Arthroscopic Management of Distal Radius Fractures

Arthroscopic Management of Distal Radius Fractures

Francisco del Piñal Editor Christophe Mathoulin Riccardo Luchetti Co-Editors

Arthroscopic Management of Distal Radius Fractures

Dr. Francisco del Piñal Private practice and Hospital Mutua Montañesa Calderón de la Barca 16-entlo. 39002 Santander Spain [email protected] Dr. Christophe Mathoulin Professor Clinique Jouvenet Institut de la Main 6 square Jouvenet 75016 Paris France [email protected]

Dr. Riccardo Luchetti Rimini Hand Surgery and Rehabilitation Center Multimedica Policlinic, Milano Via Pietro da Rimini, 4 47900 Rimini Italy [email protected]

ISBN: 978-3-642-05353-5     e-ISBN: 978-3-642-05354-2 DOI: 10.1007/978-3-642-05354-2 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009943442 © Springer-Verlag Berlin Heidelberg 2010 Chapter 2: all figures © David J. Slutsky 2007. All Rights Reserved. Chapter 4: Figures 1, 6, 8–11, and 16–19. © Francisco del Piñal 2009. All Rights Reserved. Chapter 14: 11, 13, 14, and 26. © Francisco del Piñal 2009. All Rights Reserved. Illustrations by Maximiliano Crespi This work is subject to copyright. All rights are reserved, whether the whole or part of the material is ­concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant ­protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Supported by EWAS

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Dedication

To my kids Lucía, Guillermo, and Miguel. To my admired mentors: G. Ian Taylor, who taught me the importance of anatomy and of toying with it; Ian T. Jackson, who showed me that surgery was science before art; to Luis R. Scheker, a virtuoso, who sparked my interest in hand surgery, and to all surgeons who one way or another have influenced me throughout this journey.  Paco Piñal I would like to dedicate this book to all EWAS members without whom none of this magnificent adventure would have been possible. I would particularly like to thank all the Presidents of our small but efficient society who worked hard to achieve the reputation and quality which now has established EWAS as a recognized, respected, and consulted scientific society. Finally, I would especially like to thank our current President Francisco del Piñal, who worked tirelessly countless hours, in order to publish this very good book.  Christophe Mathoulin I personally wish to dedicate a few words to the people who have helped us behind the scenes. Those people are our families (wives, partners, children, and so on). Our families harmonize our lives, help us whilst staying in the shade, support us when difficulties arise and, last but not least, stimulate us in our profession, both surgical and scientific. I do not wish to remember how many hours we have deprived them of, how many hours we have spent with books open in front of us, working on our computers to write a chapter. I prefer to remember what our editor in chief (Paco) managed to do: he not only produced his own chapter, but also corrected all the others, giving the authors advice

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and directing the drafts in conformity with his thoughts, and at the same time keeping up with work, congresses, and collateral activities. A big thank you to everybody! And of course thank you, Paco and Christophe, and all the authors. At last this book will mark an era! 

Riccardo Luchetti

Foreword

Seeing is believing. This is the title of a new campaign promoted by the International Agency for Prevention of Blindness to raise funds to help tackle avoidable loss of sight in poorly developed countries, truly an admirable initiative. This book could have used a similar leitmotiv: if you see what happens inside of a joint, you will be able to believe in your patient’s symptoms. But it would not be right. Arthroscopy is not out there just to make a diagnosis; it was not developed just to certify that the patient’s complaints are based on something physical. Arthroscopy was introduced to help patients, to make our treatments more reliable, to have better control of our procedures. It is merely a tool, indeed, but a marvelous one which nobody should underscore among all surgical options we have when it comes to solving wrist trauma. Seeing is understanding. This could be another leitmotiv for these authors’ campaign to get more hand surgeons to incorporate arthroscopy in their practices. Certainly, mastering these newly developed techniques help understanding the patient’s problems. But again, that statement would also be misleading for not always what we see through the scope is the real cause of dysfunction. The enemy may be outside of the capsular enclosure. Indeed, arthroscopy provides lots of useful information, but the surgeon need not accept biased interpretations of the patient’s problem based only on what appears on the screen. Clinical judgment needs always to rely on all sorts of information, the clinical examination being most important. Seeing is delivering. This is another possible motto for this book. If you see what you do, you will be able to deliver a better job no matter how difficult that might be. Nobody solves a puzzle without looking at it. Nobody would be happy to leave unreduced a badly displaced intra-articular fragment of a distal radial fracture if one can see it. Of course, fluoroscopy is what most of us have learned to use when reducing a distal radial fracture, but we must admit that not even the best image intensifier does offer such clear images of joint congruity as arthroscopy does. Indeed, if you see it better and you have the right skill to reduce those fragments more anatomically, your efforts will be rewarded by a higher self-esteem, but most importantly by your patient. Seeing is preventing. If you are the first to see the enemy coming, you are better prepared than the others to work on a proper line of defense before any damage has been caused. Without a thorough perception of a problem, one can hardly prevent it from happening. A bone fragment may appear stable under fluoroscopy, but this may be a false impression which could endanger our results. Indeed, steadiness of a fragment can only be ensured by challenging its stability with a palpating prove . Certainly, using arthroscopy not only helps in the diagnosis and treatment but also, and most importantly, in the prevention of complications. ix

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Enclosed in these pages is a synthesis of what a group of talented arthroscopists have learned in their search for better ways to solve wrist problems. There is a large amount of technical tips in this book that will facilitate our treatments; new indications may attract our attention. There is enormous interest in providing detailed howto-do descriptions that will guide our steps toward perfecting each one’s personal arthroscopy abilities. But above all, there is a good account of a number of mistakes that need not to be repeated, and these authors learned the hard way about all of this. Let’s be grateful that they are willing to share this vast knowledge with us, the ones who did not dare to be pioneers in this field. Let’s use their experience to make less steep our learning curves. To those who believe that there is not a real novelty in the field of wrist trauma reconstruction, here is this book to show them wrong. There are new ways of solving wrist problems; new ways that not only have been made possible as a result of the introduction of arthroscopy but also, and most importantly, as a result of the hard work and enthusiasm of those who pioneered the use of this tool in this environment. Wrist arthroscopy is here to stay, because it helps obtaining better results with less morbidity than open surgery. Arthroscopy is here to stay, because there are professionals, like the ones signing these chapters, who have collected enough experience for us to get an easy start. And this is what this book is all about: a condensed description of the indications, pearls, and pitfalls of this wonderful tool. Because arthroscopy is here to help our patients, let’s make the most of it. Institut Kaplan, Barcelona

Marc Garcia-Elias

Preface

“If a method produces better results, one must master any difficulty it presents and learn to do it well” (talking on Herbert screw). Nicholas Barton. J Hand Surg 1997;22B:153 I still remember when we were stared at in meetings as if we were aliens (and grouped under the “arthroscopists”). This feeling of being an “outsider” was not strange to me at all, as when several of us started to carry out what was called “third-generation microsurgery,” we provoked the same feelings. This convinced me that we were on the right path, and that arthroscopy was the right tool and persuade me to keep on using in it in more and more applications. One of the most fascinating fields where we were able to apply our maverick ideas was to distal radius fractures with articular involvement. The arthroscope allowed us to have a magnified view of the reduction, to detect associated chondral or ligamentous injuries, and to treat many of them. It was exciting to realize how many things we could see and fix through such tiny holes! Surprisingly, however, and despite growing literature supporting the role of arthroscopy, many surgeons are still reluctant to systematically use the arthroscope when treating distal radius fractures, when we all agree that fluoroscopy is quite inaccurate. Two of the arguments given are that no one has yet proved that the scope is better than traditional treatments in prospective-randomized studies, and the second one, more difficult to voice, is that the operation is technically difficult. Hence, why complicate one’s life with the scope if there are no advantages to be gained? Regarding the first argument, I must admit that the scientific purists are right: there are not yet Level 1 studies that have shown that arthroscopy is so much better than traditional methods in the treatment of distal radius fractures. One has to accept that innovation goes well ahead of comparative studies, and it will take some time before such studies are available. The problem is compounded by the fact that there are so many variations in a distal radius fracture that we will need a long time before each subtype is properly assessed. Can our patients wait so long to benefit from a method that allows us to see the reduction with minimum morbidity and maximum accuracy? After all, there have been many studies showing that articular congruity is the most important prognostic factor after an articular fracture, and the scope is no doubt the tool to see inside a joint. Another question altogether is if it is easy to carry out an arthroscopic-assisted reduction of articular distal radius fractures. The answer is no. As a matter of fact, things have become more and more sophisticated since the arthroscopic management of distal radius fractures has advanced enormously in the last 15 years. Renowned specialists around the world have been brought together in this book to share with us xi

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their innovative way of dealing with some of the problems. Furthermore, beginners will find the basics succinctly explained by masters in a step-by-step manner. The reader may find it perplexing that each of us might manage the same injury in a somewhat different manner. This variability is explained by the fact that very little was written at the time we began our journey seeking the same goal: anatomical reduction with minimal trauma. Don’t worry! Choose the way that suits you best and go ahead….after all, all roads lead to Rome. My advice is, “build your own foundations and steadily move forward; don’t leap into too complicated cases before you are confident with the simple ones.” As an example, as a starting point, simply washing out the hematoma would be a good exercise in order just to be acquainted with the set-up. It is pertinent to stress at this point that the arthroscope is just a tool to improve reduction, and expertise in the management of distal radius fractures with the classic techniques is more important than the arthroscopic part itself. The maxim is, ”classics first and then innovation” – ignoring this will inevitably lead to unwanted problems and bad results. If you are yet not convinced that the scope is the tool, as a simple exercise I recommend you to insert an arthroscope inside a joint with a fracture that fluoroscopically seems to be reduced. Who knows? You may just change your mind, and find this book useful. After all “seeing is believing,” as Marc Garcia-Elias writes in the Foreword. Last, but no least, I would like to thank all authors for having accepted to become part of this project, and to Christophe and Riccardo, and the EWAS group for supporting me on it. Editor in chief President of the European Wrist Arthroscopy Society

