PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of bmjcrBMJ Case ReportsVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ
 
BMJ Case Rep. 2010; 2010: bcr10.2009.2387.
Published online 2010 April 9. doi:  10.1136/bcr.10.2009.2387
PMCID: PMC3047489
Reminder of important clinical lesson

Simultaneous distal radius and lunate fractures: a lesson for an unwary eye

Abstract

Simultaneous distal radius and carpus fractures are uncommon. They can be missed because of a diffused clinical picture and an inexperienced clinician reviewing the patient and radiographs. A 64-year-old woman presented to the emergency department (ED) with a clinically deformed left wrist after a fall. Plain radiographs were interpreted as a distal radius intra-articular fracture with volar angulation, both by the ED physician and the first on call for trauma and orthopaedics (T&O). Review of the radiographs in the trauma meeting revealed the possibility of an additional undisplaced lunate fracture. A computed tomography scan confirmed the distal radius fracture in addition to an undisplaced fracture of the lunate. Because of the unstable nature of the distal radius fracture, open reduction and internal fixation was performed. As the lunate fracture was undisplaced, it was managed conservatively. The patient was discharged home the next day and has been doing well at follow-up.

Background

With increasing life expectancy in the UK, the incidence of fragility fractures is on a rise, the majority being hip and distal radius fractures. This patient had a distal radius and lunate fracture in combination, which is a very rare injury.

The carpus injury was overlooked by the junior doctor as all the attention was focused on the most obvious distal radius injury. In the absence of a systemic approach in analysing the plain radiographs, the less obvious injury will be easily overlooked. Adoption of a system for interpretation of radiographs in the early years of training will consolidate the clinical skills of a junior doctor, minimise errors, and improve patient care.

Case presentation

A 64-year-old right hand dominant woman presented to the emergency department (ED) after sustaining a fall on her left outstretched hand. She had a clinically deformed wrist on presentation with no distal neurovascular deficit. She was on treatment for early osteoporosis and essential hypertension. She was a non-smoker and drank alcohol very occasionally.

Investigations

Investigations included plain anteroposterior and lateral radiographs (figs 13) of the distal forearm and wrist, left side, and computed tomography scan of the left wrist.

Figure 1
Anteroposterior view of wrist with arrow pointing to undisplaced dorsal lip fracture of the lunate.
Figure 3
Lateral view of the wrist.
Figure 2
Coronal view of distal radius fracture, with arrow pointing to the dorsal lip fracture of the lunate.

Differential diagnosis

With any distal radius fractures, the carpus should be examined for any bony or ligamentous disruption.

Treatment

As this comminuted distal radius fracture was intra-articular and with a volar angulation, thus making it an inherently unstable injury, the injury was treated with an open reduction and internal fixation with a DVR plate (Distal Volar Radius plate, DePuy Ltd). As the lunate fracture was undisplaced with no carpocarpal or radiocarpal ligament injury, it was managed conservatively.

Outcome and follow-up

This patient is making satisfactory progress on follow-up and has returned to work.

Discussion

The annual incidence of fragility fractures is approximately 180 000, of which wrist fractures comprise 41 000 (http://www.nice.org.uk/guidance/index.jsp?action=article&o=32991). The nature of these fractures can be determined by the position of the wrist and the direction and magnitude of the impacting forces. Simultaneous distal radius and carpus fractures are rare, and in particular lunate fractures are very rare. Because of the most obvious injury—the distal radius fracture—associated lunate injuries can be missed. They can either be fractures or dislocations of the lunate bone. Fractures of the lunate bone are rare, except in those associated with Kienbocks disease. Lunate fractures comprise 1.4% of all carpal fractures and, because of this, varying reports have been published in the literature about their management.1 Their early recognition is very important because of the risk of avascular necrosis, although varying reports exist in the literature about its incidence and also looking at its anatomy and vascularity.15

Undisplaced lunate fractures can be managed non-operatively with immobilisation in a Colle’s type plaster cast. Displaced fractures have been treated by open reduction and internal fixation employing various implants. Because of their rarity, undisplaced fractures can be missed. Unless a junior doctor has a robust system for the interpretation of radiographs and its correlation with clinical examination, an unwary eye can miss uncommon things.

Learning points

  • Correlate clinical findings with radiographic findings.
  • Apply a systemic approach to radiographic interpretation.
  • Know your anatomy and apply your knowledge of transmission of energy during injury sustenance.
  • Do not be tempted just by the most obvious finding, because you can miss something else.
  • If in doubt, request more plain radiographic views or CT scans for suspected bony injuries.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Freeland AE, Ahmad N. Oblique shear fractures of the lunate. Orthopaedics 2003; 26: 805–8. [PubMed]
2. Cetti R, Christensen SE, Reuther K. Fracture of the lunate bone. The Hand 1982; 14: 80–4. [PubMed]
3. Brolin I. Post traumatic lesions of the lunate bone. Acta Orthop Scand 1964; 34: 167–82. [PubMed]
4. Teisen H, Hjarbaek J. Classification of fresh fractures of the lunate. J Hand Surg Br 1988; 13: 458–62. [PubMed]
5. Gelberman RH, Panagis JS, Taleisnik J, et al. The arterial anatomy of the human carpus, I: the extra osseous vascularity. J Hand Surg Am 1983; 8: 367–82. [PubMed]

Articles from BMJ Case Reports are provided here courtesy of BMJ Group