Clinical Details

Clinical and radiological findings:  This injury belongs to an octogenarian following a simple fall in a nursing home. A closed injury neurovascular status was difficult to determine due to cognitive deterioration. A closed reduction in the emergency department was unsuccessful due to high-grade instability and poor soft tissue envelope. Operation was done on the day of injury. Henry’s approach to the distal radius demonstrated markedly osteopenic metaphyseal bone quality and extraarticular comminution. In addition the width of the distal radial metaphysis was quite small accommodating only a three hole wide plate. Reduction was achieved precariously and held with multiple temporary k-wires pending provisional positioning of the plate. Due to poor bone quality in the diaphyseal-metaphyseal transition zone a long plate was placed into better quality diaphyseal bone proximally. A second working window proximal to the belly of flexor pollicis longus provided exposure for the proximal screw positions. Reduction and fixation of the distal radius did provide initail axial alignment of the distal ulna however this was not dynamically stable. Anterograde intramedullary nailing was not considered to provide adequate fixation. A direct lateral approach to the ulna splitting the interval between ECU and FCU with retraction of the dorsal cutaneous branch of the ulnar nerve provided adequate fracture exposure. This fracture was difficult to control prior to plating. Ultimately transfixation of both the distal and proximal ulna with k-wires into the distal radius were required to provide some temporary stability. Placement and fixation of the 2.4 mm mini fragment plate with 2.7 mm screws provided adequate longitudinal and rotational stability to allow early ROM.