Comminuted Distal Radial Fracture with Large Rotated Palmar Medial Osteochondral Fragment in the Joint.

INTRODUCTION: Intra-articular distal radius fractures have long been massively discussed in the literature, but regarding to fractures that possess rotated volar medial fragment in the joint a few amount papers has been written. In this article, we would like to emphasize the significance of the rotated palmar medial (lunate facet) fragment. CASE REPORT: A 39-year-old man fell from a height of about 3 m and landed on his right outstretched hand; within 40 min, he arrived at our clinic presenting with a severe pain and swelling in his right wrist. Initial X-rays of the wrist revealed dorsal subluxation of the radiocarpal joint with dorsal comminution of the radial articular surface and fracture of the radial styloid process, with (nearly inverted) ~ 140-150° rotation of the palmar medial fragment. With an additional volar approach, the fragment reduced and stabilized with two K-wires and wrist immobilized in external fixator. The patient returned to daily activities without any discomfort and pain after the 1 year from the surgery.
CONCLUSION: Overlooking of palmar rotated osteochondral fragment will cause deficiency to build proper pre-operative strategy to approach the reduction of the fragment. The incompetence of reduction will deteriorate the articular surface and lead to early osteoarthritis of the wrist. The surgeon should detect this fragment and should be familiar with volar approaches of the wrist. Above average surgical experience would be needed for successful reduction.

Learning Point for this Article:

To detect palmar medial fragment pre-operatively and to know the significance of the reduction of this fragment through the volar approach with capsulotomy is crucial in such cases.

Introduction

Intra-articular fractures of the distal radius are more challenging to treat than extraarticular fractures [1]. Displaced fractures of the articular surface of the distal radius have a worse prognosis than extraarticular fractures because of potential for incongruity and arthrosis of radiocarpal and distal radioulnar joints, carpal subluxation and associated intercarpal ligament injuries [1]. Intra-articular distal radius fractures have long been massively discussed in the literature, but regarding to fractures that possess rotated palmar medial fragment a few amount paper has been written [2, 3, 4, 5, 6, 7, 8, 9, 10] (Table 1). In this article, we would like to emphasize the significance of the palmar medial rotated osteocartilaginous fragment.

Table 1

Case report

A 39-year-old man fell from a height of about 3 m and landed on his right side with outstretched hand. Within 40 min, he arrived at our clinic presenting with a severe pain and swelling in his right wrist. Initial X-rays of the wrist revealed dorsal subluxation of the radiocarpal joint (Fig. 1a and b) with dorsal comminution of the radial articular surface (Fig. 1b) and fracture of the radial styloid process, with (nearly inverted) ~ 140-150° rotation of the palmar medial fragment. Computed tomography (CT) was carried out to detail the comminution and to understand the 3D configuration of the fragments (Fig. 2). The fingers were warm and capillary refill after applying pressure to distal fingertip was normal. The sensorial and motor functions of the nerves (median, ulnar, and radial nerve) were normal. No open wound was detected. The patient had no previous illness that would negatively affect emergent anesthesia. The surgery was performed that same day, only 6 h after initial admission.

Figure 1

(a) Pre-operative anteroposterior and lateral roentgenograms, (b) illustrated radiocarpal subluxation with rotated volar medial (lunate facet) osteochondral fragment adjacent to pre-operative lateral roentgenogram.

Figure 2

3D computed tomography view of the wrist. Notice rotated volar medial (lunate facet) osteochondral fragment.

