Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_574_Библиотеки_им_академика_М_И_Перельмана.pdf
The ligament attenuates then eventually tears and the degree of
rotationbetween the carpal bones increases. The scapholunate
interosseous ligament appears to tear from volartodorsal.
Eventually the ligament completely tears, and agap between
the carpal bones is noted. This arthroscopic classification of
carpal instability is based on observation of the interosseous
ligamentsboth from theradiocarpal andmidcarpal spaces
(Table 1).
The normal scapholunate and lunotriquetral interosseous
ligaments have aconcave appearance between the carpal bones
as viewed from the radiocarpal space. The scapholunate interosseous ligament is best seen with the arthroscope in the 3to4
portal.The lunotriquetral interosseous ligament is best
observed with the arthroscope placed in either the 4to5or
6-R portal. In the midcarpal space, the scapholunate ligament
should be tight and congruent without any articular step-off.
Similarly,the lunotriquetral interval should be congruent, but
normally a1-mm step-offorslight increased (play) between
the lunate and triquetrum may be seen. Aprobe or needle may
be inserted through the ulnar midcarpal portal to evaluate the
amount of play between the carpal bones.
In Geissler Grade Iinjuries, there is loss of the normal
concave appearance between the carpal bones as the interosseous ligament attenuates and becomes convex when seen in
the radial carpal space. Hemorrhage may be seen within the
ligament in acutesituations, particularly associatedwitha
fracture of the distal radius. In the midcarpal space, however,
the interval between the carpal bones is still tight, congruent
and no step-offisseen.
In GeisslerGrade II injuries,the interosseous ligament
continues to become attenuated and becomes convex as seen
in the radial carpal space similar to Grade Iinjuries. There is no
gap between the carpal bones when observed in the radial
carpal space. In the midcarpal space, the interval between the
involved carpal bones is no longer congruent and astep-offis
seen.With scapholunate instability, thereisslight palmar
flexion of the dorsal edge of the scaphoid as compared to the
lunate. In lunotriquetral instability,the interosseous ligament
becomes attenuated as seen from the radiocarpal space. In the
radial midcarpal space, there would be increased play when
thetriquetrumispalpatedwithaprobe.Again,nogap is
seenbetweenthe carpal boneswith thearthroscope in the
radiocarpal space.
In Geissler Grade III injuries, the interosseous ligament
starts to tear andseparate betweenthe carpalbones.
The ligament tears from volar to dorsal. Aprobe is frequently
helpful to demonstrate agap between the carpal bones.In
the midcarpal space, a2-mm probe may be placed between
the carpal bones and twisted. However,the dorsal portion of
the interosseous ligament is still intact, and acomplete separation of the carpal bones is not seen.
In Geissler Grade IV injuries, the interosseous ligament is
completely detached and the carpal bonesseparated. The
arthroscope may be freely passed from the radiocarpal space
through the tear to the midcarpal space. This is the so-called
“drivethrough” sign.
Geissler Grade Iinjuries are consistent with awrist sprain
and usually respond to immobilization over aperiod of several
weeks. In Geissler GradeIIand IIItears, thesemay be
arthroscopicallyreducedand pinned in an acutesituation.
Following reduction of the distal radius fracture, the carpal
bones are reduced and provisionally pinned. Usually three to
four pins are placed between the involved carpal bones. In
Geissler Grade IV injuries wherethere is acomplete detachment
of the interosseous ligament, it is felt that open repair will have
the best prognosis in an acute situation (Figs 1–3).
&
OPERATING ROOM SETUP
Small joint arthroscopic instrumentation is essential for arthroscopic-assisted reduction of distal radius fractures. Asmall joint
arthroscope is approximately2.7 mm in diameter and even
smaller arthroscopes may be utilized. When the arthroscope is
initially placed in the wrist, it is usually full of hematoma and
fracture debris. It is helpful to irrigate out the fracturedebris
and utilize ashaver (3.5 mm or less) to clear the remaining
hematoma to improve visualization. Aseparate inflow is very
TABLE 1 Geissler Arthroscopic Classification of Carpal Instability
Grade Description Management
IAttenuation/hemorrhage of interosseous ligamentasseen from the radiocarpal joint.
