Clinical Details

Clinical and radiological findings:  This young teenager sustained a fall from over 3m directly onto the outstretched hand. This high energy injury resulted in a Salter III dorsal fracture dislocation of the distal radial epiphysis. Due to incomplete skeletal maturity the fracture demonstrated characters of a Tillaux distal tibia fracture with a transepiphyseal fracture line resulting in both retained and displaced articular surface elements. The index surgery was performaed by another surgeon and comprised of closed reduction and percutaneous k-wires over the radial styloid. The intra- and postoperative films, whilst demonstrating reduction of the dorsal carpal dislocation, also demonstrated an incomplete malreduction of the radial epiphyseal fracture. The significance of the malreduction was not appreciated and only at 5 weeks was the degree of malreduction appreciated by another surgical team. After discussion both within the surgical team and with patient and family a surgical correction at six weeks was planned with a correction osteotomy through the fracture and anatomic reduction. Given the small caliber of the volar rim fragment only few available plating systems would be capable of capturing and fixing the lunate fossa. Discussions with Medartis DE provided a solution with their 1.5 mm lunate hook plates in combination with their wrist system plates. The correction took place six weeks post index surgery. Modified Henry’s to the distal radius with extension across the wrist crease following flexor carpi radialis. Careful soft tissue release provided excellent view across the complete radial metaphysis. Using 0.5 mm oscillating blade on a small handpiece the original fracture plane was osteotomised under radiological guidance. Debridement of callus and soft tissue resulted in good mobilization of the fracture fragments without injury to the residual intact aspect of the lunate fossa. A small volar arthrotomy was performed through the radioscapholunate ligament providing view of reduction of the articular surface. This arthrotomy was also used for the insertion of the volar lunate hook plate and fixation with 1.5 mm screws. A dorsal radial plate was chosen to sit parallel to the ulna plate along the radial column providing locked screw fixation into the radial styloid. Given delicate the nature of the lunate plate hooks, suture fixation of the capsule directly to the plate was performed,, hereby providing both closure of the arthrotomy and reinforcement of capsular attachment stress-relieving the plate hooks.