Distal radius fractures are common orthopedic injuries. Intra-articular die punch fractures, in particular, require precise reduction and fixation to achieve anatomical alignment and functional recovery. Despite being visible under fluoroscopy during surgery, these displaced fragments are often difficult to manipulate and reduce. We introduce a consistent cortical window technique to facilitate the reduction of die punch fractures under fluoroscopic guidance, followed by bone grafting.
For intra-articular die punch fractures, we utilized a modified Henry’s approach, dissecting the pronator quadratus muscle from the radial border and distal edge. We also released the brachioradialis tendon insertion to mitigate radial deviation forces. After manipulating the fragment and temporarily fixing it with K-wires, we applied a volar locking plate and set a cortical compression screw, checking the main alignment under fluoroscopy. At this stage, the die punch fracture often remained depressed and difficult to reduce. A consistent cortical window was identified or created at the radial border of the distal radius, beneath the dissected brachioradialis tendon. A small bone dissector was inserted through this window to reach the subchondral area and reduce the die punch fracture under fluoroscopic control. Once reduced, bone grafting was performed through the same cortical window, followed by the application of additional locking screws to complete the fixation.
This method successfully allowed for the manipulation and reduction of the die punch fragment. We have performed this technique on five die punch fractures and also used it to apply bone grafts in cases of metaphyseal bone loss in osteoporotic distal radius fractures.
Die punch fractures present a challenging aspect of distal radius fracture treatment. While arthroscopic-assisted reduction is one option, it involves additional surgical time and risk. We propose the consistent cortical window as a simpler portal for reducing die punch fragments and applying bone grafts. Further functional evaluations are needed to assess the efficacy of this surgical method.
