Fig. 14.1 Rim fractures have a lot of difficulties and complications, above all the feared volar ulnar radiocarpal dislocation that were discussed in Chapters 9 and 10. Another problem is the high risk of joint penetration with the screws (see Fig. 22.4). This is because in a typical distal radius fracture, the surgeon will have the metaphysis as a reference for the reduction of the anterior articular fragment. When pressure is applied dorsally, the volar metaphysis will adapt to the plate, and in most cases this will reduce such fragments anatomically.
Fig. 14.2 In rim fractures the surgeon has no clue regarding the angulation of the articular fragment, and the risk of screw penetration is much higher. This provides us with yet another good reason for using arthroscopy when dealing with distal radius fractures. We will discuss this issue and others in the following case of a complex marginal fracture.
Fig. 14.3 This 49-year-old mason suffered a comminuted articular fracture in a fall from a scaffold. He also sustained a spine fracture that required urgent surgery, and we first saw the patient 10 days after the original incident.
Fig. 14.4 The severity of the comminution is evident in the coronal slices, particularly in C2, where three fracture lines can be seen (arrows).
Fig. 14.5 The sagittal slices are even more worrying: There is a complex volar shearing fracture, a free osteochondral fragment (yellow arrow), and a rim-type fracture (red arrows).
Fig. 14.6 Although the axial views in this patient showed a benign configuration of the fracture in the sigmoid notch, additional information was gathered. Not only could the shape of the free osteochondral fragment (FOF) be delineated, but osteoarthritis was also revealed in the distal radioulnar joint (the yellow arrows point to the osteophytes).
Fig. 14.7 In summary, this complicated case involved a complex marginal volar shearing fracture with five articular fragments (1–5), one of which was free. Notice that the fragments had sunk 11 mm in relation to the dorsal rim of the radius, which is itself a poor reference because it was also fractured (asterisk). Another measurement taken in the sagittal plane is the length of fragments 2 and 5, useful when creating a reducing platform (see Fig. 14.9).
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