No incongruency of carpal alignment in the midcarpal space
Immobilization
II Attenuation/hemorrhage of interosseous ligamentasseen from the radiocarpal joint.
Incongruency/step-offasseen from midcarpal space. Aslight gap
(less than the width of aprobe) between the carpal bones may be present
Arthroscopic reduction and pinning
III Incongruency/step-offofcarpal alignment is seen in both the radiocarpal and
midcarpal spaces. The probe may be passed through gap between the carpal
bones
Arthroscopic/open reduction and pinning
IV Incongruency/step-offofcarpal alignment is seen in both the radiocarpal and
midcarpal spaces. Gross instability with manipulation is noted. A2.7 mm
arthroscope may be passed through the gap between the carpal bones
Open reduction and repair
FIGURE 1 Posteroanterior radiographshowing an impacted scaphoid
facet fracture of the distal radius with scapholunate instability.
224
&
Geissler
helpful to wash out the fracture debris. Inflow is placed through
the 6-U portal and the hematoma is washed out with acannula
in the traditional 3to4portal. Inflow through the arthroscope
aloneisusually notsufficientdue to thesmallsizeofthe
cannulas, which restrict flow.
Atractiontower is very useful in arthroscopic-assisted
management of intra-articular distal radius fractures. Atraction
tower allows the surgeon to flex, extend, radially and ulnarly
deviate the wrist to help reduce the fracturefragments while
maintaining constant traction. Anew traction tower from ARC
Surgical (Hillsboro, Oregon, U.S.A) has been designed to allow
the surgeon to simultaneouslyevaluatearthroscopically the
articular reduction and monitor the reduction under fluoroscopy.The traction bar is placed at the side of the wrist rather
than at its center so it does not block fluoroscopic evaluation
and the surgeon does not need to work around acentral bar.
In addition, another advantage of having the traction bar at the
side rather than centrally is that this allows the surgeon to
simultaneously arthroscope the wrist dorsally and stabilizes
FIGURE 2 Arthroscopic evaluation of the wrist showing aGeissler
Grade IV complete tear of the scapholunateinterosseous ligament.
FIGURE 3 Posteroanterior radiographfollowing arthroscopic reduction
and elevation of the impacted scaphoid facet fracture. In Geissler Grade
IV injuries, it is recommended that asmall incisionismade for direct
primaryrepair of acompletetearinthe scapholunate interosseous
ligament.
FIGURE 4 The ARC (Hillsboro,Oregon,U.S.A.) traction tower. The
wrist may be suspended in the vertical position, and the traction bar at the
side allows for fluoroscopic evaluation of the wrist as it is still in traction.
FIGURE 5 The ARC (Hillsboro,Oregon,U.S.A.) traction tower may be
flexed so the wrist may be suspended in the horizontal position for wrist
arthroscopy.
Reduction of Intraarticular Distal Radius Fractures
&
225
the fracture through avolar approach (Fig. 4). The surgeon can
fluoroscopically evaluate the position of the plate and screw
insertionduringstabilization. This newtractiontower also
allows the surgeon to perform arthroscopic-assisted fixation
in either the vertical or horizontal planes depending on the
surgeon’s preference (Fig. 5).
If the traction tower is not available, the wrist may be
suspended by finger traps attached to aweight over the end of a
hand table in the horizontal position, or with ashoulder holder
in the vertical position. Asmall bump is useful to place under
the wrist if weights are being utilized at the end of the table to
obtain the wrist in slight palmar flexion.
Patients whosustain ahigh-energy injury to thedistal
radius frequently have swollen wrists. Because of this reason,
it is difficult to palpate the traditional extensor tendon landmarks for wrist arthroscopy.Bony landmarks, however,usually
can still be palpated and marked. The traditional viewing portal
is the 3–4 portal, which is made between the third and fourth
extensor compartments. The 3to4portal is in line with the radial
border of the long finger.The 4–5 working portal is made in line
with the mid-axis of the ring finger.The extensor carpi ulnaris
usually can be palpated. The 6-U portal is made ulnar to the
tendon, and the 6-R working portal may be made radial to the
extensor carpi ulnaris. Precise portal placement is mandatory
for arthroscopic-assisted reduction of distal radius fractures.
