Fig. 15.1 This 39-year-old man, with a psychiatric history of borderline cognitive capacity, suffered this fracture while working as an assistant gardener. His post-reduction radiographs do not look terribly bad, though they begged for surgery. Post-reduction radiographs may be misleading, however; the plaster hides a lot of information, and the reduction may give a false feeling of benignity to the original trauma. I always ask for the initial films, because they can give me much more information.
Fig. 15.2 As a matter of fact, the original radiographs were revealing: another panicking explosion-type distal radius fracture in a perhaps uncooperative patient. There are several more features that made this fracture much more complicated than the previous cases.
Fig. 15.3 The coronal slices demonstrate two features with a grim prognosis: loss of the ulnar pillar (yellow arrows) and a sunken free osteochondral fragment (FOF) (red arrows).
Fig. 15.5 The axial cuts show destruction of the posterior aspect of the sigmoid notch (also evident in the C3 and C4 slices). This together with the displaced ulnar styloid caused concern about the bony stability of the distal radioulnar joint (DRUJ). This set of pictures also obliges me to stress the importance of ordering a CT scan in complex cases. Spending time scanning the different sections gives invaluable information.
Fig. 15.7 After studying the CT scan, I came up with this “picture” of the deformity. Perhaps the greatest indicators for labeling this fracture as having a bad prognosis are the comminution of the ulnar pillar and a large FOF. However, the most concerning issue turned out to be the derangement of the sigmoid notch.
