SCIENTIFIC ARTICLE
Headless Bone Screw Fixation for Combined Volar Lunate Facet Distal Radius Fracture and Capitate Fracture: Case Report Michael J. Waters, BMBS, David E. Ruchelsman, MD, Mark R. Belsky, MD, Matthew I. Leibman, MD
We report a case of concomitant fractures of the volar lunate facet of the distal radius and capitate body. Surgical fixation was achieved with open reduction internal fixation using headless compression screws for both fractures. Because of the nature of complications seen after both operative and nonsurgical management, these fractures warrant particular attention. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Capitate fracture, distal radius fracture, headless compression screw, lunate facet.
C
distal radius and capitate are uncommon and may be seen after high-energy mechanisms of trauma to the wrist.1 The volar lunate facet of the distal radius is essential in the stability of the radiocarpal joint,2 and its volar rim is particularly susceptible to fracture.3 The short radiolunate ligament arises from the volar rim of the lunate facet and attaches to the radiopalmar surface of the lunate, preventing volar subluxation of the carpus. Fracture of the volar lunate facet, particularly with avulsion fracture of the short radiolunate ligament, may predispose to volar subluxation of the entire carpus.2 Treatment of fractures involving the volar lunate facet is challenging. Fixation options depend on the size of the fragment, concomitant injuries, and surgeon preference. Several methods of fixation have been described, including wire-loop fixation,4 arthroscopicassisted pinning,5 open reduction internal fixation with volar plating,6 and a combination of volar plating with dorsal external fixation.7 Improvements in ONCOMITANT FRACTURES OF THE
From the Department of Orthopaedic Surgery, Newton-Wellesley Hospital and Tufts University School of Medicine, Newton, MA. Received for publication July 7, 2012; accepted in revised form March 26, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David E. Ruchelsman, MD, Hand Surgery, PC, 2000 Washington Street, Blue Building, Suite 201, Newton, MA 02462; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.034
anatomically precontoured volar distal radius plates allow buttressing and fixation of this anatomic region when fracture of the volar lunate facet is a component of more complex articular fractures of the distal radius. The availability of variable-angle locking screws has also been beneficial for these technically demanding fractures when they occur in isolation. However, loss of fixation of the volar lunate facet fragment with resultant volar-ulnar subluxation of the carpus after volar plating occurs8 and requires revision or salvage. Isolated volar lunate facet fractures are rare.2 Capitate fractures are also rare and account for 1% to 2% of all carpal fractures.9 Capitate fractures are associated with complex, high-energy wrist injuries and are rarely isolated because of the capitate’s protected position in the wrist. Transcapitate fractures are most often seen in association with greater arc perilunate injuries and with fractures of the scaphoid and distal radius. Isolated fractures are uncommon.9 Displaced capitate fractures are usually treated with open reduction internal fixation. We report a case of concomitant fractures of the volar lunate facet and capitate body. Surgical fixation was achieved through volar and dorsal exposures with countersunk headless compression screws. CASE REPORT A healthy 28-year-old woman presented to our tertiary referral hand surgery center with right wrist pain
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
LUNATE FACET AND CAPITATE FRACTURES
FIGURE 1: Initial posteroanterior plain radiograph showing equivocal scapholunate widening. On retrospective review, a fracture of the capitate body can be identified.
and swelling after a high-energy bicycling accident. She had fallen over the handlebars and landed on the right hand. She presented approximately 10 days after the injury after radiographic workup at an outside institution that included plain radiographs and magnetic resonance imaging (MRI). Injury radiographs revealed equivocal widening of the right scapholunate joint with no acute fracture initially identified (Fig. 1). The MRI demonstrated fracture of the volar lunate facet with associated periarticular soft tissue edema and an oblique fracture of the capitate body (Fig. 2). There was no associated injury to the intercarpal ligaments, extrinsic carpal ligaments, or triangular fibrocartilage complex. Upon presentation, the remainder of the musculoskeletal examination was unremarkable. A computed tomography scan with coronal and sagittal plane reconstructions demonstrated a minimally displaced volar lip fracture of the lunate facet of the distal radius. The fragment measured 16 5 6 mm (Fig. 3). There was 1 to 2 mm of articular displacement and no volar subluxation of the radiocarpal joint. The oblique fracture of the capitate body was displaced in the sagittal plane. The fracture demonstrated 2 mm of translation and impaction (Fig. 4). J Hand Surg Am.