Francisco del Piñal

Contents

  1

Pre-Operative Assessment in Distal Radius Fractures . . . . . . . . . . . . Gregory I. Bain

1

  2

Portals and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David J. Slutsky

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  3

Management of Simple Articular Fractures . . . . . . . . . . . . . . . . . . . . Ferdinando Battistella

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  4

Treatment of Explosion-Type Distal Radius Fractures . . . . . . . . . . . . Francisco del Piñal

41

  5

Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability . . . . . . . . . . . . . . . . . . . . . . Alejandro Badia

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Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Andrea Atzei

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  7

Radial Side Tear of the Triangular Fibrocartilage Complex . . . . . . . Toshiyasu Nakamura

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Arthroscopic Management of Scapholunate Dissociation . . . . . . . . . . Tommy Lindau

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Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Didier Fontès

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Management of Concomitant Scaphoid Fractures . . . . . . . . . . . . . . . 117 Christophe Mathoulin

11

Perilunate Dislocations and Fracture Dislocations/ Radiocarpal Dislocations and Fracture Dislocations . . . . . . . . . . . . . . 127 Mark Henry

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The Role of Arthroscopy in Postfracture Stiffness . . . . . . . . . . . . . . . Riccardo Luchetti

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Treatment of the Associated Ulnar-Sided Problems. . . . . . . . . . . . . . Pier Paolo Borelli and Riccardo Luchetti

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Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Francisco del Piñal

191

The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist: Midcarpal Joint . . . . Joseph F. Slade

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Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pak-cheong HO

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Pre-Operative Assessment in Distal Radius Fractures Gregory I. Bain

Introduction The determinants of clinical outcome following distal radial fracture are multi-factorial and may provide several challenges to the treating surgeon. These can be considered under the following headings: patient history including medical co-morbidities, functional demands and injury history; examination findings including the condition of the soft tissue envelope and neurological status; radiographic parameters including fracture characteristics, articular involvement, stability features and associated injuries to the ulna or carpus. Finally, classification of the injury may aid treatment selection and prognostic prediction. With vigilant pre-operative planning, the surgeon can ensure the best outcome for an individual patient.

History The expectations of the individual and society have increased over the past few decades such that poor results are less acceptable in modern hand surgery. Functional disability and degenerative osteoarthritis may result from distal radius fractures, but they may not correlate with the subjective assessment of outcome or satisfaction. Age, hand dominance, occupation, compliance and functional demands should all be considered.

G. I. Bain Department of Orthopaedics and Trauma, University of Adelaide, Royal Adelaide and Modbury Public Hospital, 196, Melbourne Street, North Adelaide, SA 5006, Australia e-mail: [email protected]

Details of the mode of injury should be sought as this will inform our understanding of the energy applied to the limb. Most distal radius fractures are sustained as a result of a fall from standing height with the wrist in an extended position. These are considered low-energy injuries. In most cases the soft tissue injury is minimal, although in elderly patients with a more fragile soft tissue envelope and poorer protective reflexes the injury may be more extensive. With the wrist extended, the point of maximal load in the scaphoid and lunate fossa of the distal radius moves from a relatively volar position towards the dorsal lip. Therefore, an axial load applied in this position will result in the typical injury pattern with comminution of the dorsal cortex and dorsal angulation of the distal fragment. A fall from a height of greater than two metres, sporting injuries and motor vehicle accidents are highenergy injuries. The soft tissue envelope may be significantly disrupted in these patients, and the fracture may be comminuted. The clinician should be alert to the possibility of injury elsewhere in the ipsilateral extremity, other musculoskeletal trauma and injury to other systems. The young patient with a distal radius fracture will typically have been subject to a high-energy injury with complex fracture patterns and extensive soft tissue damage but will have high functional demands. The injury will often require invasive treatment to restore distal radial anatomy. Wrist function may also be critical in the older patient who, for example, requires the use of a walking aid to maintain independence, or suffers dysfunction of the contralateral arm. The patient with multiple injuries requires further consideration, especially those who may require use of their arm to aid their mobility or rehabilitation. Medical co-morbidities are a critical factor when considering operative management. Benefits of various

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_1, © Springer-Verlag Berlin Heidelberg 2010

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treatment options must be weighed against the risks of operative intervention in systemic illnesses. Specialists from other medical disciplines should be consulted if necessary, and patients must be counselled appropriately regarding the choice of treatment and likely prognosis. Those with low-energy fractures or other evidence of osteoporosis should be investigated appropriately with bone mineral density scans and commenced on suitable therapy. Counselling an individual patient on the likely recovery period and functional outcome can be challenging. Excellent function may result despite deformity and malunion in some patients, where others experience long-term pain and disability in the presence of an apparently minor fracture [11, 59]. As a general rule, the closer an injury to normal anatomical limits, the less functional disturbance can be expected following union [41]. The majority of patients experience a good final result [9, 31, 59, 66], but complete functional recovery is uncommon [5].

G. I. Bain

soft tissue loss or deficit, external fixation may be the preferred treatment option to stabilize a wrist fracture. Internal fixation may still be considered in combination with soft tissue coverage procedures in combination with a plastic surgeon. Median nerve compression symptoms may arise following distal radial fracture, or pre-existing symptoms may deteriorate following fracture [35, 62]. Acute symptoms may relate to nerve compression from fracture displacement, and these will often resolve within weeks of fracture reduction. Alternately, symptoms may progress and require operative carpal tunnel decompression [6]. Guidelines for prophylactic carpal tunnel decompression are unclear, but may include cases with exacerbation of pre-existing carpal tunnel syndrome and those with compartment syndrome.

Investigations X-Ray

Examination Quality of the skin and soft tissues around the wrist are critical in managing distal radius fractures. The patient may have systemic disease involving the skin, such as eczema or psoriasis. Skin abnormalities near planned incision or pin sites may greatly increase the risk of infection and force an alteration of the desired treatment plans. Unlike trauma in some other body regions, it is uncommon for soft tissue swelling to delay definitive management of a wrist fracture. Care should be taken with surgical timing, particularly, in high-energy injuries with extensive soft tissue contusion, fracture blisters or open wounds. Open wounds in the region of a fracture should be assumed to signify an open fracture until proven otherwise in the operating theatre. Surgical debridement and wound lavage should be conducted in the operating theatre as soon as practical. Vascular or neurological compromise should also expedite treatment. In a grossly displaced fracture, urgent closed reduction and splintage in the emergency department will decrease tension on soft tissue structures. Compartment syndrome is a rare occurrence in distal radius fractures, but may occur in high-energy forearm fractures [58, 63]. In regions of severe

Pre-operative planning in all distal radius fractures will include plain radiographs of the wrist, together with views of the remainder of the forearm and elbow. For adequate film quality, radiographs may need to be taken without plaster casts or splints. Good quality plain radiographs reveal the majority of important details necessary for planning management, and also provide baseline films for comparison during follow-up. Associated abnormalities of the distal ulna or carpal bones may require further imaging or consideration intra-operatively. Normal Parameters An understanding of normal distal radius anatomy is crucial for accurate injury assessment. The articular surface normally displays 10–12° of volar tilt, 22–23° of radial inclination and 11–12  mm of radial length [19, 22, 42]. Ulnar variance, the relation of the radial articular surface to the ulnar head, is ±1 mm [21, 42]. This measurement must be taken in neutral forearm rotation, as relative ulnar length alters with supination and pronation of the forearm [14, 22, 51]. Functional results are related to anatomical restoration [24, 53], as minor anatomical disturbances can

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Table 1.1  Radiographic criteria for acceptable healing of a distal radius fracture. (Courtesy of Graham [22], with permission) Radiographic criterion Acceptable measurement Radioulnar length

Radial shortening <5 mm at DRUJ compared with contralateral wrist

Radial inclination

Inclination on PA film ³15°

Radial tilt

Sagittal tilt on lateral projection between 15° dorsal tilt and 20° volar tilt

Articular incongruity

Radiocarpal articular incongruity of £2 mm

significantly affect wrist mechanics. The distal radius normally accepts approximately 82% of axial load, with the remainder through the ulna via the triangular fibrocartilage complex [50]. However, in the presence of only 20° of dorsal tilt, 50% of the load is distributed through the ulna, and the radiocarpal forces shift to the dorsal scaphoid articular facet [46]. These anatomical derangements manifest in poor functional results, with malunions in more than 20° of dorsal angulation displaying impairment of grip strength and endurance. The wrist tolerates radial shortening poorly, with 2.5 mm of shortening increasing the loading of the distal ulna from 18 to 42% of the total load [28, 50, 52] (see Table 1.1). On the PA radiograph, radial inclination and ulnar variance should be measured with relation to a central reference point on the ulnar border of the radial articular surface, to allow for changes of position in the dorsal and volar ulnar corners in angulated fractures [42] (Fig. 1.1). The adequacy of a lateral radiograph can be assessed by the relation of the pisiform to the scaphoid. In a true lateral view, the pisiform overlaps the distal pole of the scaphoid, but in relative pronation or supination this relationship is disrupted [42]. The attainment of a true lateral view is essential, as this has a significant effect on radial and carpal alignment measurements [8]. Standard PA and lateral views may be supplemented by further useful views. Allowing for the normal 22–23° radial articular inclination, a radiograph taken with the forearm inclined 20–25° in a radial direction will show a true lateral view of the articular surface [39]. Medoff further recognized the relevance of a 10° radial inclination of the ulnar twothirds of the articular surface, and advocates a 10° lateral view to profile the lunate facet [42]. Oblique PA radiographs in partial pronation and supination further

Fig. 1.1  Measurement of the radial inclination and ulnar variance in relation to the central reference point on the ulnar border of the radius. This point reduces variations with excessive dorsal or volar tilt of the distal fragment

display the dorsal lunate fossa and radial styloid, respectively (Figs. 1.2 and 1.3).