If the portal is placed too proximal, the arthroscope may be
placed within the fracture itself, and if it is placed too distally
can cause injury to either the articular surface of the carpus,
or the interosseous ligaments. It is extremely useful to place
an 18-gauge needle into the proposed portal location prior to
making askin incision (Fig. 6). Aportal is made by pulling the
skin with the surgeon’s thumb against the tip of aNo. 11 blade.
This decreases the risk of injury to the cutaneous nerves. Blunt
dissection is then continued with ahemostat to the level of the
joint capsule. The arthroscope with ablunt trocar is initially
introduced into the 3to4portal, which is the primary viewing
portal in wrist arthroscopy.
&
INDICATIONS
Ideal timing for arthroscopic-assisted reduction of distal radius
fractures appears to be between 3and 10 days. Earlier attempts
at arthroscopic fixationmay result in troublesome bleeding
which obscuresvisualization. Fractures that are over 10 days
old are difficult to disimpact and elevate up with percutaneous
techniques.
LaFontaine hasdescribed several radiographic features
that signify when afracture of the distal radius is unstable
(14). These features include initial dorsal angulation greater
than 208 ,extensive dorsal comminution, associatedulnar
styloid fractures, significant intra-articular involvement, and
patient age greater than 60 years.
Fractureswithout extensive metaphysealcomminution
are most ideal for arthroscopic-assisted management. Radial
styloid fractures, die punch fractures, three-part “T” fractures,
and four-part fractures are all indicated for arthroscopic-assisted
reduction and internal fixation (15). Three-part and four-part
fractures are managed by acombination of arthroscopic-assisted
fixation and open reduction. In these incidences, the fracture is
stabilized by avolar plate through avolar approach. The joint
capsule is not incised. The fractureisprovisionally pinned and
stabilized under fluoroscopy.Final articular reduction is then
performed as the joint surface is arthroscopically visualized. The
fracture fragments are manipulated arthroscopically,and then
thedistalscrews are insertedthrough theplate to stabilize
the fracture.
&
SURGICAL TECHNIQUE
&
Radial Styloid Fractures
Aradial styloid fracture is the most ideal fracturepattern to
manage arthroscopically,particularly if one is just beginning
to gain experience with arthroscopic-assisted fixation of distal
radiusfractures (16).Closedreductionand percutaneous
fixationofthe radial styloidfragmentmay be attempted
underfluoroscopy.The radial styloidfragmentcan almost
alwaysbeclosedreduced.Following percutaneous stabilization, thewrist may then be placed in tractionand
arthroscopically evaluated. This allows the fracturehematoma
debris to be washed out and also to assess for any associated
intra-articular soft tissue injuries. The arthroscope is initially
placed in the 3to4portal and the reduction of the radial styloid
fracture is observed. However,with the arthroscope placed in
the 3to4portal, it comes directly over the fracturesite. It is best
then to place the arthroscope in the 4to5or 6-R portal to look
across the wrist to judge the rotation and reduction of the radial
styloid fragment. Frequently,the articular reduction may look
anatomic under fluoroscopy,but the radial styloid fragment
may be still slightly rotated as viewed arthroscopically.The
guidewiresmay be backed outofthe shaftleaving them
only in theradial styloidfragmentifthe radial styloidis
rotated. The guidewires may then be utilized as joysticks to
control the rotation of the radial styloid fragment and then
advanced across the fracture site once the reduction is judged
anatomic as viewed arthroscopically.Atrocar may be introduced through the 3to4portal to provide additional control
of the radial styloid fragment as it is being manipulated with
the joysticks. The positions of the guidewires are then checked
underfluoroscopy.Ifthe guidewiresare in appropriate
position, acannulated screw may be placed over the guidewire
through acannula to stabilize the radial styloid fragment.