Treatment

Under general anesthesia with tourniquet application, the initial closed reduction was attempted with longitudinal traction and the rotated fragment could not be reduced. For reduction of the volar rotated fragment, the modified Henry approach [11, 12, 13] was utilized. The plane between the flexor carpi radialis and radial artery was opened and the pronator quadratus muscle is incised on its radial border, exposing the distal radius. It is stripped off the distal radius together with the periosteum. The horizontal capsulotomy parallel with the border lunate facet of the radius was carried out to approach the intra-articular rotated fragment. The radial styloid fragment was reduced with the aid of finger pressure in a dorsal-to-volar direction. The entrapped and rotated volar medial fragment was reduced by a maneuver in the opposite direction and the fragment was gripped using Kelly hemostatic forceps, gently pivoted on its own axis (with the aid of soft tissue attachments) and reduced. These reduced fragments were stabilized using two K-wires. Following this, the joint spanning external fixator was utilized to keep the reduced fragment together with initial reduction position (the wrist was positioned in palmar flexion with slide ulnar deviation). At the end of procedure, the final confirmation reduction was performed with C-arm and before discharging the patient postoperative radiography was taken (Fig. 3).

Figure 3

Post-operative anteroposterior and lateral roentgenograms. Notice the reduced palmar medial fragment.

Follow-up

After 5 weeks postoperatively, the external fixator removed, physical treatment started. The post-operative 4-month X-rays revealed that the volar fragment united with good alignment. However, dorsal half of the joint healed a little irregular (Fig. 4). The patient achieved 60-70° of palmar flexion and 60-65° of dorsiflexion (Fig. 5) and returned to daily activities without any discomfort and pain after 1 year from the surgery. In last telephone call (after 18 months from the surgery), he stated that he was satisfied with clinical results.

Figure 4

Post-operative 4 months roentgenograms. Notice the united volar fragment with slight regional osteoporosis and good alignment. However, dorsal half ofthe joint seems mild irregular.

Figure 5

Clinical picture that shows palmar flexion and dorsal extension at 1 year from the surgery.

