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The patient, a 42 firefighter, suffers a right distal radius volar shearing fracture (that is, a break that occurs in a bone when subjected to two forces in parallel and opposite direction) in a motorcycle accident. Trauma affects both the metaphysis, which supports the articular surface, and the joint itself. distal radius fracture
The problem
The violence of the fracture produces comminution, that is, multiple fragments. A fragment of the scaphoid fossa sinks deep into the metaphysis. In turn, an extraarticular comminution is generated combined with marginal fractures.
The goals
The main objective is to ensure that the patient recovers normal function as soon as possible.
The plan
First, a plate is placed on the anterior face of the radius. The plate acts as a pillar between the diaphysis fragments and the articular surface, and allows the length of the radius to be restored. This support system facilitates the placement of the limb in traction to perform a dry arthroscopy procedure, which now allows the reduction of joint fragments. To avoid fragmentation, the fragments are pushed from down to up after the surgeon accesses through a small hole in the metaphysis.
Dry arthroscopy – technique developed by Dr Piñal himself (‘Dry Arthroscopy of the Wrist: Surgical Technique‘, Journal of Hand Surgery American Edition Vol. 32A, Issue 1, January 2007, Pages 119-123) allows to act without extravasation of fluids around the joint, bone landmarks can be easily palpated during the procedure, and visibility is far superior to that of the classical technique.
‘Atlas of distal radius fractures’ chapter 6 video 6, Management of small fragments (Spanish subtitles).
The development of this technique of arthroscopic reduction and rigid fixation combination by Dr Piñal allows the use of arthroscopy in complex wrist fractures, avoiding shortening and bone collapse (‘Arthroscopic Reduction of Comminuted Intra-Articular Distal Radius Fractures With Diaphyseal -Metaphyseal Comminution‘, Journal of Hand Surgery American Edition Vol. 39, Issue 5, May 2014, Pages 835-843).
The results
The rigidity, obtained by the rigid synthesis, and the restoration of the anatomy, derived from the reduction by arthroscopy, allow mobilization in the first 24 hours. One week after the procedure, the patient achieves complete pronation and supination, and in a few weeks, fully recovers mobility.