Fracture Characteristics Extra-articular fractures of the distal radius do not involve the radiocarpal or radioulnar joint surfaces; however, the importance of optimal management should not be underestimated. There still exists a potential for gross anatomical derangement, malunion and functional deficit. The presence of the metaphyseal comminution and the initial displacement of the fracture aid the selection of the treatment modality due to fracture instability. If these fractures are displaced, the distal radioulnar joint is likely to be injured. Involvement of the articular surface is an important fracture characteristic, as incongruity of the joint surface can adversely affect outcome [29]. Patients must be counselled appropriately regarding the risk of degenerative arthritis [18, 29]. Knirk and Jupiter studied 43 intraarticular fractures for a mean of 6.7 years using plain radiographs, and found radiographic evidence of arthritis in 91% of those with residual articular incongruity, but only 11% of those who healed with a congruous articular surface [29]. Plain radiographs should be scrutinized for fracture lines extending into the radiocarpal or radioulnar joints, and CT (computed tomography) examination undertaken if the surgeon considers it will  aid in treatment. Melone proposed that the radial

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Fig. 1.2  Normal PA, pronated oblique and lateral radiographs

Fig. 1.3  PA, oblique and lateral radiographs showing a comminuted intra-articular fracture. The oblique view shows displacement of the dorsal ulnar corner fragment

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Fig. 1.4  Fragment classification system showing the common articular fragments. These include the radial styloid, dorsal ulnar corner, dorsal wall, volar rim and free intra-articular fragments

articular surface fractures into three predictable fragments, including the radial styloid, palmar medial and dorsal medial fragments [43]. In forming the lunate fossa and distal radioulnar joint, the importance of the two medial fragments for articular function is highlighted. If present, anatomical reduction of these two fragments is critical to outcome. In complex fracture fixation, their reduction early in the procedure can form a cornerstone from which other regions are reconstructed. Melone also introduced a classification with five subtypes, importantly recognizing that fragment location and malrotation may contribute to fracture instability and inability to be reduced by closed means [43–45]. Medoff introduced additional concepts regarding articular fragmentation patterns, including the common central articular fragments and dorsal wall fragment [42] (Fig. 1.4). A key concept regarding articular fractures is that each articular rim fragment should have an intact radiocarpal or radioulnar ligamentous attachment. These ligaments not only reinforce their zones of attachment, but also contribute to fracture location via avulsion mechanisms, leading to the common fragmentation patterns described by Melone and Medoff (Fig. 1.5). These fracture pattern models are a useful guide in the majority of injuries. Recent work by the authors of this chapter has shown that, at the rim of the distal radius, fracture lines are most likely to propagate in the interval between ligamentous attachments. The ligaments seemingly reinforce the skeleton. However, a fracture line may be present in any location on the articular surface, particularly in highenergy comminuted injuries where high-quality imaging is required to properly define an individual fracture.

Fig. 1.5  Axial distal radius illustration with major radiocarpal and radioulnar ligament attachment regions. A: TFCC attachment to sigmoid notch. B: Radioscapholunate mesentery attachment. C: Extremely elastic dorsal wrist joint capsule attachment. The articular surface is most likely to fracture between ligamentous attachments, in regions A, B and C

Current recommendations for fracture reduction include an intra-articular step of 2  mm or more [22, 29]; however, nil displacement is desirable in younger and highly functioning individuals [64]. Central articular depressed fragments signify a need for open reduction. They are unlikely to be amenable to closed treatment as there are no ligamentous attachments to these fragments to allow successful reduction by ligamentotaxis. Despite the suitability of the volar locking plate in the majority of cases requiring internal fixation,

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including those with the familiar dorsal metaphyseal comminution, dorsal and dual approaches are still required for anatomical reduction in some cases. The presence of dorsal shear fragments may necessitate dorsal plating. A potential need for dorsal plate positioning should be considered pre-operatively, and the patient specifically counselled regarding future plate removal and the possibility of extensor tendon irritation or rupture. In some cases of severe fracture comminution, a distal radius fracture may be unreconstructable, and a bridging external fixator or primary wrist arthrodesis may be considered. The common radial styloid fragment often includes the terminal fibres of the brachioradialis insertion [42]. This muscle acts as a significant deforming force in fractures of the distal radius, and particularly on the radial styloid fragment when present [30, 56]. In operative open reductions, this tendon may need to be released or lengthened [30, 49]. Ulnar styloid fractures are a common accompaniment to distal radial fractures, occurring in up to 70% of cases [20, 36]. Nonetheless, injuries to the distal radioulnar joint or triangular fibrocartilage complex can be difficult to recognize on plain radiographs, with the potential for chronic pain and instability [29, 37]. Basal ulnar styloid fractures are more likely than small avulsion fractures near the distal tip to result in DRUJ instability [37]. Whereas some authors recommend internal fixation of basal styloid fractures or splintage in the position of maximal stability, there is some evidence to suggest that these extra measures will not affect the eventual outcome. A recent large multi-centre study has concluded that the association of a basal ulna styloid fracture has no bearing on the outcome following distal radius fracture even when initially displaced more than 2 mm [60]. This study has some limitations inherent in the design, in particular that DRUJ instability was not reproducibly assessed, and therefore the conclusions may be open to challenge. Pain often prevents timely clinical testing of the DRUJ pre-operatively or in those cases treated non-operatively. However, following internal fixation of a distal radius fracture, DRUJ stability should be routinely tested and documented. Closed manipulation and repeat radiographic or fluoroscopic examination may further guide treatment. The success of reduction manoeuvers and fracture stability may be judged by these methods if doubt exists, and progression to more invasive fixation performed if necessary.

G. I. Bain

Associated injuries to the DRUJ, carpal bones and ligaments, or elbow region should be defined, and an appropriate management plan devised. High-energy fractures in particular have an elevated risk of concurrent injuries to both local and remote regions of the limb.

Fracture Stability The stability of a wrist fracture refers to its capacity to withstand displacement following manipulation into an anatomic position. Numerous factors contribute to this, including bone quality, initial fracture displacement, comminution and the amount of energy applied to the wrist at the time of injury. Closed manipulation and cast application is often valuable in the acute presentation of grossly displaced fractures. In some cases, it may be the only treatment that is required; however, judgement should be based on the patient characteristics and an assessment of fracture stability. Numerous authors have further quantified the factors leading to fracture instability. Mackenney and coworkers examined factors contributing to early or late instability, dependent on the presence of fracture displacement at presentation. In fractures minimally displaced at presentation, they discovered significant risks of early or late instability with age >80 years, any form of comminution, positive ulnar variance and dorsal angulation of 5–10° [40]. Overall, similar factors were relevant to fractures displaced at the time of presentation. Assessment should be made of the radiocarpal alignment on the lateral radiograph following reduction. Lines drawn through the long axis of the capitate and radius should cross within the carpus; otherwise there is imbalance and progressive loss of reduction, or poor functional outcome may be observed. Lafontaine also included radiocarpal intraarticular involvement and associated ulnar fracture as risk factors for instability [34] (Fig. 1.6). Furthermore, patient age greater than 60 years or the presence of 4 mm of shortening have been reported as indicative of instability [1, 47]. Medoff recognized the implication of dorsal radiocarpal instability in the presence of a dorsal wall fragment [38, 42]. In addition, a small series has been published recommending caution in the presence of a palmar lunate fossa fragment, which may cause volar radiocarpal instability [3] (Fig. 1.7). Careful attention should be given to these palmar or dorsal rim

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Fig. 1.6  Unstable distal radius fracture, with instability features including comminution, dorsal angulation, radiocarpal articular involvement and positive ulnar variance. There is also the com-

mon avulsion fracture of the ulnar styloid tip, most likely of no consequence

fragments and CT requested if necessary to exclude radiocarpal subluxation. These fragments will require anatomical reduction if displaced. The extent of metaphyseal comminution is important in judging stability [17]. The radial cortex should ideally form an intact scaffolding to help maintain anatomical reduction, but comminution or poor bone quality will impair this function. Osteopenic or osteoporotic bone not only lacks intrinsic structure but is less likely to successfully hold Kirshner wires and other forms of internal fixation. Conversely, highenergy injuries in good quality bone may have a similar effect, causing marked initial displacement, severe comminution and extensive soft tissue stripping. Gross fracture displacement at the time of presentation implies a great degree of soft tissue stripping [11]. Principally, it is loss of the periosteal sleeve at the fracture site that contributes to instability. Traditionally, stable fixation of these grossly unstable injuries has been near unattainable. However, the advent of

locking plate technology has revolutionized treatment of many unstable fracture patterns in both normal and poor quality bone [48, 49]. Assessment of fracture stability is a useful tool for formulating appropriate management plans and counselling patients on risk of loss of reduction if closed means are chosen. Serial plain radiographs are routinely performed within 1–2 weeks following a closed manipulation to confirm maintenance of fracture reduction.