Early in the author ’s experience, only Kirschner wires were
utilized to stabilize the radial styloid fragment. However,the
FIGURE 6 Patients who sustain adistal radius fracture frequently have
swollen wrists. It is important to utilize the bony landmarks to identify the
preciselocation of the wristarthroscopy portals. It is helpful priorto
committing to askin incision to place aneedle in the proposed portal
location.
226
&
Geissler
protruding Kirschner wires frequently irritated the skin and
potentially hampered rehabilitation. Now,headless cannulated
screwsare preferred to stabilize the radial styloid fragment.
This eliminates any soft tissue irritation from the Kirschner
wiresprotrudingfrom theskin. Recently,new self-drilling
headlessscrews have beenintroduced (AcutrakII-Acumed,
Beaverton, Oregon, U.S.A.) which now eliminates the step of
drilling andfurther simplifiesthe procedure.The headless
screw decreases any metal prominence exiting from the bone,
which decreases irritation of the thumb extensor tendons and
helps promote an earlier range of motion.
An alternativetechnique to stabilizethe radial styloid
fragment is to place the guidewiresunder fluoroscopy in the
radial styloid fragment alone and not cross the fracturesite
(Fig. 7). The position of the guidewire in the radial styloid
fragment in relation to the fracture is viewed directly under
fluoroscopy.The wrist is then suspended in atraction tower and
the standard arthroscopy portals are made. Again, the best
portal to judge rotation of the radial styloid fragment is with
the arthroscope in the 6-R portal. The arthroscope is placed in
the 6-R portal, and then the joysticks are used to manipulate
andcontrolrotation of theradialstyloidfragmentbackto
the articular surface of the distal radius (Figs. 8and 9). Once
the fractureisjudged anatomic as viewed arthroscopically,the
guidewiresare advanced across the fracture site (Figs. 10–12).
It is important when the guidewires are initially placed into
theradial styloidtoprotect thesurrounding soft tissues,
FIGURE 7 Aguidewire may be placed in the radial styloid alone, but not
across the fracture site to be utilized as ajoystick.
FIGURE 8 Arthroscopic view of adisplaced radial styloid fracture with
the scope in the 6-R portal. The previously inserted guidewire can be
seen just into the radial styloid fragment to be used as ajoystick.
FIGURE 9 Arthroscopic view with the arthroscope in the 6-R portal
showing anatomic reduction of theradialstyloid fracture using a
combination of the previously inserted guidewire and atrocar inserted
into the 3to4portal. The 6-R portal is the best portal to judge rotation of
the radial styloid fracture.
FIGURE 10 Lateral radiograph showing afracture dislocation of the
radial styloid.
Reduction of Intraarticular Distal Radius Fractures
&
227
particularly the dorsal sensory branch of the radial nerve. The
guidewiresmay be placed througha14-gaugeneedle or,
alternatively,anoscillating drill is used to insert the guidewires.
The cutaneous nerves will not wrap aroundthe Kirschner wires
as they are being inserted with an oscillating drill.