FIGURE 2: An MRI study demonstrates a fracture of the volar lunate facet with associated periarticular soft tissue edema and oblique fracture of the capitate.
We used an extended carpal tunnel approach with mobilization of the median nerve to access the distal radius facet fracture. This approach provided adequate exposure to the most ulnar and distal portions of the distal radius, which safely preserved the origin of the volar extrinsic radiocarpal ligamentous complex on the lunate facet fragment during internal fixation. Using the interval between the flexor tendons and ulnar neurovascular bundle, the fracture was anatomically reduced and provisionally held reduced with a 0.9mm (0.035-in) Kirschner wire. Definitive fixation was achieved with a countersunk 1.5-mm, noncannulated headless compression screw (Synthes, Paoli, PA). r
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LUNATE FACET AND CAPITATE FRACTURES
avoid disrupting the volar intercarpal ligaments. Although it necessitated a second incision, the dorsal approach gave easy access to the capitate head with superficial dissection. The capitate body fracture was impacted and shortened. Through the midcarpal joint, the head of the capitate was manually subluxated dorsally to access the starting point for the provisional wire. A 1.1-mm (0.045-in) wire was used as a joystick to provisionally reduce and pin the fracture. An 18-mm-long, 2.4-mm cannulated headless compression screw (Synthes) was countersunk beneath the distal articular surface of the capitate. We used a proximal-to-distal screw orientation to obtain an optimal central screw placement within the longitudinal axis of the capitate. Orthogonal fluoroscopic imaging confirmed the anatomical reduction and fixation. The wrist and elbow were initially immobilized in a sugar tong orthosis and then in a long-arm cast for 2 weeks. A short-arm cast was used for an additional 2 weeks. Progressive range of motion was initiated at 4 weeks postoperatively. Serial radiographs confirmed maintained reduction of the fractures. Three months after surgery, the patient had functional range of wrist motion. She reported no pain. Grip strength was 27 kgf compared with 32 kgf on the unaffected side. Radiographs at 3 months demonstrated that both fractures were healed. The radiocarpal joint was concentrically aligned with no evidence of volar subluxation (Fig. 5).
FIGURE 3: Computed tomography demonstrates the displaced fracture of the volar lunate facet of the distal radius.
DISCUSSION Combined fractures of the distal radius and carpus occur after high-energy trauma to the wrist and carpus. In a retrospective review of 170 distal radius fractures, 11 patients (7%) had 1 or 2 concomitant carpal fractures.1 The scaphoid accounts for most of these fractures; however, other bones of the carpus can also be fractured.1 Diagnosis of carpal fractures in the setting of high-energy distal radius fractures remains a challenge to clinicians, and advanced imaging is often necessary to diagnose carpal injuries not apparent on routine radiography. Eleven of the 15 carpal fractures in a study required computed tomography in addition to plain radiographs for diagnosis.1 Capitate fractures in particular pose diagnostic difficulties, with 57% missed on initial plain radiographs.10 In this case, an MRI was performed at an outside institution, presumably owing to substantial wrist pain and swelling in the setting of an apparently normal plain radiograph. It is our practice to investigate with MRI wrist injuries with normal initial
FIGURE 4: Computed tomography demonstrates the displaced fracture of the capitate (arrows) and the displaced fracture of the volar lunate facet.
Orthogonal fluoroscopic images confirmed anatomical fixation of the volar lunate facet fragment and concentric alignment of the radial carpal joint. A radial inclination image assessed the radial articular alignment and confirmed subchondral positioning of the implant and no subluxation of the lunate. The capitate fracture was approached through a dorsal longitudinal incision. We chose not to approach the capitate from an extended volar incision to J Hand Surg Am.