CT Imaging CT is invaluable in assessing selected intra-articular fractures, where it is superior to plain radiographs [10, 23, 25, 27, 54]. Studies by Kreder and Cole both highlight the difficulty of assessment of plain radiographs to determining articular incongruity, with poor intra-observer and inter-observer reliability [10, 33].

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G. I. Bain

Fig. 1.7  Plain radiographic findings in an acute wrist injury may seem relatively benign. CT better defines the injury, in this case a displaced palmar ulnar fragment with associated palmar carpal subluxation

Anatomical reduction of the distal radioulnar joint is a primary goal in any articular fracture, and CT clearly displays involvement of the radial sigmoid notch. Pruitt et al. analyzed 18 fractures pre-operatively, and showed that CT was better than plain radiographs at demonstrating involvement of the DRUJ, central articular depression and fracture comminution [54]. Central articular “die punch” fragments are particularly difficult to visualize on plain films and are well defined on CT. These fragments have no ligamentous attachments [7] and will not be amenable to closed reduction via ligamentotaxis (Fig. 1.8). Harness et al. revealed that three-dimensional reconstructions of CT images with

subtraction of the carpal bones can further aid in fracture visualization [23]. Small displaced or rotated fragments may be relevant to the treatment of a particular injury. For example, the presence of an ulno-palmar rim fragment can signify short radiolunate ligament avulsion and resultant volar carpal instability [3] (Fig. 1.4). The size and location of fracture fragments identified on axial, coronal and sagittal CT images thus may influence the surgical approach and the fixation method. Some surgeons advocate mapping around fracture fragments on preoperative radiographs to plan a reduction. CT is more reliable for this, but the benefits must be weighed

1  Pre-Operative Assessment in Distal Radius Fractures

9

Fig. 1.8  CT of an intra-articular fracture shows excellent fragment detail for operative planning. Note particularly the depressed central articular fragment and the scapholunate dissociation

against the need for a higher patient radiation exposure and greater cost. A further benefit of CT is its ability to assess fracture characteristics post-operatively and without removing plaster casts.

MRI and Arthroscopy MRI is not routinely used for distal radius fractures; however, it is effective at characterizing ligamentous and carpal injuries in cases with suspicious features on plain radiographs or CT. Richards et al. assessed 118 wrists following acute distal radius fracture, finding 46 TFCC tears, and scapholunate ligament tears in 22% of intra-articular fractures [55]. Spence et  al. studied 21 intra-articular distal radius fractures with MRI, finding six scapholunate ligament tears and two TFCC tears [61]. As an alternative to MRI, intra-operative arthroscopy can assess associated soft tissue injuries [55], and may be performed “dry” in an acute injury to reduce the risk of compartment syndrome from fluid extravasation [12, 13]. Arthroscopy may also be used to aid articular reduction [4], but will not be discussed in detail in this pre-operative planning discussion. Fractures involving a split between the scaphoid and

lunate facets are associated with high rates of scapholunate ligament tears, which may be present in up to 45% of intra-articular fractures [55, 57, 61, 65]. Many of these ligament tears are incomplete and probably inconsequential; however, those with evidence of complete scapholunate ligament disruption benefit from early operative treatment [57].

Fracture Classification Classification systems can provide a framework for the management of distal radius fractures and aid with prognostic expectations. The most commonly quoted classification is the Arbeitsgemeinschaft für Osteosyn­ thesefragen (AO) system. This system divides distal radius fractures into extra-articular (type A), partial articular (type B), and complete articular (type C), with further divisions and subdivisions to encompass most possible fracture configurations. The AO system has shortcomings with poor inter-observer reliability regarding its subtypes [16, 32], and its complexity limits its daily use. Most useful for daily management is the use of basic fracture description. There will rarely be confusion if

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an injury is presented as a radial styloid fracture, rather than an AO type B1 fracture. This also allows more accurate and reproducible communication with nonorthopaedic physicians. Still in routine use are numerous eponymous terms, including Colles’, Smith’s and Barton’s fractures. Although helpful if used correctly, the injuries are often quite different to those originally described. To many referring doctors who infrequently treat wrist injuries, a Colles’ fracture may be used as a generic description of any distal radius fracture, and clarification of the injury features should be sought. A number of classification schemes have been published, each with its own merits and disadvantages. The Frykman classification favourably includes the presence or absence of an ulnar styloid fracture [20], but lacks adequate detail with regards to the distal radius fracture. It thus includes severe high-energy comminuted fractures in the same group as much simpler low-energy injuries and is not useful in determining management options or prognosis. Melone classified articular fractures into five groups and was the first to  include articular fragmentation patterns [43]. Unfortunately, the Melone, Mayo, Frykman and AO classifications have all been shown to have sub-optimal inter-observer and intra-observer reliability [2]. The Fernandez classification differs from others through its description of injury mechanisms, including bending, compression, shearing and avulsion [15, 26]. Considering that treatment will often involve reversal of the initial pathological forces and subsequent maintenance of stability, the concepts contained in this classification can be very beneficial.

Summary Appropriate treatment of a distal radius fracture initially requires careful consideration of patient characteristics, functional demands and soft tissue condition. Associated injuries to the ulna and carpal ligaments are common and should be sought. CT imaging is particularly valuable in assessing fractures involving the articular surface. Recognition of common articular fragmentation patterns and instability features can aid treatment choice to prevent poor outcomes due to malunion or degenerate arthritis. Advanced age, fracture comminution and displacement are key indicators of instability. Surgical treatment should ideally provide adequate reduction and

G. I. Bain

stability to allow restoration of distal radial anatomy and subsequent function. Acknowledgement  To co-authors Daniel G Mandziak, M.B.B.S., Royal Adelaide Hospital and Adam C Watts M.B.B.S., F.R.C.S.(Tr and Ortho), Modbury Public Hospital, Adelaide, Australia for their contribution to this chapter.

References   1. Abbaszadegan H, Jonsson U, von Sivers K. Prediction of instability of Colles’ fractures. Acta Orthop Scand. 1989;60: 646–50   2. Andersen DJ, Blair WF, Steyers CM Jr, et al. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg [Am]. 1996;21:574–82   3. Apergis E, Darmanis S, Theodoratos G, et al. Beware of the ulno-palmar distal radial fragment. J Hand Surg [Br]. 2002; 27:139–45   4. Auge WK II, Velazquez PA. The application of indirect reduction techniques in the distal radius: the role of adjuvant arthroscopy. Arthroscopy. 2000;16:830–5   5. Bacorn RW, Kurtzke JF. Colles’ fracture; a study of two thousand cases from the New York State Workmen’s Compensation Board. J Bone Joint Surg Am. 1953;35-A: 643–58   6. Bauman TD, Gelberman RH, Mubarak SJ, et al. The acute carpal tunnel syndrome. Clin Orthop Relat Res. 1981;(156): 151–6   7. Berger RA. The anatomy of the ligaments of the wrist and distal radioulnar joints. Clin Orthop Relat Res. 2001;(383): 32–40   8. Capo JT, Accousti K, Jacob G, et al. The effect of rotational malalignment on X-rays of the wrist. J Hand Surg Eur. 2009; 34:166–72   9. Cassebaum WH. Colles’ fracture; a study of end results. J Am Med Assoc. 1950;143:963–5 10. Cole RJ, Bindra RR, Evanoff BA, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal radius: reliability of plain radiography versus computed tomography. J Hand Surg [Am]. 1997;22: 792–800 11. Cooney WP III, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles’ fractures. J Bone Joint Surg Am. 1979;61:840–5 12. del Piñal F. Dry arthroscopy of the wrist: its role in the management of articular distal radius fractures. Scand J Surg. 2008;97:298–304 13. del Piñal F, Garcia-Bernal FJ, Pisani D, et al. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am. 2007; 32:119–23 14. Epner RA, Bowers WH, Guilford WB. Ulnar variance–the effect of wrist positioning and roentgen filming technique. J Hand Surg [Am]. 1982;7:298–305 15. Fernandez DL. Fractures of the distal radius: operative treatment. Instr Course Lect. 1993;42:73–88 16. Flinkkila T, Nikkola-Sihto A, Kaarela O, et al. Poor interobserver reliability of AO classification of fractures of the