Discussion

In this article, we would like to emphasize the significance of the rotated volar medial (lunate facet) fragment. The explanation of these kinds of fractures (one large volar osteochondral fragment that rotated and entrapped in the joint with comminuted distal radius fracture) will only possible with Melone [2, 3] classification. He designated the articular fractures into four basic components: Radial shaft, radial styloid, dorsal medial fragment, and palmar medial fragment. The key medial fragments, which possess strong ligamentous attachments to both carpus and the ulnar styloid, have been designated as a medical complex, which profoundly affects both the radiocarpal and radioulnar joints are the basis on which distal radial articular fractures are classified into four categories (Type 1-4) [2, 3]. Our case could be classified as “Type IV” in Melone classification system. Melone commented in his original paper that those first three types could be treated with closed manipulation-percutaneous pin fixation. Type IV fractures necessitate the open reduction to correct the displacement of rotated medial palmar fragment rather than the other types (Type I, II, and III) [2, 3]. He reported largest cohort of this type of fracture (15 cases) with good and satisfactory results [3]. Plenty of studies had been performed regarding to assess the interobserver reliability and intraobserver reproducibility of classification systems that were interested with distal radius fractures. Given the low degree of interobserver and intraobserver agreement for each of the distal radius fracture classifications in those studies, their use as the sole means for determining the direction of treatment or for the direct comparison of results among different studies is not warranted [14, 15, 16, 17, 18, 19]. Yet among all other classification systems, Melone classification system is unique for defining rotated volar medial fragment, and it helps with decision- making for the surgical approach. Halbrecht and Stuchin [4] reported one case that possesses palmar medial fragment 180° rotation into the joint such that the articular cartilage was facing the radial shaft. They used dorsoradial approach to reduce the fragment and fixation was achieved with multiple K-wires. In this case, a non-displaced scaphoid fracture coexisted with distal radius comminuted intra-articular fracture. They immobilized the wrist with cast for 8 weeks. They emphasized the importance of CT to understand the fracture pattern and underlined necessity of the open reduction and internal fixation. Takami et al. [5] reported two cases. One of them is very similar to our case in which they used to palmar approach to reduce rotated fragment. They stabilized this reduction with multiple K-wires and immobilized wrist in cast for 4 weeks. In contrast with these cases, we secured reduction with two K- wires with external fixator for 5 weeks. In both cases, they reported, the surgery was not performed within the same day (in the first case, it was 3 weeks, and in the second case, 7 weeks after the injury). Furthermore, both cases required carpal tunnel decompression. They achieved good clinical-functional results. They emphasized the need for open reduction with palmar approach and agreed with Melone’s findings regarding the insufficiency of closed reduction. Chin and Jupiter [6] reported four cases with (Melone Type 4) displaced volar lunate facet osteochondral fractures (without any rotation). They recommend wire loop fixation to those fractures and reported good-to-excellent results. In contrast to our case, their cases had not include rotated palmar medial fragment in the joint. Panagopoulos et al. [7] reported a case very similar to us, but they reduced the rotated palmar medial fragment through the dorsoradial approach and stabilized with external fixator for 6-week immobilization. They did not detail the reduction maneuver of the fragment through the dorsoradial approach. However, their case was evidenced good healing and perfect radiological alignment with late post-operative X-rays. They emphasized the Melone deduction regarding to need for open reduction in those type fractures involving rotated palmar medial fragment. Uzel et al. [20] proposed the volar medial approach to access the medal side of the distal radius (lunate facet) and the distal radioulnar joint. They performed a mixed study that includes dissections of five cadavers with 10 wrist and four cases with Melone Type IV distal radius fractures (with rotated palmar medial fragment). They commented that the Henry approach is not adequate to access medial side of the volar distal radius unless it is extended proximally. In addition, they underlined that the median nerve might be stretched due to excessive retraction with nearby tendons. (According to their comment, to access palmar medial fragment necessitates excessive retraction of the tendon groups toward to ulnar side in Henry approach). They also proposed that detachment of the pronator quadratus from its distal attachment would be beneficial for further healing as ulnar and radial insertions are left intact. After this study Uzel et al. [8] reported four cases with the particularity of having a 90° or 180° rotated lunate fossa. They used volar medial approach between the flexors tendons and the ulnar bundle to pin the fragment of lunate fossa. They commented that using volar medial approach facilitates visualization of rotated fragment compared to the Henry’s approach and avoids the excessive traction of the median nerve. In our case, we used classic modified volar Henry approach and we were not encountered median nerve symptoms due to excessive traction of median nerve. In two cases, they used external fixator for maintaining reduction. Apergis et al. [9] and Tan and Chew [10] reported cases with fractures with volar ulnar fragment. They emphasized the importance of the ulnar palmar fragment for the stability of radiocarpal joints. In contrast of our case, in those cases, the fragments were not rotated and entrapped in the joint. These types of fractures necessitate complex strategy plan before the surgery. Because an additional intervention will be mandatory to reduce volar dislocated osseocartilaginous fragment. It would be impossible to fix this fragment with screw through the volar plate due to its’ small size. Thus, sole volar plate option for fixation would not be feasible. A sole external fixator would be also inappropriate because closed reduction could not be achieved in those fractures. The surgeon should be familiar with modified Henry approach or volar medial approach and should know the difficulty of reduction of rotated fragment. Volar medial approach is also another option and preferable depending on the surgeon’s choice as Uzel et al. proposed. This paper has a value of regarding to review of published articles in this topic, detailing the approach with discussions and highlighting the Melone classification system guidance for the management.

Conclusion

Literature highlighted the importance of this rare type fracture. In such cases, overlooking the possible volar rotated osteochondral fragments can cause a weakness in planning the pre-operative measures for fragment reduction. An incomplete reduction might damage the articular surface, increasing the possibility of early osteoarthritis of the wrist significantly. The reduction and fixation of these kinds of volar rotated intra- articular fragments necessitate volar extra exposure with capsulotomy in addition to classic reduction techniques (closed reduction with longitudinal traction or open reduction with classic volar approach) of the wrist fractures. The surgeon should detect this fragment clearly and should be familiar with volar approaches to the wrist. For a successful reduction, the surgeon should have the proper surgical skills and experience with such relatively complex surgeries.

Comminuted distal radial fractures that possess rotated palmar medial fragment in the joint deserve more attention than the ordinary distal radius articular fractures. To detect palmar medial fragment and build a pre-operative strategy regarding to the reduction of the fragment would positively affect stability of the wrist and clinical results.