3
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LUNATE FACET AND CAPITATE FRACTURES
FIGURE 5: Plain radiographs 3 months postoperatively demonstrate the position of headless screws after open reduction internal fixation: A anterior-posterior and B lateral views.
plain radiographs and with pain and swelling not responding to immobilization. Isolated fracture of the volar lunate facet is rare. This type of fracture is more commonly associated with complex intra-articular fractures of the distal radius.8 In a quantitative anatomical study using 3dimensional computed tomography, the volar lunate facet was observed to project approximately 3 mm anterior to the flat volar surface of the distal radius with an average 5-mm anterior-posterior thickness.3 These dimensions make the volar rim particularly susceptible to fracture as a result of shearing forces.3 The anterior projection of the volar lunate facet presents a challenge to the hand and wrist surgeon in the setting of distal radius fracture, especially when the volar fragment is small. In this case, the small volar fragment identified on computed tomography most likely resulted from a severe shearing insult. The concomitant fractures J Hand Surg Am.
could represent a variant of a greater arc perilunate injury. Restoration of the normal anatomy of the radiocarpal joint with stabilization of the volar lunate facet is paramount in ensuring a good functional outcome. Nonsurgical management of short radiolunate ligament avulsion fractures in a cast or orthosis has been associated with high rates of volar wrist subluxation.2 Wire-loop fixation has been reported in 4 patients with small volar lunate facet fragments, without complication.4 Volar plating, usually performed on larger volar fragments, has been associated with loss of fixation, loss of wrist range of motion, and tendon rupture.6 Harness et al8 reported on 7 cases of failed volar lunate facet fixation with resultant volar-ulnar carpal subluxation. An incongruent radiocarpal joint can lead to late degenerative changes, which highlights the r
Vol. -, - 2014
LUNATE FACET AND CAPITATE FRACTURES
importance of adequate fixation of the volar lunate facet fragment. The use of headless compression screw fixation in upper limb periarticular trauma continues to expand.11e14 Headless compression screw fixation has been previously used for fracture of the capitate when it is part of a greater arc perilunate injury.14 We used a 1.5-mm headless compression screw for the displaced lunate facet fracture primarily because of its distal location. The fracture fragment was 16 mm long but narrow, accommodating only 1 point of fixation. We elected to use this implant because it provided a lowprofile construct with minimal risk of flexor tendon irritation. Preoperative templating of fragment size is essential when considering the use of countersunk fixation. Headless bone screws could potentially be used to augment volar locking plate fixation in complex distal radius fractures with a lunate facet fragment. Rotational stability of the lunate facet fragment is a concern with single headless screw fixation; however, achieving a second point of fixation may not be possible with small fracture fragments. In this case, we achieved fixation of concomitant volar lunate facet and capitate fractures using headless compression screws. Short-term complications noted with other surgical techniques were not seen in this single case study. A major limitation of this study is the 3-month follow-up, which did not allow for identification of possible long-term complications including capitate avascular necrosis. Owing to the nature of complications seen after both operative and nonsurgical management, fractures in this region warrant particular attention.
J Hand Surg Am.
5
REFERENCES 1. Komura S, Yokoi T, Nonomura H, Tanahashi H, Satake T, Watanabe N. Incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures. J Hand Surg Am. 2012;37(3):469e476. 2. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the ulnopalmar distal radius fragment. J Hand Surg Br. 2002;27(2):139e145. 3. Andermahr J, Lozano-Calderson S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg Am. 2006;31(6):892e895. 4. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg Am. 1999;24(3): 525e533. 5. Weisler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10(3):139e144. 6. Rampoldi M, Marsico S. Complications of volar plating of distal radius fractures. Acta Orthop Belg. 2007;73(6):714e719. 7. Ruch DS, Yang C, Smith BP. Results of palmar plating of the lunate facet combined with external fixation for the treatment of high-energy compression fractures of the distal radius. J Orthop Trauma. 2004; 18(1):28e33. 8. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg. 2004;86(9):1900e1908. 9. Geissler WB, Slade JF. Fractures of the carpal bones. In: Green DP, ed. Operative Hand Surgery. 6th ed. Philadelphia, PA: Churchill Livingstone; 2011:639e707. 10. De Schrijver F, De Smet L. Isolated fracture of the capitate: the value of MRI in the diagnosis and follow up. Acta Orthop Belg. 2002;68(3):310e315. 11. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am. 2008;90(60):1321e1329. 12. Burkhart KJ, Nowak TE, Appelmann P, Sternstein W, Rommens PM, Mueller LP. Screw fixation of radial head fractures: compression screw versus lag screw-a biomechanical comparison. Injury. 2010;41(10): 1015e1019. 13. Fowler JR, Ilyas AM. Headless compression screw fixation of scaphoid fractures. Hand Clin. 2010;26(3):351e361. 14. Apostolides JG, Lifchez SD, Christy MR. Complex and rare fracture patterns in perilunate dislocations. Hand (N Y). 2011;6(3):287e294.