1  Pre-Operative Assessment in Distal Radius Fractures d­ istal radius. Additional computed tomography is of minor value. J Bone Joint Surg Br. 1998;80:670–2 17. Flinkkila T, Nikkola-Sihto A, Raatikainen T, et al. Role of metaphyseal cancellous bone defect size in secondary displacement in Colles’ fracture. Arch Orthop Trauma Surg. 1999;119:319–23 18. Forward DP, Davis TR, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg Br. 2008;90:629–37 19. Friberg S, Lundstrom B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol Diagn (Stockh). 1976;17:249–56 20. Frykman G. Fracture of the distal radius including sequelae– shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand Suppl. 1967; 108:103+ 21. Gelberman RH, Salamon PB, Jurist JM, et al. Ulnar variance in Kienbock’s disease. J Bone Joint Surg Am. 1975;57:674–6 22. Graham TJ. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg. 1997;5:270–81 23. Harness NG, Ring D, Zurakowski D, et al. The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures. J Bone Joint Surg Am. 2006;88:1315–23 24. Howard PW, Stewart HD, Hind RE, et al. External fixation or plaster for severely displaced comminuted Colles’ fractures? A prospective study of anatomical and functional results. J Bone Joint Surg Br. 1989;71:68–73 25. Johnston GH, Friedman L, Kriegler JC. Computerized tomographic evaluation of acute distal radial fractures. J Hand Surg [Am]. 1992;17:738–44 26. Jupiter JB, Fernandez DL. Comparative classification for fractures of the distal end of the radius. J Hand Surg [Am]. 1997;22:563–71 27. Katz MA, Beredjiklian PK, Bozentka DJ, et al. Computed tomography scanning of intra-articular distal radius fractures: does it influence treatment? J Hand Surg [Am]. 2001; 26:415–21 28. Kazuki K, Kusunoki M, Shimazu A. Pressure distribution in the radiocarpal joint measured with a densitometer designed for pressure-sensitive film. J Hand Surg [Am]. 1991; 16: 401–8 29. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647–59 30. Koh S, Andersen CR, Buford WL Jr, et al. Anatomy of the distal brachioradialis and its potential relationship to distal radius fracture. J Hand Surg [Am]. 2006;31:2–8 31. Kopylov P, Johnell O, Redlund-Johnell I, et al. Fractures of the distal end of the radius in young adults: a 30-year followup. J Hand Surg [Br]. 1993;18:45–9 32. Kreder HJ, Hanel DP, McKee M, et al. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996;78:726–31 33. Kreder HJ, Hanel DP, McKee M, et al. X-ray film measurements for healed distal radius fractures. J Hand Surg [Am]. 1996;21:31–9 34. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20:208–10

11 35. Lewis MH. Median nerve decompression after Colles’s fracture. J Bone Joint Surg Br. 1978;60-B:195–6 36. Lidstrom A. Fractures of the distal end of the radius. A clinical and statistical study of end results. Acta Orthop Scand Suppl. 1959;41:1–118 37. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg [Am]. 2000;25:464–8 38. Lozano-Calderon SA, Doornberg J, Ring D. Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation. J Bone Joint Surg Am. 2006;88:1486–93 39. Lundy DW, Quisling SG, Lourie GM, et  al. Tilted lateral radiographs in the evaluation of intra-articular distal radius fractures. J Hand Surg [Am]. 1999;24:249–56 40. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006; 88:1944–51 41. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br. 1988;70:649–51 42. Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin. 2005;21:279–88. 43. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15:217–36 44. Melone CP Jr. Open treatment for displaced articular fractures of the distal radius. Clin Orthop Relat Res. 1986;(202): 103–11 45. Melone CP Jr. Distal radius fractures: patterns of articular fragmentation. Orthop Clin North Am. 1993;24:239–53 46. Miyake T, Hashizume H, Inoue H, et al. Malunited Colles’ fracture. Analysis of stress distribution. J Hand Surg [Br]. 1994;19:737–42 47. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg [Am]. 2004;29:1128–38 48. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am]. 2004;29:96–102 49. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006;445:58–67 50. Palmer AK. The distal radioulnar joint. Anatomy, biomechanics, and triangular fibrocartilage complex abnormalities. Hand Clin. 1987;3:31–40 51. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg [Am]. 1982;7:376–9 52. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg [Am]. 1990;15:721–7 53. Porter M, Stockley I. Fractures of the distal radius. Intermediate and end results in relation to radiologic parameters. Clin Orthop Relat Res. 1987;220:241–52 54. Pruitt DL, Gilula LA, Manske PR, et al. Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg [Am]. 1994;19:720–7 55. Richards RS, Bennett JD, Roth JH, et  al. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg [Am]. 1997;22: 772–6

12 56. Sarmiento A. The brachioradialis as a deforming force in Colles’ fractures. Clin Orthop Relat Res. 1965;38:86–92 57. Shih JT, Lee HM, Hou YT, et al. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue management of distal radius. Hand Surg. 2001;6:127–35 58. Simpson NS, Jupiter JB. Delayed onset of forearm compartment syndrome: a complication of distal radius fracture in young adults. J Orthop Trauma. 1995;9:411–8 59. Smaill GB. Long-term follow-up of Colles’s fracture. J Bone Joint Surg Br. 1965;47:80–5 60. Souer JS, Ring D, Matschke S, et al. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-andscrew fixation of a distal radial fracture. J Bone Joint Surg Am. 2009;91:830–8 61. Spence LD, Savenor A, Nwachuku I, et al. MRI of fractures of the distal radius: comparison with conventional radiographs. Skeletal Radiol. 1998;27:244–9

G. I. Bain 62. Sponsel KH, Palm ET. Carpal tunnel syndrome following Colles’ fracture. Surg Gynecol Obstet. 1965;121:1252–6 63. Stockley I, Harvey IA, Getty CJ. Acute volar compartment syndrome of the forearm secondary to fractures of the distal radius. Injury. 1988;19:101–4 64. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg [Am]. 1994;19:325–40 65. Varitimidis SE, Basdekis GK, Dailiana ZH, et al. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg Br. 2008;90: 778–85 66. Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg [Am]. 2000;25:19–28

2

Portals and Methodology David J. Slutsky

Introduction Wrist arthroscopy has steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of distal radius fractures. The ability to visualize the fracture fragments under high power magnification enables the surgeon to anatomically reduce the articular surface with minimally invasive percutaneous techniques. Many studies have demonstrated the superiority of an arthroscopic-assisted reduction of a displaced intraarticular fracture over a fluoroscopic reduction which has been shown to correlate with improved wrist motion and grip strength. Doi and coworkers performed a prospective study comparing 34 intraarticular distal radius fractures treated with arthroscopic reduction, pinning (ARIF), and external fixation vs. 48 fractures treated with open plate fixation (ORIF) or with pinning ± external fixation. At an average follow-up of 31 months, the ARIF group had significantly better ranges of flexion-extension, radial-ulnar deviation, and grip strength (p < 0.05). Radiographically, the ARIF group had better reduction of volar tilt, ulnar variance, and articular gap reduction [8]. Ruch et al. compared the functional and radiologic outcomes of arthroscopically-assisted (AA) percutaneous pinning and external fixation vs. fluoroscopicallyassisted (FA) pinning and external fixation of 30 patients with comminuted intraarticular distal radius fractures. Patients who underwent AA surgery had significantly improved supination compared with those who underwent FA surgery (88 vs. 73°). AA reduction

D. J. Slutsky, MD, FRCS(C) The Hand & Wrist Institute, 2808, Columbia Street, Torrance, CA 90503, USA e-mail: [email protected]

also resulted in improved wrist extension (77 vs. 69°) and wrist flexion (78 vs. 59°) [18]. The following chapter will discuss the portal placement and methodology of wrist arthroscopy along with its application in the treatment of distal radius fractures.

Relevant Anatomy The standard portals for wrist arthroscopy are mostly dorsal. This is in part due to the relative lack of neurovascular structures on the dorsum of the wrist as well as the initial emphasis on assessing the volar wrist ligaments. The dorsal portals which allow access to the radiocarpal joint are so named in relation to the tendons of the dorsal extensor compartments. For example, the 1–2 portal lies between the first extensor compartment tendons which include the extensor pollicus brevis (EPB) and the abductor pollicus longus (APL), and the second extensor compartment which contains the extensor carpi radialis brevis and longus (ECRB/L). The 3–4 portal is named for the interval between the third dorsal extensor compartment which contains the extensor pollicus longus tendon (EPL) and the fourth extensor compartment which contains the extensor digitorum communis (EDC) tendons. In a similar vein, the 4–5 portal is located between the EDC and the extensor digiti minimi (EDM). The 6R portal is located on the radial side of the extensor carpi ulnaris (ECU) tendon as compared to the 6U portal which is located on the ulnar side (Fig. 2.1a–c). The midcarpal joint is assessed through two portals, which allow triangulation of the arthroscope and the instrumentation. The midcarpal radial portal (MCR) is located 1  cm distal to the 3–4 portal and is bounded radially by the ECRB and ulnarly by the EDC. The

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_2, © Springer-Verlag Berlin Heidelberg 2010

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a

D. J. Slutsky

b

c

Fig. 2.1  Dorsal portal anatomy. (a) Cadaver dissection of the dorsal aspect of a left wrist demonstrating the relative positions of the dorsoradial portals. EDC extensor digitorum communis; EPL extensor pollicus longus; SRN superficial radial nerve.

