Carpal Bone Fractures in Distal Radial Fractures: Is Computed Tomography Expedient?

To the Editor: We read with great interest the article “Evaluation of associated carpal bone fractures in distal radial fractures” by Heo et al. We would like to congratulate the authors for this study. However, the article left a few seminal questions unaddressed that we would like to draw the authors’ attention to. The authors mentioned that out of 223 fractures of the distal end of the radius, which were subjected to computed tomography (CT) evaluation, 46 patients had an associated carpal-bone fracture. They were silent, however, about how many of these associated carpal bone fractures were picked-up on plain X-rays. A CT undoubtedly helps in diagnosing undisplaced or minimally displaced fractures; however, this cannot be the story in all cases. Indeed, plain radiographs can definitely aid in diagnosing the obvious, if not all of these fractures. Type C2 and C3 are a result of high-energy trauma, and 40 out of the 46 cases of the carpal bone fractures were identified in these fracture subtypes. If we go by the current study, the incidence of carpal bone fractures is 28.36% in these two types as against 4.87% in all other types combined together. High-energy trauma has been found to be associated with a higher risk for associated carpal bone injuries. Thus, it would not be wise to perform screening CT scans for all fracture types. It is an expensive investigation that subjects a patient to substantive amounts of radiation exposure. Moreover, in a recent study by Jorgsholm et al., it was identified that even a CT scan is not always 100% sensitive in diagnosing carpal bone fractures and some of these fractures are liable to be missed on a CT as well. It is important to decide a treatment protocol, rather than subjecting all patients with distal radius fractures to CT examination. Patients with Type C2 and C3 types should be looked with a high degree of suspicion and as approximately one-third of them have been found to be associated carpal bone fractures, mobilization can be delayed as it does not lead to unsatisfactory outcome. Moreover, there is a high incidence of associated soft tissue injury in these patients perpetuated by high energy trauma. Delayed mobilization will also aid in healing of these injuries.