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Headless Bone Screw Fixation for Combined Volar Lunate Facet Distal Radius Fracture and Capitate Fracture: Case Report Michael J. Waters, BMBS, David E. Ruchelsman, MD, Mark R. Belsky, MD, Matthew I. Leibman, MD
We report a case of concomitant fractures of the volar lunate facet of the distal radius and capitate body. Surgical fixation was achieved with open reduction internal fixation using headless compression screws for both fractures. Because of the nature of complications seen after both operative and nonsurgical management, these fractures warrant particular attention. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Capitate fracture, distal radius fracture, headless compression screw, lunate facet.
C
distal radius and capitate are uncommon and may be seen after high-energy mechanisms of trauma to the wrist.1 The volar lunate facet of the distal radius is essential in the stability of the radiocarpal joint,2 and its volar rim is particularly susceptible to fracture.3 The short radiolunate ligament arises from the volar rim of the lunate facet and attaches to the radiopalmar surface of the lunate, preventing volar subluxation of the carpus. Fracture of the volar lunate facet, particularly with avulsion fracture of the short radiolunate ligament, may predispose to volar subluxation of the entire carpus.2 Treatment of fractures involving the volar lunate facet is challenging. Fixation options depend on the size of the fragment, concomitant injuries, and surgeon preference. Several methods of fixation have been described, including wire-loop fixation,4 arthroscopicassisted pinning,5 open reduction internal fixation with volar plating,6 and a combination of volar plating with dorsal external fixation.7 Improvements in ONCOMITANT FRACTURES OF THE
From the Department of Orthopaedic Surgery, Newton-Wellesley Hospital and Tufts University School of Medicine, Newton, MA. Received for publication July 7, 2012; accepted in revised form March 26, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David E. Ruchelsman, MD, Hand Surgery, PC, 2000 Washington Street, Blue Building, Suite 201, Newton, MA 02462; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.034
anatomically precontoured volar distal radius plates allow buttressing and fixation of this anatomic region when fracture of the volar lunate facet is a component of more complex articular fractures of the distal radius. The availability of variable-angle locking screws has also been beneficial for these technically demanding fractures when they occur in isolation. However, loss of fixation of the volar lunate facet fragment with resultant volar-ulnar subluxation of the carpus after volar plating occurs8 and requires revision or salvage. Isolated volar lunate facet fractures are rare.2 Capitate fractures are also rare and account for 1% to 2% of all carpal fractures.9 Capitate fractures are associated with complex, high-energy wrist injuries and are rarely isolated because of the capitate’s protected position in the wrist. Transcapitate fractures are most often seen in association with greater arc perilunate injuries and with fractures of the scaphoid and distal radius. Isolated fractures are uncommon.9 Displaced capitate fractures are usually treated with open reduction internal fixation. We report a case of concomitant fractures of the volar lunate facet and capitate body. Surgical fixation was achieved through volar and dorsal exposures with countersunk headless compression screws. CASE REPORT A healthy 28-year-old woman presented to our tertiary referral hand surgery center with right wrist pain
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
LUNATE FACET AND CAPITATE FRACTURES
FIGURE 1: Initial posteroanterior plain radiograph showing equivocal scapholunate widening. On retrospective review, a fracture of the capitate body can be identified.
and swelling after a high-energy bicycling accident. She had fallen over the handlebars and landed on the right hand. She presented approximately 10 days after the injury after radiographic workup at an outside institution that included plain radiographs and magnetic resonance imaging (MRI). Injury radiographs revealed equivocal widening of the right scapholunate joint with no acute fracture initially identified (Fig. 1). The MRI demonstrated fracture of the volar lunate facet with associated periarticular soft tissue edema and an oblique fracture of the capitate body (Fig. 2). There was no associated injury to the intercarpal ligaments, extrinsic carpal ligaments, or triangular fibrocartilage complex. Upon presentation, the remainder of the musculoskeletal examination was unremarkable. A computed tomography scan with coronal and sagittal plane reconstructions demonstrated a minimally displaced volar lip fracture of the lunate facet of the distal radius. The fragment measured 16 5 6 mm (Fig. 3). There was 1 to 2 mm of articular displacement and no volar subluxation of the radiocarpal joint. The oblique fracture of the capitate body was displaced in the sagittal plane. The fracture demonstrated 2 mm of translation and impaction (Fig. 4). J Hand Surg Am.