Lister’s tubercle = asterisk. (b) Relative positions of the dorsoulnar portals. EDM extensor digiti minimi; DCBUN dorsal cutaneous branch of the ulnar nerve. (c) Positions of the 6R and 6U portals (Copyright by Dr. Slutsky [23])

ulnar midcarpal portal (MCU) is similarly located 1–12 cm distal to the 4–5 portal and is bounded by the EDC and the EDM. The relative safety of the portals has been studied by the way of cadaver dissection. Although some artifact is inescapable due to the displacement of neurovascular structures postmortem, this research provides some useful guidelines. In the clinical situation, distortion of the topographical anatomy due to fracture/dislocation or swelling as well as the use of intraoperative traction may increase the potential for harm; hence, a standardized method for establishing each portal is useful.

styloid and bifurcates into a major volar and a major dorsal branch at a mean distance of 4.2 cm proximal to the radial styloid [24]. Branches of the superficial radial nerve (SRN) that were radial to the portal were within a mean of 3  mm (range 1–6  mm), whereas, branches that were ulnar to the portal were at a mean of 5 mm (range 2–12 mm) (Fig. 2.2). The radial artery was found at an average of 3 mm radial to the portal (range 1–5 mm). Up to 75% of the time, there occurs either partial or complete overlap of the lateral antebrachial cutaneous nerve (LABCN) with the SRN[13]. In an anatomical study by Steinberg et al., the LABCN was present within the anatomic snuffbox in 9 of 20

Dorsal Portals Dorsal Radiocarpal Portals Abrams and coworkers performed anatomical dissections on 23 unembalmed fresh cadaver extremities and measured the distances between the standard dorsal portals and the contiguous neurovascular structures [1]. The 1–2 portal was found to be the most perilous. The radial sensory nerve exits from under the brachioradialis approximately 5  cm proximal to the radial

Fig.  2.2  Branches of the superficial radial nerve (SRN). SR1 minor dorsal branch; SR2 major dorsal branch; SR3 major palmar branch (Copyright by Dr. Slutsky [23])

2  Portals and Methodology

(45%) specimens. Based on these findings, they recommended a more palmar, proximal portal in the snuffbox that was no more than 4.5  mm dorsal to the first extensor compartment and within 4.5 mm of the radial styloid [24]. Branches of the SRN that were radial to the 3–4 portal were located at a mean distance of 16  mm (range, 5–22 mm). In one specimen, an ulnar branch of the SRN was found 6 mm ulnar to the portal. The distance to the radial artery was a mean of 26.3 mm (range 20–30  mm). Sensory nerves were remote to the 4–5 portal, except in one case, where an aberrant SRN branch was found 4 mm radial to the portal. The dorsal cutaneous branch of the ulnar nerve (DCBUN) arises from the ulnar nerve on an average of 6.4 cm (SD = 2.3 cm) proximal to the ulnar head and becomes subcutaneous 5 cm proximal to the pisiform. It crosses the ulnar snuffbox and gives off 3–9 branches that supply the dorsoulnar aspect of the carpus, small finger, and ulnar ring finger [4]. The mean distance of the DCBUN to the 6R portal was 8.2  mm (range 0–14 mm). Transverse branches of the DCBUN were found in 12/19 specimens and were noted to be within 2 mm of the portal (range 0–6 mm). The mean distance of the branches of the DCBUN that were radial to the 6U portal was 4.5  mm (range 2–10  mm), while branches that were ulnar to the portal ranged from 1.9 to 4.8 mm on an average. Any transverse branches of the DCBUN were generally proximal to the portal at an average of 2.5 mm.

Dorsal Midcarpal Portals Branches of the SRN were found radial to the MCR portal at a mean of 7.2 mm (range 2–12 mm; SD = 2.7) Two specimens contained SRN branches ulnar to the portal at 2 and 4 mm. Branches of the SRN were generally remote from the MCU portal except in one specimen (1 mm). Branches of the DCBUN were found at a mean distance of 15.1 mm (range 0–25 mm; SD = 4.6).

Triquetro-Hamate (TH) Portal This portal enters the midcarpal joint at the level of the TH joint ulnar to the ECU tendon. The entry site is

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Fig. 2.3  View of the ulnar aspect of a left wrist demonstrating the relative positions of the triquetro-hamate (TH) portal and the 6U portal. DCBUN dorsal cutaneous branch of the ulnar nerve; UN ulnar nerve (Copyright by Dr. Slutsky [23])

both ulnar and distal to the MCU. Branches of the DCBUN are most at risk (Fig. 2.3).

Dorsal Radioulnar Portals These portals lie between the ECU and the EDM tendons. Transverse branches of the DCBUN were the only sensory nerves in proximity to the dorsal radioulnar portal at a mean of 17.5  mm distally (range 10–20 mm) (Fig. 2.4a).

Volar Portals Volar Radial Portal An anatomic study was performed on five fresh frozen cadaver arms to determine the safe landmarks for a volar radial (VR) portal after arterial injection studies to highlight the vascular anatomy [20]. The proximal and distal wrist creases were marked. The volar skin was then removed and the flexor carpi radialis tendon (FCR) sheath was divided. The tendon was retracted ulnarly and a trochar was inserted into the radiocarpal joint at the level of the proximal wrist crease. The trochar was noted to enter the radiocarpal joint between the radioscaphocapitate ligament (RSC) and the long radiolunate ligament (LRL) in four specimens and through the LRL ligament in one specimen. The median nerve was 8 mm (6–10 mm) ulnar to the VR portal, while the palmar cutaneous branch passed

16 Fig. 2.4  Dorsal DRUJ portal anatomy. (a) Relative position of the proximal (PDRUJ) and distal (DRUJ) portals. (b) Close up with the dorsal capsule removed demonstrating the position of the needles in relation to the dorsal radioulnar ligament (asterisk). AD articular disc; UC ulnocarpal joint; UH ulnar head (Copyright by Dr. Slutsky [23])

D. J. Slutsky

a

4 mm (3–5 mm) ulnar to the portal. The radial artery was 5.8 mm (4–6 mm) radial to the portal and its superficial palmar branch was located 10.6 mm (6–16 mm) distal to the portal. The SRN lay 15.6 mm (12–19 mm) radial to the portal. The portal was 12.8  mm (12– 14 mm) distal to the border of the pronator quadratus, which roughly corresponds to the palmar radiocarpal arch [9]. The palmar cutaneous branch was the closest in proximity but always lies to the ulnar side of the FCR [5, 14]. The superficial palmar branch of the radial artery passed through the subcutaneous tissue over the tuberosity of the scaphoid and was out of harm’s way with an incision at the proximal wrist crease [10, 17]. When the trochar was placed through the floor of the FCR tendon sheath at the proximal palmar crease, the carpal canal was not violated. It was thus apparent that there was a safe zone comprising the width of the FCR tendon plus at least 3 mm or more in all directions, that was free of any neurovascular structures.

Volar Radial Midcarpal (VRM) Portal The volar aspect of the midcarpal joint was identified with a 22 gauge needle through the same skin incision and a blunt trochar was inserted. It was necessary to angle the trochar in a distal and ulnar direction

b

(approximately 5°) in order to access the midcarpal joint through the same skin incision. The trochar passed closer but still deep to the superficial palmar branch of the radial artery, which coursed more superficially over the scaphoid tuberosity at that level. The distance between the volar radiocarpal and volar midcarpal entry sites averaged 11 mm (7–12 mm).

Volar Ulnar Portal In a companion study, a volar ulnar (VU) portal was established via a 2 cm longitudinal incision made along the ulnar edge of the finger flexor tendons at the proximal wrist crease [22]. The flexor tendons were retracted radially and a trochar was introduced into the radiocarpal joint. The ulnar styloid marked the proximal point of the VU portal, approximately 2  cm distal to the pronator quadratus. The portal was in the same sagittal plane as the ECU subsheath and penetrated the ulnolunate ligament (ULL) adjacent to the radial insertion of the triangular fibrocartilage. The ulnar nerve and artery were generally more than 5 mm from the trochar, provided the capsular entry point was deep to the ulnar edge of the profundus tendons. The palmar cutaneous branch of the ulnar nerve (nerve of Henlé) was highly variable and not present in every specimen. This inconstant branch provides sensory fibers to the skin in the

2  Portals and Methodology

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distal ulnar and volar part of the forearm to a level of 3 cm distal to the wrist crease. Its territory may extend radially beyond the palmaris longus tendon [3]. This branch tends to lie just to the ulnar side of the axis of the fourth ray, but it was absent in 43% of specimens in one study [15]. Martin et  al. demonstrated that there was no true internervous plane due to the presence of multiple ulnar-based cutaneous nerves to the palm, which puts them at risk with any ulnar incision [14]. Since there is no true safe zone, careful dissection and wound spread technique should be observed.

Volar Distal Radioulnar (VDRU) Portal [21] The topographical landmarks and establishment of the portal are identical to those of the VU portal. The same risks also apply. The capsular entry point for the VDRU lies 5  mm to 1  cm proximal to the ulnocarpal entry point (Fig. 2.5a, b).

Field of View The following describes the typical field of view as seen through a 2.7 mm arthroscope under ideal conditions. Synovitis, fractures, ligament tears, and a tight a

Fig. 2.5  Volar DRUJ portals. (a) Volar aspect of a left wrist demonstrating the relative positions of the VU and volar DRUJ (VDR) portals in relation to the ulnar nerve(asterisk) and ulnar artery (UA). FDS flexor digitorum sublimus; FCU flexor carpi ulnaris. (b) Close up view after the volar capsule is removed showing position of needles in relation to the volar radioulnar ligament (asterisk). Tr triquetrum; UH ulnar head (Copyright by Dr. Slutsky [23])

wrist joint may limit the field of view which necessitates the use of more portals to adequately assess the entire wrist [19]. 1–2 portal: Structures visualized are limited to the radial aspect of the wrist. Radius: scaphoid and lunate fossa, dorsal rim of radius. Carpus: proximal and radial scaphoid, proximal lunate. Volar capsule: oblique views of the radioscaphocapitate (RSC) ligament, long radiolunate ligament (LRL), short radiolunate ligament (SRL). Dorsal capsule: oblique views of the dorsal radiocarpal ligament (DRCL). TFC: poorly visualized. 3–4 portal: almost a complete panoramic view of the entire volar radiocarpal joint Radius: scaphoid and lunate fossa, volar rim of radius. Carpus: proximal scaphoid and lunate, dorsal and membranous scapholunate interosseus ligament (SLIL). Volar capsule: RSC, radioscapholunate ligament (RSL), LRL, ulnolunate ligament (ULL). Dorsal capsule: oblique views of the DRCL insertion onto the dorsal SLIL. TFC: radial insertion, central portion, ulnar attachment, palmar and dorsal radioulnar ligaments (PRUL, DRUL), prestyloid recess ± pisotriquetral orifice. 4 –5 portal: this portal gives improved views of the ulnar aspect of the radiocarpal joint including TFCC b