&
Three-Part Fractures
Three-part fractures involve the displaced fractureofthe radial
styloidand lunatefacet.Inthree-partfractures,the radial
styloid may be closed reduced and percutaneously stabilized
under fluoroscopic guidance. The radial styloid fragment may
then be utilized as alandmark to which the depressed lunate
facet fragment is reduced. Following percutaneous reduction
and stabilization of the radial styloid fragment, the wrist is then
suspended in the traction tower and fracture hematoma and
debris are arthroscopically evacuated. The depressed lunate
facet fragment is best seen with the arthroscope in the 3to4
portal.An18-gaugeneedlemay be placed percutaneously
directly over the depressed fragment and utilized as alandmark. AlargeSteinmann pin is then placed approximately2cm
proximal to the18-gaugeneedleintothe depressed lunate
fragment, which is then elevated. Once the fragment is elevated
back to the radial styloid fragment, abone tenaculum is useful
to reduce the fracturegap between the radial styloid fragment
and thelunatefacet fragment and to provide provisional
stabilization.Oncethe fracture fragmentsare anatomically
reducedasviewedarthroscopically, guidewires arethen
placed transversely from the radial styloidintothe lunate
facet fragment. The guidewires are placed into the subchondral
bone. If adorsal die punch fragment is present, it is important
that the guidewires are aimed dorsally to capture this dorsal
fragment. In addition, it is important to pronate and supinate
the wrist to insure the transverse pins have not violated the
DRUJ. The transverse pins may appear under fluoroscopy to
nothavepenetrated theDRUJ, butbecause of the concave
nature of the DRUJ, in actuality they may have protruded into
the joint (Figs. 13 and 14). Headless cannulated screws are then
placed over the transverse guidewire to stabilize the lunate facet
fragment. One headless cannulated screw may be placed to
stabilize the radial styloid fragment and asecond screw is then
placed transversely over the guidewire to support the impaction of the lunate facet fragment (Figs. 15–18). The headless
cannulated screwsagain decrease soft tissue irritation when
compared to protruding Kirschner wires, and promotes earlier
range of motion and rehabilitation. Abone graft may be placed
FIGURE 11 Lateral radiographfollowing arthroscopic reduction and
stabilizationwith aheadlesscannulatedscrew. Notice how the carpus is
reduced with the radial styloid fragment.
FIGURE 12 Posteroanterior radiograph showing anatomic restoration
of the articular surface following the fracture dislocation to the distal
radius. Aheadless cannulated screw is utilized rather than multiple
Kirschner wires as it facilitatesrehabilitation.
FIGURE 13 Posteroanterior radiographshowing adisplaced three-part
fracture of the distal radius.
228
&
Geissler
FIGURE 14 Posteroanterior radiograph followingarthroscopic
reduction with Kirschner wires of the three-part distal radius fracture.
FIGURE 15 Posteroanterior radiograph showing adisplaced three-part
fracture of the distal radius.
FIGURE 16 Arthroscopic view with the arthroscope in the 3to4portal
showing the displaced lunate facet fragment.
FIGURE 17 Arthroscopic view following reduction of the lunate facet
fragment. The 3to4portal is the best portal to view reduction and
elevation of an impacted lunate facet fragment.
FIGURE 18 Two headless cannulated screws were utilized to support
the reduction. One headless screw was placed through the radial styloid
fragment andthe second transversely in thesubchondral bone to
stabilizethe impacted lunate facetfragment. Headless cannulated
screws are preferred over Kirschner wires, which hamper rehabilitation.
Reduction of Intraarticular Distal Radius Fractures
&
229
through asmall dorsal incision between the fourth and fifth
dorsal compartments to avoid late settling of fracture fragments
if extensive metaphyseal comminution is present.
&
Three-Part Fractures with Extensive Metaphyseal
Comminution
Avolar plate may be utilized if extensive metaphyseal comminution is present (Fig. 19). Early in the author ’s experience,
thesefractures werestabilized with Kirschnerwires and
headless cannulatedscrewswith additional bone graft.
However,with the recent introduction and popularity of volar
plate stabilization for fractures of the distal radius, acombined
open and arthroscopicapproach is now recommended. These
strong volarplateshaveexcellent fixation in patients with
good bone stock, andpromoteearlier rangeofmotionand
rehabilitation.
In this scenario, astandard volar approach is made over the
radial side of the flexor carpi radialis tendon. Dissection is
continued down thesheathwiththe flexorpollicislongus
FIGURE 19 Displacedthree-part fracture of thedistalradius with
metaphyseal comminution.
FIGURE 20 In three-part fractures with metaphyseal comminution, a
combination of open surgery with arthroscopic surgery is preferred.An
Acu-loc (Acumed, Beaverton, Oregon) volar distal radius plate is placed
through astandard volar incision.
FIGURE 21 The fluoroscopic view following percutaneous stabilization
of the fracture and provisional placement of the volar plate. An attempt is
made to reduce thearticular surfaceasclosely as possibleunder
fluoroscopic control.