FIGURE 2: An MRI study demonstrates a fracture of the volar lunate facet with associated periarticular soft tissue edema and oblique fracture of the capitate.
We used an extended carpal tunnel approach with mobilization of the median nerve to access the distal radius facet fracture. This approach provided adequate exposure to the most ulnar and distal portions of the distal radius, which safely preserved the origin of the volar extrinsic radiocarpal ligamentous complex on the lunate facet fragment during internal fixation. Using the interval between the flexor tendons and ulnar neurovascular bundle, the fracture was anatomically reduced and provisionally held reduced with a 0.9mm (0.035-in) Kirschner wire. Definitive fixation was achieved with a countersunk 1.5-mm, noncannulated headless compression screw (Synthes, Paoli, PA). r
Vol. -, - 2014
LUNATE FACET AND CAPITATE FRACTURES
avoid disrupting the volar intercarpal ligaments. Although it necessitated a second incision, the dorsal approach gave easy access to the capitate head with superficial dissection. The capitate body fracture was impacted and shortened. Through the midcarpal joint, the head of the capitate was manually subluxated dorsally to access the starting point for the provisional wire. A 1.1-mm (0.045-in) wire was used as a joystick to provisionally reduce and pin the fracture. An 18-mm-long, 2.4-mm cannulated headless compression screw (Synthes) was countersunk beneath the distal articular surface of the capitate. We used a proximal-to-distal screw orientation to obtain an optimal central screw placement within the longitudinal axis of the capitate. Orthogonal fluoroscopic imaging confirmed the anatomical reduction and fixation. The wrist and elbow were initially immobilized in a sugar tong orthosis and then in a long-arm cast for 2 weeks. A short-arm cast was used for an additional 2 weeks. Progressive range of motion was initiated at 4 weeks postoperatively. Serial radiographs confirmed maintained reduction of the fractures. Three months after surgery, the patient had functional range of wrist motion. She reported no pain. Grip strength was 27 kgf compared with 32 kgf on the unaffected side. Radiographs at 3 months demonstrated that both fractures were healed. The radiocarpal joint was concentrically aligned with no evidence of volar subluxation (Fig. 5).
FIGURE 3: Computed tomography demonstrates the displaced fracture of the volar lunate facet of the distal radius.
DISCUSSION Combined fractures of the distal radius and carpus occur after high-energy trauma to the wrist and carpus. In a retrospective review of 170 distal radius fractures, 11 patients (7%) had 1 or 2 concomitant carpal fractures.1 The scaphoid accounts for most of these fractures; however, other bones of the carpus can also be fractured.1 Diagnosis of carpal fractures in the setting of high-energy distal radius fractures remains a challenge to clinicians, and advanced imaging is often necessary to diagnose carpal injuries not apparent on routine radiography. Eleven of the 15 carpal fractures in a study required computed tomography in addition to plain radiographs for diagnosis.1 Capitate fractures in particular pose diagnostic difficulties, with 57% missed on initial plain radiographs.10 In this case, an MRI was performed at an outside institution, presumably owing to substantial wrist pain and swelling in the setting of an apparently normal plain radiograph. It is our practice to investigate with MRI wrist injuries with normal initial
FIGURE 4: Computed tomography demonstrates the displaced fracture of the capitate (arrows) and the displaced fracture of the volar lunate facet.
Orthogonal fluoroscopic images confirmed anatomical fixation of the volar lunate facet fragment and concentric alignment of the radial carpal joint. A radial inclination image assessed the radial articular alignment and confirmed subchondral positioning of the implant and no subluxation of the lunate. The capitate fracture was approached through a dorsal longitudinal incision. We chose not to approach the capitate from an extended volar incision to J Hand Surg Am.
