Arthroscopic assisted treatment of distal radius fractures and concomitant injuries

Abstract

Wrist arthroscopy is mainly used to assist fracture reduction and fixation and to diagnose and treat concomitant injuries mainly to the scapholunate (SL), lunotriquetral (LT) ligament and the triangular fibrocartilage complex (TFCC). Arthroscopy is beneficial in improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures (DRFs). Yet, the literature that the functional outcome correlates with the use of arthroscopy, is limited. Non-surgical treatment and immobilization is recommended for Geissler grade I-III Sl-ligament injuries, while open reduction, ligament suture and/or K-wire pinning is mandatory for complete ligament tears according to Geissler grade IV. This manuscript describes the current literature and gives insight into the authors' opinions and practice.

Keywords: Arthroscopic treatment; Concomitant injuries; Distal radius fracture; Injury; Intrinsic ligament.

Fig. 1

Patient lying in a supine position with the upper extremity suspended by the use of finger traps

Fig. 2

Four kg traction weight applied on the wrist

Fig. 3

Standard arthroscopy portals 3/4, and 6R with the camera in the 3/4 portal

Fig. 4

Radiocarpal view a before fracture reduction and b after fracture reduction

Fig. 5

Intra-articular fibrous tissue formation (FTF)

Fig. 6

Intra-articular view after debridement of FTF

Fig. 7

Radiocarpal view: balloon sized scapholunate ligament Geissler grade 1; L lunate, SL scapholunate ligament, S scaphoid

Fig. 8

Midcarpal view: radius joint surface can be seen with the hook between scaphoid and lunate indicating a scapholunate ligament tear Geissler grade 4; S scaphoid, RS radial joint surface, L lunate

Fig. 9

Midcarpal view: widening of the lunotriquetral joint with the hook between the triquetrum and lunate indicating a lunotriquetral ligament tear; T triquetrum, L lunate, H hamate

Fig. 10

Dorsovolar view: initial assessment of the injured wrist with a loss of the radial inclination and radial length

Fig. 11

Lateral view: initial assessment showing the loss of radio-ulnar and dorso-palmar inclination

Fig. 12

CT scan of a dorsovolar view after reduction and cast immobilization showing the defect zone of the intermediated column and fracture involvement of the DRUJ

Fig. 13

CT scan of a lateral view of the intermediate column showing the volar fragment of the intermediate column, a fracture gap and step of more than 2 mm and the volar fragment additionally toppled

Fig. 14

CT scan of a lateral view of the ulnar column showing the additional ulnar fragment flipped 90°

Fig. 15

CT scan of an axial view with the numbered intraarticular fragments 1: radial styloid, 2: dorso-ulnar fragment, 3: fragment of the intermediate column 4: volar fragment

Fig. 16

Initial view of the displaced fracture fragments after inserting the arthroscope through the 3/4 portal

Fig. 17

Arthroscopic view after debridement using the wrist shaver; all fragments are visualized. 1: radial fragment, 2: volar fragment, 3: intermediate fragment, 4: dorsal fragment

Fig. 18

Arthroscopic view after arthroscopical fracture reduction showing an anatomical alignment of the involved fragments. 1: radial fragment, 2: volar fragment, 3: intermediate fragment

Fig. 19

Dorsovolar fluoroscopic view at the end of the surgery showing the main screw fixation directed to the ulnar corner

Fig. 20

Lateral fluoroscopic view showing the screws in a subchondral position

Fig. 21

Dorsovolar and lateral x-ray control four weeks after surgery

Fig. 22

Dorsovolar and lateral X-ray control 4 weeks after surgery

Fig. 23

Dorsovolar and lateral X-ray control 1 year after surgery

Fig. 24

Dorsovolar and lateral X-ray control 1 year after surgery

Fig. 25

Lateral view in a flexed and extended position of the wrist before implant removal

Fig. 26

Lateral view in a flexed and extended position of the wrist before implant removal

Fig. 27

Arthroscopic view of the palmar side identifying palmar scar formations

Fig. 28

Arthroscopic view of the palmar side identifying palmar scar formations

Fig. 29

Arthroscopic view of the dorsal side identifying palmar scar formations

Fig. 30

Arthroscopic view of the dorsal side identifying palmar scar formations

Fig. 31

Arthroscopic view after debridement showing a gap at the volar side

Fig. 32

Lateral view in a flexed and extended position of the wrist after implant removal and arthroscopic debridement showing an improved range of motion

Fig. 33

Lateral view in a flexed and extended position of the wrist after implant removal and arthroscopic debridement showing an improved range of motion

Fig. 34

Clinical photographs in wrist extension and flexion after implant removal

Fig. 35

Clinical photographs in wrist extension and flexion after implant removal