FIGURE 22 Thewrist is then suspendedinthe ARC(Beaverton,
Oregon) traction tower where the articularreduction may then be fine
tuned arthroscopically.
230
&
Geissler
identifiedand retracted ulnarly. Thepronator quadratusis
released offits radialborderexposing thefracturesite.
The radial styloid fragment can be anatomically reduced back
to theshaftasvieweddirectly throughthe incision.Itis
frequently helpfultoreleasethe brachioradialistofacilitate
reductionofthe radial styloidfragment. The lunate facet
fragment may be seen through the volar approach and can be
anatomically reduced and pinned. Avolar plate is placed and
the fractureprovisionally pinned through the plate as viewed
fluoroscopically (Figs. 20 and 21). The wrist is then suspended
in thetraction tower and the articularreductionisviewed
arthroscopically (Figs. 22–24). If the articular reduction is not
anatomic, the pins may be removed from the plate and the
articular reduction may be fine tuned as viewed arthroscopically.Once the reduction is felt to be anatomic, the pins are
placed back through the plate to provisionally stabilize the
fracture (Fig.25).The most distal screws arethenplaced
through the plate into the articular fragments.
In dorsal die punch fractures, arthroscopy is especially a
useful adjunct (17). The dorsal die punch fragments are difficult
to view frequently through avolar approach (Fig. 26). In these
fractures, the volar plate is placed and the fractureisprovisionally pinned under fluoroscopy.The wrist is then suspended in
the traction tower,and the reduction of the dorsal die punch
fragment is arthroscopically evaluated (Fig. 27). Frequently,it
still needs to be further elevated. The dorsal die punch fragment
is best visualized with the arthroscope either in the 6-R portal,
or through the volar portal (18). The volar portal is made by
placing the arthroscope with ablunt trocar between the radial
FIGURE 23 Frequently, multiple loose bodies may be identified in the
joint.Sometimesthese loose bodies mayblock reduction andare
removed.
FIGURE 24 Arthroscopic view showing the volar wrist capsule to have
pulled offthe distal radius. In this case, the capsule was in the fracture
site initially blocking reduction.
FIGURE 25 The volar capsule was arthroscopically removed from the
fracture site, the fracturecould thenbeanatomicallyreduced and
stabilized.Oncethe articular reductionwas judged to be anatomic
under arthroscopy,the distal locking screws were placed into the plate.
It is helpful to place the first screw in anon-locking mode to help reduce
the bone to the plate. The remainder of the screws are then placed in a
locking fashion.
FIGURE 26 Computed tomographyscan showing adistal-dorsal lip
fracture of the distal radius.
Reduction of Intraarticular Distal Radius Fractures
&
231
scaphocapitate and long radial lunate ligament. The cannula
is pushed throughthisinterval, andisthenseen through
the volar incision. Aswitching stick is then placed through
the arthroscopiccannula into the volar incision. The arthro-
scopic cannula is then placed over the switching stick and the
arthroscope may be placed into the volar portal to view the
dorsal die punch fragment (Fig. 28). In the author ’s experience,
the dorsal die punch fragment is usually well visualized with
the arthroscope in the 6-R portal. This fragment is then further
elevatedpercutaneously with aSteinmann pin. Once the
articular surface is judged anatomic, the fracture fragment is
pinned through the plate. As the distal screws are inserted into
the plate, the screwsmay be seen arthroscopically to directly
enter into the dorsal die punch fragment (Fig. 29). This ensures
anatomic reduction and stabilization of the dorsal die punch
fragment, which would be very difficult through atraditional
open volar approach.
&
Four-Part Fractures
In four-part fractures, the lunate facet is divided into volar and
dorsal fragments. The volar–ulnar fragment is unable to be
reduced by closed manipulation. Traction causes the palmar
wrist capsule to rotate the volar–ulnar fragment. In four-part
fractures, astandard volar approach is made to the distal radius
as describedabove. The radial styloid fragment is reduced
underdirectvisualizationthrough theopenincision. The
volar–ulnar fragment is then reduced under direct observation
by reducing it back to theshaft andtothe radial styloid
fragment. It may then be provisionally pinned transversely.