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and is useful for instrumentation when combined with the 6R. Radius: lunate fossa, volar rim of radius. Carpus: proximal lunate, triquetrum, dorsal and membranous lunotriquetral ligament (LTIL). Volar capsule: RSL, LRL, ULL. Dorsal capsule: poorly seen. TFC: radial insertion, central portion, ulnar attach­ ment, PRUL, prestyloid recess ± pisotriquetral orifice. 6R portal: This gives a more direct line of sight with the dorsal LTIL and is typically used for instrumentation or outflow. Radius: poorly seen. Carpus: proximal lunate, triquetrum, dorsal and membranous LTIL. Volar capsule: ULL and ulnotriquetral ligament (UTL). Dorsal capsule: poorly seen. TFC: radial insertion, central portion, ulnar attachment, PRUL, prestyloid recess ± pisotriquetral orifice. 6U portal: This is also mostly used for outflow, but it is also useful for instrumentation for debridement of palmar LTIL tears in combination with the VU portal. Radius: sigmoid notch. Carpus: proximal triquetrum, membranous LTIL. Volar capsule: oblique views of the ULL and ULT. Dorsal capsule: oblique views of the DRCL TFC: dorsal rim and radial attachment. VR portal: This portal is mostly indicated to assess the palmar SLIL and the DRCL. It is also of use for AA fixation of distal radius fractures due to the direct line of sight with the dorsal rim fragments [8]. Radius: scaphoid and lunate fossa, dorsal rim of radius. Carpus: proximal palmar scaphoid and lunate, palmar, and membranous SLIL. Volar capsule: oblique views of the RSL, LRL, ULL. Dorsal capsule: direct in-line views of the DRCL. TFC: oblique views of the radial insertion, central portion, ulnar attachment, PRUL and DRUL. VU portal: This portal is mostly indicated to assess the palmar LTIL and the dorsal ulnar capsule. It is also of use for debridement of palmar LTIL tears. Radius: sigmoid notch region of lunate fossa. Carpus: proximal palmar lunate and triquetrum, palmar and membranous LTIL. Volar capsule: poorly seen.

D. J. Slutsky

Dorsal capsule: direct in-line views of the dorsoulnar capsule including the ECU subshetah. TFC: radial insertion, central portion, ulnar attachment, DRUL.

Radial Midcarpal Portal Volar: continuation of the RSC ligament. Radial: scaphotrapezial-trapezoidal (STT) joint and distal scaphoid pole. Proximal: SLIL joint, LTIL joint, distal scaphoid, distal lunate. Distal: proximal capitate, capitohamate ligament, oblique views of proximal hamate.

Ulnar Midcarpal Portal Volar: continuation of the volar ulnocarpal ligament (important in midcarpal instability). Radial: distal articular surface of the lunate and triquetrum and partial scaphoid. Proximal: LTIL joint, SLIL joint. Distal: proximal hamate, capitohamate ligament, oblique views of proximal capitate.

Dorsal DRUJ Portals: Proximal and Distal Volar: palmar radioulnar ligament Radial: sigmoid notch, radial attachment of TFC Ulnar: limited view of DRUL Distal: proximal surface of articular disc (AD)

Volar DRUJ Portal Volar: DRUL Radial: sigmoid notch, radial attachment of TFC Ulnar: foveal attachment of deep fibers of TFCC Distal: proximal surface of AD

Methodology: Diagnostic Survey The patient is positioned supine under general anesthesia with the arm abducted under tourniquet control. A 2.7  mm 30° angled scope along with a camera

2  Portals and Methodology

19

attachment is used along with some method of overhead traction. The structures that should be visualized as a part of a standard exam include the radius articular surface, the proximal scaphoid and lunate, the volar carpal ligaments, the scapholunate (SLIL) and lunotriquetral (LTIL) interosseous ligaments, and the triangular fibrocartilaginous complex (TFCC). It is the author’s practice to establish the dorsal portals first and then start the arthroscopic examination with the VR portal in order to visualize the palmar SLIL and the DRCL to minimize artifact secondary to iatrogenic trauma to the dorsal capsular structures. The VU portal is utilized to assess the palmar LTIL and DRUL, ECU subsheath and radial TFCC attachment. The scope is then inserted in the 3–4 portal followed by various combinations of the 4–5 portal and 6R portal. The 6U portal is mostly used for outflow, but it may be used for instrumentation when debriding palmar LTIL tears. Midcarpal arthroscopy is performed next to assess the integrity of the intercarpal ligaments and to inspect for chondral lesions or loose bodies in the midcarpal joint. The special use portals such as the dorsal and volar distal radioulnar joint (DRUJ) portals and the 1–2 portal are used as needed.

4–5 Portal

3–4 Portal

6R, 6U Portals

The surgeon is initially seated facing the dorsal surface of the wrist. The concavity overlying the lunate between the EPL and the EDC is located just distal to Lister’s tubercle, in line with the second webspace. The radiocarpal joint is identified with a 22 gauge needle that is sloped 10° palmar to account for the volar inclination of the radius. The joint is injected with 5  mL of saline. A shallow skin incision is made to avoid injuring small branches of the SRN or superficial veins. Tenotomy scissors or blunt forceps are then used to spread the soft tissue and pierce the dorsal capsule. This technique is repeated for each portal. The vascular tuft of the RSL is directly in line with this portal. Superior to the RSL is the membranous portion of the SLIL. The insertion of the dorsal capsular attachment can often be visualized by rotating the scope dorsally while looking ulnarwards. The radioscapholunate (RSL) and LRL are radial to the portal and can be probed with a hook in the 4 –5 portal. The SRL, TFCC and ulnolunate (ULL) and ulnotriquetral (ULT) ligaments are ulnar to the portal.

The 6R portal is identified on the radial side of the ECU tendon, just distal to the ulnar head. The scope should be angled 10° proximally to avoid hitting the triquetrum. The TFCC is immediately below the entry site. The LTIL is located radially and superiorly, whereas the ulnar capsule is immediately adjacent to the scope. The 6U portal is located ulnar to the ECU tendon. This portal can be used to view the dorsal rim of the TFCC or for instrumentation when debriding the palmar LTIL.

The interval for the 4–5 portal is identified with a 22 gauge needle inserted between the EDC tendons and the EDM, in line with the ring metacarpal. Due to the normal radial inclination of the distal radius, this portal lies slightly proximal and about 1 cm ulnar to the 3–4 portal. Views of the ulnar half of the lunate are obtained by moving the scope radially, whereas the triquetrum is seen by angling the scope in a superior and ulnar direction. The LTIL is often difficult to differentiate from the carpal bones without probing. The ULL and ULT can be seen on the far end of the joint. Proximally, the radial insertion of the TFCC blends imperceptibly with the sigmoid notch of the radius, but it can be palpated with a hook probe in either the 3–4 or 6R portal. The peripheral insertion of the TFCC slopes upwards into the ulnar capsule. The volar and DRULs can be probed for laxity/tears, but they are not seen as distinct structures since they blend with the TFCC. The pisotriquetral orifice (PTO) is just distal and anterior to the prestyloid recess and is found within the substance of the ULT just anterior to the proximal articular surface of the triquetrum.

Midcarpal Portals The midcarpal radial (MCR) portal is found 1 cm distal to the 3–4 portal. The (STT) joint lies radially and can be seen by rotating the scope dorsally. The scapholunate (SL) articulation which is proximal to this portal can be probed for instability or step-off. By moving the scope in an ulnar direction, the lunotriquetral (LT) articulation

20

D. J. Slutsky

comes into view. Superiorly, the proximal surface of the capitate, the interosseous ligament, and the hamate are seen. The midcarpal ulnar (MCU) portal is located 1 cm distal to the 4–5 portal or 1.5 cm ulnar and slightly proximal to the MCR portal, in line with the ring metacarpal axis. Normally, there is very little step-off between the distal articular surfaces. When there is any doubt, the traction should be released and the SL joint should be viewed with the scope in the MCU, whereas the LT joint should be viewed with the scope in the MCR.

Volar Portals To establish the VR radial portal, the surgeon is seated facing the volar aspect of the wrist. A 2 cm transverse or longitudinal incision is made in the proximal wrist crease overlying the FCR tendon. It is not necessary to specifically identify the adjacent neurovascular structures, provided the anatomical landmarks are adhered to. The tendon sheath is divided and the FCR tendon is retracted ulnarly. The radiocarpal joint space is identified with a 22 gauge needle and distended with 5 mL of saline. Tenotomy scissors or forceps are used to pierce the volar capsule. A blunt obturator and trochar are then introduced followed by the arthroscope. The midcarpal joint can be accessed through the same skin incision by angling the trochar 1  cm distally and approximately 5° ulnarwards. A hook probe is inserted through the 3–4 portal and it is used to assess the palmar aspect of the SLIL and the DRCL. A useful landmark when viewing from the VR portal is the intersulcal ridge between the scaphoid and lunate fossae. The a

b

Fig. 2.6  Technique for VU portal. (a) Skin incision for VU portal. FCR flexor carpi radialis tendon; FDS flexor digitorum sublimus. (b) FDS retracted, saline injection of radiocarpal joint. (c)

origin of the DRCL is seen immediately ulnar to this ridge, just proximal to the lunate. The VU portal is established via a 2  cm longitudinal incision centered over the proximal wrist crease along the ulnar edge of the finger flexor tendons. The tendons are retracted to the radial side and the radiocarpal joint space is identified with a 22 gauge needle (Fig. 2.6a–c). Blunt tenotomy scissors or forceps are used to pierce the volar capsule, followed by insertion of a cannula and blunt trochar, then the arthroscope. The ulnar nerve is protected by use of the cannula and a more radial entry site. The median nerve is protected by the adjacent flexor tendons. The palmar region of the LTIL can usually be seen slightly distal and radial to the portal. A hook probe is inserted through the 6R or 6U portal.

