A 71-year-old right hand dominant female patient with no comorbidities was admitted in our institution after suffering a fall from her own height. Plain radiographs and CT scan were performed. The patient had a C2 fracture according to AO/ASIF classification with dorsal metaphyseal comminution (Figure 1). Seven days later, the patient underwent surgical treatment: using a volar approach, open reduction and internal fixation with volar locking plate was performed. Drilling was performed only through the volar cortex without violating dorsal cortex as we usually do when performing this technique, in order to avoid extensor tendon erosion. Attention was specially paid to restoration of the articular surface and radial bone angles. Dorsal fragments from metaphyseal comminution were left in site, maintained by the dorsal periosteum. Postoperative X-rays showed adequate fracture reduction. However, dorsal metaphyseal fragments were larger than usual and displaced in a perpendicular plane in relation with the dorsal radial cortex (Figure 2). The patient was splinted for 15 days and then moved onto a removable wristband, starting rehabilitation protocol. Three-month follow-up showed that the patient's wrist had full-range motion, no pain, and the Disabilities of the Arm, Shoulder and Hand (DASH) score of 37.
Six months after surgery, the patient's DASH score improved to 9, maintaining a full range of motion, but she addressed dorsal wrist tenderness, with incomplete extension of the index finger. Her Visual Analogue Scale (VAS) for pain at rest was 1 but increased to 4 with activity. Normal "tenodesis effect" was reported, but the patient could not further extend her index finger with the hand on top of a table, as she could do with the other three ulnar fingers.
Musculoskeletal ultrasound showed the presence of tenosynovitis of the fourth compartment and thinning of the index extensors at the radioulnar space, compatible with tendon rupture. New X-rays and CT scan showed sequel bone spicules at the dorsal epiphysis of the radius (Figure 3). Fracture was already consolidated, and there was no screw protrusion through the dorsal radial cortex. Surgical exploration was performed. A dorsal longitudinal approach through Lister's tubercle and third compartment with extensor retinaculum exposure was done. Extensor pollicis longus was unscathed. The fourth compartment was explored, with evidence of EDC rupture and EIP laceration (Figure 4). Large bone spurs from the dorsal radius were observed below the tendon plane in relation to Lister's tubercle, generating friction with the extensor apparatus. We confirmed no screws were prominent through the dorsal cortex. Dorsal bone spurs were resected, and tenodesis of EDC to the middle finger tendon was performed. A retinacular flap was designed to protect the tendons from the underlying bone. Volar plate was removed using the previous volar approach, and fracture consolidation was evidenced. The patient underwent physiotherapy rehabilitation, wearing a dynamic elastic band splint. At three-month follow-up, the patient had complete flexion and extension of the fingers, with some slight extensor plus noted as she fully flexed her wrist while her fingers were passively flexed.