Avolar distal radius plateisthenplacedand thefracture
fragments are provisionally pinned.
The wrist is then suspended in the traction tower and the
arthroscope is placed in the 3to4portal. The dorsal–ulnar
fragment is best viewed with the arthroscope either in the 6-R
portal or through the volar portal. The dorsal–ulnar fragment
is then percutaneously elevated back to the radial styloid and
then thereducedvolar–ulnar fragment,which areusedas
landmarks. The dorsal–ulnar fragmentisthen provisionally
pinned, and the distal screws are placed through the plate to
stabilizethe dorsalfragments. Particularly in smalldorsal
fragments, thearthroscopeisausualadjunct to directly
view theinsertion of thescrews into thedorsalfracture
fragments.
FIGURE 27 Arthroscopic view with the arthroscope in the 6-R portal to
view the dorsal lip fracture following reduction. Arthroscopycan be a
valuable adjunct in these very distal dorsal lip fractures.The pins through
the plate may be visualized going into the fracture fragments directly,
arthroscopically confirming secure fixation of the dorsal lip fragments
when aplate is placed on the volar surface.
FIGURE 28 The articular reduction of the dorsal lip may be viewed
either with the arthroscope in the 6-R portal or as demonstratedhere with
the arthroscope in the volar portal between the radial scaphocapitate and
long radial lunate ligaments.
FIGURE 29 Fluoroscopic view confirming the locking screw is being
placed into the distal dorsal lip fragment.
232
&
Geissler
&
Ulnar Styloid Fractures
Stabilization of an associated ulnar styloid fragment is quite
controversial (19). Wrist arthroscopy provides some rationale
as to when to stabilize an associated ulnar styloid fragment.
The tension of the articular disc is palpated arthroscopically
following anatomic reduction of the distal radius fracture.The
articular disc is best viewed with the arthroscope in the 3to4
portal. Aprobe is then inserted through the 6-R portal to palpate
the disc. If there is good tension to the articular disc when
palpated, the majority of the fibers of the triangular fibrocartilage complex are felt to be still attached to the base of the ulna.
Aperipheral tear of the articular disc is suspected when the
disc has lost its tension by palpation. Aperipheral tear may be
obscured by hematoma, and it is important to insert the shaver
through the 6-R portal to debride any hematoma to view the
ulna periphery of the articular disc. The articular disc may then
be arthroscopically repaired to the base of the ulna with suture
anchors if aperipheral tear is identified (20).
Stabilization of alargeulnar styloid fragment is considered
when the articular disc is lax when palpated and no peripheral
tear is identified. In this situation, the majority of the fibers of
the articular disc are attached to the displaced ulnar styloid
fragment. Asmall incision is made between the interval of the
extensor carpi ulnaris and flexor carpi ulnaris. Blunt dissection
is carried down to protect the dorsal sensory branch of the
ulnar nerve, which is located volar to the incision. The ulnar
styloid fragment is clearedoffracturedebris and anatomically
reduced. The fragment may be stabilized by either atension
band,Kirschnerwireorpreferably by asmall headless
cannulated screw.
&
OUTCOMES
Theliterature is relatively sparseregarding the results
of arthroscopic-assistedfixationofdisplaced intra-articular
fractures of thedistalradius(6,16–18,21–24).Stewart et al.
presented acomparison study of 12 open and 12 arthroscopicassisted reductions of comminuted fractures of the distal radius
(24). In his series, all fractures wereclassified as Frykman type
VII or VIII. In the arthroscopic group, they had five excellent, six
good, and one fair result. There were no excellent results in the
open group. They also concluded that the arthroscopic group
had asignificantly increasedrange of motion as compared to
that of the groupthat underwent open stabilization.
