Fig. 6.1 When fragments are small and jammed, there is a real risk of fragmentation if the surgeon pulls with the shoulder probe while attempting to reduce them. In such cases I either use a periosteal elevator as a shovel (see Figs. 8.12, 13.16, or 19.11) or, in an infallible trick, push the fragment from below, as illustrated in this chapter in a clinical case.
Fig. 6.2 The sunken fragments are approached through an accessory window in the metaphysis and pushed up from below with an instrument like a dental tamper.
Fig. 6.3 My preferred tool is this sturdy but delicate instrument. Its curved end permits movement inside the metaphyseal void.
Fig. 6.4 This 42-year-old fireman sustained this fracture in a motorbike injury. This appears to be a case of a typical volar shearing fracture (discussed in Chapter 7), but it has several concerning features.
Fig. 6.5 First of all, a large (but narrow) fragment in the scaphoid fossa (asterisk) has sunk deeply into the metaphysis (arrows point to the step-off).
Fig. 6.6 Second, there is comminution on the volar metaphysis combined with marginal fractures. Because the fracture is a volar shearing type, a buttress plate is the fixation method of choice. Although a volar plate may reduce the ulnar fragment (by restoring the volar cortex shape), it will have no effect on the sunken radial fragment.
