This retrospective study evaluated 20 patients with a fracture of the dorsal margin of the distal radius with associated dorsal radiocarpal subluxation. There were 14 men and 6 women with an average age of 36 years (range, 20 - 61 years). Fifteen fractures involve the dominant extremity. The injuries were grouped into 4 overall patterns.
Group 1 involved a volar impaction pattern observed in 6 patients which consisted of dorsal angulation of a large volar articular fragment representing the majority of the radiocarpal articular surface with a relatively well aligned volar cortical fracture. Group 2 involved a displaced, rotated volar fragment pattern seen in 10 patients which consisted of a fractured volar fragment involving the origin of the long and short radiolunate ligaments. Group 3 included 2 patients with central impaction characterized by central articular impaction in addition to the dorsal marginal shearing fracture without volar fracture or volar ligament disruption. Group 4 involved a radiocarpal fracture dislocation in 2 patients which consisted of complete dislocation of the lunate from a relatively intact lunate facet of the distal part of the radius.
Nineteen patients were treated operatively and 1 patient declined operative treatment. Eleven were treated through a dorsal exposure alone, 7 were treated through a combined dorsal and volar exposure and 1 was treated through a volar exposure alone. One patient had recurrent dorsal subluxation of the radiocarpal joint after plate removal. Average follow-up was 30 months (range, 12 - 60 months) after the initial surgery. Sixteen patients had mild pain, 3 had moderate pain and 1 had severe pain. None of the patients, including the one with recurrent dorsal dislocation, had symptoms or signs referable to instability of the wrist or distal radioulnar joint.
The final average amount of wrist motion was 59 degrees of flexion, 56 degrees of extension, and 31 degrees of radial deviation and 35 degrees of ulnar deviation. Final average forearm motion was 87 degrees of pronation and 85 degrees of supination. Final grip strength averaged 85% of the contralateral uninvolved hand. All fractures healed and final average radiographic measures were 18 degrees of ulnar inclination, 4 degrees of dorsal tilt and 1 mm. of ulnar negative variance. Five patients had radiographic signs of arthrosis. The average DASH score was 15 points and according to the modification of the Gartland and Werley system by Sarmiento et al., 30% had an excellent result, 60% had a good result and 10% had a fair result. The average Mayo wrist score was 75 points (range, 55 to 90 points).
This study identifies common characteristics identified in the relatively uncommon dorsal articular margin fracture with associated dorsal radiocarpal subluxation. The findings of the study bring attention to the associated volar injuries which may ultimately require a combined dorsal and volar approach to provide optimal treatment. These injuries are seen in relatively young patients as a result of high-energy injuries. Relative shortening of the radius with respect to the ulna was not a problem in this fracture and restoration of the normal palmar tilt of the distal part of the radius was found to be quite challenging.
Distal, Radius, Fracture, Subluxation, Articular
J Bone and Joint Surg