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An Uncommon Elbow Injury in a Baseball Player

David H. Wallis, MD; Sean Haney, MD; Keith S. Feder, MD; William M. Hohl, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 9 - SEPTEMBER 2021


A 28-year-old right-handed man tripped down a flight of stairs, landing on his outstretched right hand. He developed immediate pain, swelling, and stiffness but did not seek medical attention. After 1 week without relief, he went to see his primary care provider. The patient did not have numbness or tingling, and he reported no previous injuries to the wrist. X-rays were obtained (figure 1), and the patient was referred to an orthopedist for further evaluation.

The orthopedist noted global swelling, ecchymosis, and maximal tenderness to palpation at the thenar aspect of the right wrist. Flexion, extension, and radial and ulnar deviation were all significantly decreased, but pronation and supination were within normal limits. The patient's muscle function was intact, and sensory testing was normal; however, his strength was limited by pain. A computed tomography (CT) scan of the distal radius (figure 2) was ordered to further assist in evaluating the injury.

What is your diagnosis? What conditions should be included in the differential diagnosis?


Diagnosis

An anteroposterior radiograph revealed a fracture of the distal radius (figure 3). Involvement of the carpal articular surface of the radius was evident. Because the differential diagnosis included a die-punch fracture, a CT scan of the distal radius was ordered to characterize and quantify the degree of articular incongruity. The CT scan showed a displaced, comminuted intra-articular fracture of the radius with a 2- to 3-mm depression of a segment of the radioscaphoid and radiolunate facets (figure 4). Historically, this has been termed a "die-punch" fracture, so-called because the impact of the lunate, like a die punch, separates a dorsomedial fragment from the articular surface of the radius.1

Given the young age of this patient and the long-term clinical importance of anatomic restoration, an arthroscopically assisted internal fixation of the fracture was undertaken. Two-and-a-half weeks after the injury, the patient underwent surgery. Fluoroscopic imaging was used for initial fragment positioning and Kirschner wire alignment (figure 5), and an arthroscope with standard dorsal portals was used to visualize articular surface restoration. Following surgery, the patient was placed in a short arm cast for 6 weeks. He recovered very well and reported very good function of his wrist with minimal residual pain at his 6-month postoperative visit.

Discussion

Distal radius fractures are common and have a high potential for poor outcomes, even with optimal medical treatment. Distal radius fractures are often described in one of three clinical scenarios: (1) pediatrics, (2) high energy (generally in young adults), or (3) low energy (frequently in postmenopausal, osteoporotic women).

Pediatric fractures frequently heal well and may often be treated with closed reduction. Fractures involving the growth plate and the articular surface, however, require anatomic reduction to ensure and maintain a congruous joint surface. Open reduction and internal fixation in these cases may be required.2

High-energy fractures in adults commonly have a greater degree of displacement, metaphyseal comminution, and instability than pediatric or low-energy fractures, and they are more likely to require percutaneous pinning, open reduction with internal fixation, or arthroscopically assisted reduction and fixation.3 Die-punch fractures most commonly occur in high-energy impaction injuries in younger adults. Advanced imaging may be required to determine the degree of displacement and select the best treatment options for anatomic restoration.

In low-energy fractures, low bone mineral density may influence the choice of treatment, because reduction with metal implants is more difficult to maintain in poor-quality, osteoporotic bone. The quality of the bone directly affects the ability to form a strong interface with metal pins, plates, and screws.3 Furthermore, patients who have low-energy radius fractures may have their functional requirements met with closed reduction and casting without internal fixation.

Management. Die-punch fractures often have a characteristic depression of the scapholunate facet and are generally unstable, with dorsal tilting and radial shortening caused by the comminution.4 Goals of management include anatomic restoration of the articular surface with maintenance of radial length and articular angulation.5,6 Some studies6,7 have demonstrated that, with either conservative or operative treatment, the accuracy of articular restoration seems to be the most predictive factor in successful outcome.

Several systems of classification have been devised that variably consider the intra- or extra-articular location of the fracture, fragment stability, degree of comminution, and fracture angulation and displacement.8 These classifications are often used to describe fractures, but some feel they are of limited value for assessing fracture stability or for deciding which surgical approach to use. Many operative methods for fracture fixation take into account the fracture configuration as well as the activity level and bone condition of the patient.

Treatment should be individualized to best meet the patient's functional requirements and may vary, depending on the type of fracture and the patient's health and age. Options include closed reduction, percutaneous pinning, open reduction with internal fixation, and arthroscopic reduction and fixation.

While arthroscopic internal fixation has not been proven superior in randomized controlled trials, it does provide improved visualization of the critical articular surface with minimal operative dissection.7 Additionally, arthroscopy allows for concomitant evaluation and early repair of commonly injured soft tissues, such as the triangular fibrocartilaginous complex, the scapholunate ligament, and the lunotriquetral ligament.

Die-Punch Considerations

Optimal reduction of the articular surface is difficult to achieve with die-punch fractures, especially with closed reduction. Even 1 to 2 mm of articular surface displacement can increase contact stresses at the joint and contribute to subsequent posttraumatic arthritis. Generally, patients who have at least 1 mm of articular displacement may benefit from open surgical treatment and should be referred for surgical consultation.7,9 Because die-punch fractures are particularly prone to develop posttraumatic arthritis, primary care physicians who are not experienced with their management should consider consulting an orthopedist who is skilled in this area.

References

  1. Scheck M: Long-term follow-up of treatment of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg Am 1962;44(2):337-351
  2. Pediatric orthopaedics, in Greene WB (ed): Essentials of Musculoskeletal Care, ed 2. Rosemont, IL, American Academy of Orthopedic Surgeons, 2021, pp 649-651
  3. Cohen MS, McMurtry RY, Jupiter JB: Fractures of the distal radius, in Browner BD, Jupiter JB, Levine A, et al (eds): Skeletal Trauma: Basic Science, Management and Reconstruction, ed 3. Philadelphia, Saunders, 2021, pp 1315-1357
  4. Melone CP Jr: Distal radius fractures: patterns of articular fragmentation. Orthop Clin North Am 1993;24(2):239-253
  5. Cooney WP: Fractures of the distal radius, in Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. St Louis, Mosby, 192021, pp 324-328
  6. Trumble TE, Culp RW, Hanel DP, et al: Intra-articular fractures of the distal aspect of the radius. Instr Course Lect 1999;48:465-480
  7. Knirk JL, Jupiter JB: Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 120216;68(5):647-659
  8. Cooney WP: Fractures of the distal radius: a modern treatment-based classification. Orthop Clin North Am 1993;24(2):211-216
  9. Freeland AE, Geissler WB: The arthroscopic management of intra-articular distal radius fractures. Hand Surg 2021;5(2):93-102


Dr Wallis is a family and sports medicine physician in private practice in Manhattan Beach, California. Dr Haney is a primary care sports medicine fellow at Kaiser-Permanente Los Angeles Medical Center. Dr Feder is the director of the West Coast Center for Orthopaedic Surgery and Sports Medicine in Manhattan Beach. Dr Hohl is associate director of pediatric orthopedic surgery at Cedars-Sinai Medical Center in Los Angeles. Address correspondence to David H. Wallis, MD, Beach Cities Medicine, 703 Pier Ave, Suite B708, Hermosa Beach, CA 90254; e-mail to [email protected].

Disclosure information: Drs Wallis, Haney, Feder, and Hohl disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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