3
r
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4
LUNATE FACET AND CAPITATE FRACTURES
FIGURE 5: Plain radiographs 3 months postoperatively demonstrate the position of headless screws after open reduction internal fixation: A anterior-posterior and B lateral views.
plain radiographs and with pain and swelling not responding to immobilization. Isolated fracture of the volar lunate facet is rare. This type of fracture is more commonly associated with complex intra-articular fractures of the distal radius.8 In a quantitative anatomical study using 3dimensional computed tomography, the volar lunate facet was observed to project approximately 3 mm anterior to the flat volar surface of the distal radius with an average 5-mm anterior-posterior thickness.3 These dimensions make the volar rim particularly susceptible to fracture as a result of shearing forces.3 The anterior projection of the volar lunate facet presents a challenge to the hand and wrist surgeon in the setting of distal radius fracture, especially when the volar fragment is small. In this case, the small volar fragment identified on computed tomography most likely resulted from a severe shearing insult. The concomitant fractures J Hand Surg Am.
could represent a variant of a greater arc perilunate injury. Restoration of the normal anatomy of the radiocarpal joint with stabilization of the volar lunate facet is paramount in ensuring a good functional outcome. Nonsurgical management of short radiolunate ligament avulsion fractures in a cast or orthosis has been associated with high rates of volar wrist subluxation.2 Wire-loop fixation has been reported in 4 patients with small volar lunate facet fragments, without complication.4 Volar plating, usually performed on larger volar fragments, has been associated with loss of fixation, loss of wrist range of motion, and tendon rupture.6 Harness et al8 reported on 7 cases of failed volar lunate facet fixation with resultant volar-ulnar carpal subluxation. An incongruent radiocarpal joint can lead to late degenerative changes, which highlights the r
Vol. -, - 2014
LUNATE FACET AND CAPITATE FRACTURES
importance of adequate fixation of the volar lunate facet fragment. The use of headless compression screw fixation in upper limb periarticular trauma continues to expand.11e14 Headless compression screw fixation has been previously used for fracture of the capitate when it is part of a greater arc perilunate injury.14 We used a 1.5-mm headless compression screw for the displaced lunate facet fracture primarily because of its distal location. The fracture fragment was 16 mm long but narrow, accommodating only 1 point of fixation. We elected to use this implant because it provided a lowprofile construct with minimal risk of flexor tendon irritation. Preoperative templating of fragment size is essential when considering the use of countersunk fixation. Headless bone screws could potentially be used to augment volar locking plate fixation in complex distal radius fractures with a lunate facet fragment. Rotational stability of the lunate facet fragment is a concern with single headless screw fixation; however, achieving a second point of fixation may not be possible with small fracture fragments. In this case, we achieved fixation of concomitant volar lunate facet and capitate fractures using headless compression screws. Short-term complications noted with other surgical techniques were not seen in this single case study. A major limitation of this study is the 3-month follow-up, which did not allow for identification of possible long-term complications including capitate avascular necrosis. Owing to the nature of complications seen after both operative and nonsurgical management, fractures in this region warrant particular attention.
J Hand Surg Am.
5
REFERENCES 1. Komura S, Yokoi T, Nonomura H, Tanahashi H, Satake T, Watanabe N. Incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures. J Hand Surg Am. 2012;37(3):469e476. 2. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the ulnopalmar distal radius fragment. J Hand Surg Br. 2002;27(2):139e145. 3. Andermahr J, Lozano-Calderson S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg Am. 2006;31(6):892e895. 4. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg Am. 1999;24(3): 525e533. 5. Weisler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10(3):139e144. 6. Rampoldi M, Marsico S. Complications of volar plating of distal radius fractures. Acta Orthop Belg. 2007;73(6):714e719. 7. Ruch DS, Yang C, Smith BP. Results of palmar plating of the lunate facet combined with external fixation for the treatment of high-energy compression fractures of the distal radius. J Orthop Trauma. 2004; 18(1):28e33. 8. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg. 2004;86(9):1900e1908. 9. Geissler WB, Slade JF. Fractures of the carpal bones. In: Green DP, ed. Operative Hand Surgery. 6th ed. Philadelphia, PA: Churchill Livingstone; 2011:639e707. 10. De Schrijver F, De Smet L. Isolated fracture of the capitate: the value of MRI in the diagnosis and follow up. Acta Orthop Belg. 2002;68(3):310e315. 11. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am. 2008;90(60):1321e1329. 12. Burkhart KJ, Nowak TE, Appelmann P, Sternstein W, Rommens PM, Mueller LP. Screw fixation of radial head fractures: compression screw versus lag screw-a biomechanical comparison. Injury. 2010;41(10): 1015e1019. 13. Fowler JR, Ilyas AM. Headless compression screw fixation of scaphoid fractures. Hand Clin. 2010;26(3):351e361. 14. Apostolides JG, Lifchez SD, Christy MR. Complex and rare fracture patterns in perilunate dislocations. Hand (N Y). 2011;6(3):287e294.
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