Doi et al. reported their results in asimilar comparison
studyof38patients whounderwent arthroscopic-assisted
fixationincomparisonwith thosepatientswho underwent
open reduction(21). Theauthors similarlyfoundthatthe
arthroscopic grouphad improved range of motion as compared
to the open group. Ruch reportedhis comparison study of 15
patients who underwent arthroscopic-assisted reduction and
15 patients who underwent closed reduction and stabilization
by external fixation (23). In the 15 patients who underwent
arthroscopic reduction, 10 patients had atear of the triangular
fibrocartilage complex. Seven of the 10 patients sustained a
peripheral tear of the articular disc and underwent arthroscopic
repair.Nopatients in the arthroscopic group had any signs of
DRUJ instabilityatfinalfollow-up.Inthe 15 patients who
underwent closed reduction and external fixation, four patients
presented with instability of the DRUJ at final follow-up visit.
Potentially,these patients had aperipheral tear of the triangular
fibrocartilage complex, which could have been acutely repaired
at the time of fracture stabilization.
Geissler and Freeland reviewed their results of 33 patients
who underwent arthroscopic-assisted reduction of comminuted intra-articular fracturesofthe distal radius (22). In their
series,25patients had an anatomic reduction, and eight
patients had a1-mm articular step-offatfinal follow-up visit.
The patients wereevaluated utilizing the modified Mayo wrist
score, and there were 20 excellent, 10 good,and three
fair results in their series. In addition, they analyzed their
final results based on associated injuries to the interosseous
ligament. They noted when aGeissler Grade II injury to the
scapholunate interosseous ligament was present, it did not
affect thefinal prognosisinany fracture pattern. Geissler
GradeIIinjurieswere evenly distributedthroughouttheir
series, and did not correlate to the final prognosis. However,
when aGeissler Grade III or IV tear was present combined
with an AO Type Cfracture, it significantly affected the final
prognosis. In thefive patients with AO Type Cfracture
without an interosseous ligament tear,all the five patients
had an excellent result. However,inthe five patients with an
AO Type Cfracture with aGeissler III or IV interosseous
ligamenttear, therewerefourgoodresults andone fair
result. It appeared that the presence of aGeissler Grade III
or IV interosseous ligament tear significantly affected the final
prognosis in AO Ty pe Cfractures in their study.
&
SUMMARY
Wrist arthroscopy is avaluable adjunct in the management of
displaced intra-articular fracturesofthe distal radius. It allows
for evaluation of articularreduction underbright lightand
magnified conditions.Particularly,wrist arthroscopyallows
for detection of rotation of fracturefragments, which is very
difficult to judge underfluoroscopy. It hasbeenpreviously
reported that restoration of the articular surface is important
and affectsthe patient’s finalprognosis (2–5). In addition,
evacuation of the fracturehematoma and debris may result in
improved range of motion as previously documented by the
comparison studies of Stewart and Doi (21,24).
Wristarthroscopyalsoallows for thedetection and
management of associated intra-articular soft tissue injuries,
which have been shown to occur frequently with intra-articular
fracturesofthe distal radius. It is felt that management of acute
soft tissue injuries has abetter prognosis as compared to chronic
reconstruction. Tears of the triangular fibrocartilage complex
have been shown to be the most frequently associated soft tissue
injury associated with fractures of the distal radius. This may
explain why patients continue to complain of persistent ulnarsided wrist pain despite an anatomically healed fracture of the
distal radius (10,13,19). Chondral defects or loose bodies which
frequently are not seen on plain radiographs are frequently
identified arthroscopically and can be removed from both the
radiocarpal and midcarpal spaces. Lastly,wrist arthroscopy
provides arationale of when to stabilize displaced ulnar
styloid fragments when associated with afracture of the distal
radius (17).
&
SUMMATION POINTS
Indications
&
One-, two-, three-, or four-part distal radius fractures.
&
Ulnar styloid fracture when associated with DRUJ instability
or laxity in the triangular fibrocartilage complex.
&
When combined with avolar plate: fractures with metaphyseal comminution.
Reduction of Intraarticular Distal Radius Fractures&233