Fig. 13.1 I defined an explosion type distal radius fracture as one that results in four or more articular fragments and/or a free osteochondral fragment (del Piñal 2010). From the beginning you know you have a problem—but don’t panic since most of these cases can be dealt with if one follows the principles that have been covered so far: Restore length by reducing the anterior-ulnar fragment, and work from larger fragments to smaller and preferably from ulnar to radial. These radiographs correspond to a 42-year-old man who works as a painter and fell from a ladder.
Fig. 13.2 The axial slices looked much worse than the radiographs. You can count at least four articular fragments—at worst could be seven—in slice A2.
Fig. 13.3 The C4 slice demonstrates major dorsal comminution.
Fig. 13.4 The sagittal views further delineate the fracture. Despite the severity, by mentally picturing S4, S5, and A1 joined together, the surgeon can be assured that it is going to be “clear sailing”—there is a large volar ulnar fragment, and luckily this is the key fragment upon which one can rebuild the radius. “Lucky” surgeon!
Fig. 13.5 As shown in this artistic rendering, a large volar ulnar fragment, such as in this patient’s case, allows the surgeon to restore length and avoid any risk of malalignment from ulnar or radial translocation.
Fig. 13.6 The length of the radius has been restored by traction. Note that when the volar ulnar fragment was pushed with a Freer (arrow), the volar metaphysis was anatomically reduced. Therefore the articular portion of this fragment (the volar fragment) will automatically be reduced. As we are dealing with a large fragment, there is no risk of radial translocation.
Fig. 13.7 The stabilization of the fragments proceeded as usual. Screws maintained plate positioning, and K-wires provided temporary articular reduction. In these types of fractures the main goal is to reduce the number of unstable fragments and then fine-tune the reduction of the rest during arthroscopy.
Fig. 13.8 The corresponding fluoroscopic view before arthroscopy. The reduction in the radial part of the joint looks awful, but the surgeon should not worry about it. Remember that preferably the surgeon should work from ulnar to radial, and this will allow the scope to be advanced upon a stable platform (see Fig. 3.30 and Chapter 11). At this point, the hand was put in traction and the ulnar part of the joint was assessed.
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