaphysis), anatomical differences, or simply loss of reduction, the anterior fragment may end up sunken dorsally, as it is here.
Fig. 5.2 This is the preoperative CT study of a 54-year-old female civil servant. She sustained a fall in a motorbike accident 1 week earlier. The fracture seemed to be simple with just two main articular fragments, one of them minimally displaced.
Fig. 5.3 The axial views revealed an undisplaced scaphoid fossa fracture (red arrows) and a major dorsal displacement of the dorsal fragment (yellow arrows).
Fig. 5.4 The coronal slices on the CT helped to delineate the dorsal rotation of the anterior fragment and the dorsal splaying of the posterior fragment. The cortical fragment (red arrows) would benefit from a lag screw to the plate, but nothing else was needed. Overall this was a benign fracture.
Fig. 5.5 Initially the plate was placed too distally. The radiographs may be misleading, but there is a clue that never fails: if you feel resistance while drilling the K-wire, you are in the wrong place. Such resistance is a likely indicator that you are perforating subchondral bone. However, all is not lost. If the screw of the elliptical hole is correctly placed (in the middle of the elliptical hole), the plate can be easily repositioned. For this patient the K-wires were removed, the screw was slightly loosened, and the plate was eased proximally 4 mm, with care not to lose longitudinal alignment.
Fig. 5.6 The plate is correctly placed here, with enough space for the ulnar distal screw. This can be inferred by the existence of sufficient space between the subchondral bone of the lunate fossa and the ulnar K-wire (arrows). Interestingly, the lateral view gave no clue that anything might be wrong inside the joint.