DRUJ Portals The dorsal aspect of the DRUJ joint can be accessed through a proximal and distal portal. The proximal portal is mostly for outflow and can be identified by inserting a 22 gauge needle horizontally at the neck of the distal ulna. The distal portal (DDRUJ) is identified just proximal to the 6R portal, underneath the DRUL. This portal can be used for outflow drainage or for instrumentation. It lies on top of the ulnar head, but underneath the TFCC. The topographical landmarks and establishment of the VDRU portal are identical to those of the VU portal. The capsular entry point lies 5–10 mm proximally [21]. There is more room on the volar ulnar aspect of the DRUJ for the insertion of an arthroscope with relatively c

Insertion of cannula through capsule deep to FDS tendons (Copyright by Dr. Slutsky [23])

2  Portals and Methodology

21

unimpeded views of the proximal articular disk and the foveal attachments. The VDRU portal is accessed through the VU skin incision. A 1.9  mm small joint arthroscope can be used since gaining access to the DRUJ can be difficult, especially in a small wrist, but a standard 2.7 mm scope provides a better field of view. It is useful to leave a needle or cannula in the ulnocarpal joint for reference. The DRUJ is located by angling a 22 gauge needle 45° proximally, and then injecting the DRUJ with saline. Once the correct plane is identified, the volar DRUJ capsule is pierced with tenotomy scissors followed by a cannula with a blunt trochar and then the arthroscope. Alternatively, a probe can be placed in the DDRUJ portal and advanced through the palmar incision to help locate the joint space. It can then be used as a switching stick over which the cannula is introduced. Initially, the DRUJ space appears quite confined, but over the course of 3–5 min, the fluid irrigation expands the joint space, which improves visibility. A burr or thermal probe can be substituted for the 3 mm hook probe through the DDRUJ as necessary.

[11] (Fig. 2.7); hence, a suspicion of a significant acute SLIL or LTIL tear or DRUJ instability due to a suspected TFCC tear are additional indications. Traction views will help to sort out the fracture anatomy. It is my preference to perform a CT scan along with coronal views to rule out an unrecognized sagittal split as well as to assess the congruency of the sigmoid notch.

Contraindications Large capsular tears which carry the risk of marked fluid extravasation, active infection, neurovascular compromise, and distorted anatomy are some typical contraindications. Marked metaphyseal comminution, shear fractures and a volar rim fractures require open treatment, although the arthroscope can be inserted to check the adequacy of the joint reduction. Due to the risk of late collapse, adjuvant internal fixation with locking plates is advised in elderly and osteopenic patients since fracture site settling may occur for up to 6 months [7].

Arthroscopic-Assisted Fixation: Distal Radius

Equipment and Implants

Indications

Required

More than 2 mm of articular displacement or gap are typical indications for surgical treatment. Isolated radial styloid fractures and simple three-part fractures are most suited to this technique. Displaced intraarticular fractures of the distal radius are often associated with unrecognized intraarticular soft tissue injuries

In general, a 2.7 mm 30° angled scope along with a camera attachment is used. A fiberoptic light source, video monitor, and printer have become the standard of care. Digital systems allow direct writing to a CD and superior video quality as compared to analog cameras. A 3 mm hook probe is needed for palpation of intracarpal

a Fig. 2.7  Soft tissue injuries associated with distal radius fractures. (a) Avulsed radioscaphocapitate (RSC) and long radiolunate ligaments (LRL) viewed from the 3–4 portal. (b) Avulsed ulnolunate ligament (asterisks) seen from the 4–5 portal (Copyright by Dr. Slutsky [23])

b

22

structures. Some method of overhead traction is useful. This may include a traction from the overhead lights or a shoulder holder along with 3–5 Kgr sand bags attached to an arm sling. A traction tower such as the Linvatec tower (Conmed – Linvatec Corporation, Largo, FL) or the ARC traction tower (Arc Surgical LLC, Hillsboro, OR) greatly facilitates instrumentation. The use of a motorized shaver or diathermy unit such as the Oratec probe (Smith and Nephew, NY) is useful for debridement. A motorized 2.9  mm burr is needed for bony resection. A variety of Steinman pins and small elevators are useful for the elevation of bony fragments. A K-wire driver and intraoperative fluoroscopy are integral to the procedure. A distal radius locking plate set should be available as per surgeon preference.

Optional There are a variety of commercially available suture repair kits including the TFC repair kit by Arthrex (manufacturer) or Linvatec (Conmed – Linvatec Corporation). Ligament repairs can also be facilitated by the use of a Tuohy needle which is generally found in any anesthesia cart. Specially designed jigs have been made to facilitate repair of radial TFC tears although Trumble et al. have described a method with meniscal repair needles passed through a suction cannula in the 6U portal [26].

Surgical Technique Intraoperative fluoroscopy is used frequently throughout the case, with the C-arm positioned horizontal to the floor. It is preferable to wait for 3–5 days to allow the initial intraarticular bleeding to stop. The author has found it useful to perform much of the procedure without fluid irrigation using the dry technique of del Piñal [6] which eliminates the worry of fluid extravasation. If fluid irrigation is used, inflow is through a large bore cannula in the 4–5 or 6U portal with the outflow through the arthroscope cannula. The working portals include the VR and 6R portal for fracture visualization and the 3–4 portal for instrumentation – but all of the portals are used interchangeably. Lactated Ringer’s solution is preferred over saline, and the forearm is wrapped with coban to limit extravasation. The

D. J. Slutsky

fracture hematoma and debris are lavaged and any early granulation tissue is debrided with a resector. Mehta and colleagues described a 5 level algorithm for reducing the fracture fragments [16]. This included the “London technique” where the K-wires were advanced through the distal ulna into the subchondral distal radius and withdrawn from the radial aspect so that they do not encroach on the DRUJ.

Radial Styloid Fractures It is easiest to obtain the reduction through ligamentotaxis while the arm is suspended in the traction tower. A Freer elevator may also be placed in the fracture site to facilitate this step. A 1 cm incision is made over the styloid to prevent injury to the SRN, and two 1.5 mm K-wires are inserted for manipulation of the styloid fragment. The fracture site is best assessed by viewing across the wrist with the scope in the 6R portal, in order to gauge the rotation of the styloid. The K-wires are used as joysticks to manipulate the fragment, and then, one K-wire is driven forward to capture the reduction. One or two cannulated screws are used to stabilize the fracture fragment.

Three-Part Fractures Three-part fractures are comprised of a radial styloid fragment and a medial or lunate fragment. The radial styloid fracture is reduced and pinned as above. It is then used as a landmark to which the depressed lunate fragment is reduced. An elevator or large pin is inserted percutaneously to elevate the lunate fragment. Tena­ culum forceps with large jaws are used to hold the reduction and to prevent crushing the SRN. The reduction is captured with horizontal subchondral K-wires, stopping short of the DRUJ. It is paramount to bone graft the metaphyseal defect through a small dorsal incision to prevent late collapse. The VR portal aids in the reduction of any dorsal die punch fragments. Once the reduction has been achieved, some type of neutralization device is desirable such as a bridging external fixator. More recently, volar locking plates and/or headless cannulated screws have been used. It is my preference to use a nonbridging external fixator to allow early wrist motion (The Fragment Specific Fixator, South Bay Hand Surgery, LLC. Torrance, CA) (Fig. 2.8a–n).

2  Portals and Methodology

23

a d

b

c

e

h

f

g

i

Fig.2.8  Arthroscopic-guided pinning and nonbridging external fixation. (a) Comminuted intraarticular distal radius fracture. ­(b) Lateral View. (c) Anteroposterior CT view reveals the extent of the intraarticular fragmentation. (d) Lateral CT highlights the small dorsal rim fragments. (e) Coronal CT view shows the sigmoid notch disruption.

(f) Arthroscopic view of joint surface showing the degree of comminution. (g) A percutaneous is inserted through the ulna to capture and control the medial fragment. (h) Percutaneous reduction of dorsal tilt. (i) Fluoroscopic appearance.

24

D. J. Slutsky

j

k

l

n

m

Fig. 2.8  (continued)  (j) Arthroscopic view following reduction and pinning. (k) Fluoroscopic view after arthroscopic reduction. (l) Application of nonbridging external fixator. (m) Result at 6

months with restored radial height and tilt. (n) Congruent joint space with neutral lateral tilt (Copyright by Dr. Slutsky [23])

Postoperative splinting in supination in between therapy helps prevent a pronation contracture.

Four-Part Fractures In four-part fractures, the lunate facet is split into volar and dorsal fragments. The volarmedial fragment must usually be reduced through an open incision since wrist traction rotates this fragment and prevents reduction by closed means (Fig.  2.9). The radial styloid fragment is reduced with ligamentotaxis and temporarily held with K-wires. A standard volar approach or a limited volar ulnar incision can be made. The volarmedial fragment is reduced under direct observation by pinning it back to the shaft and the radial styloid fragment. A 2.4 mm volar locking plate is provisionally applied to hold the reduction. The reduction is checked through the 6R and VR portals. The dorsomedial fragment is then elevated back to the radial styloid and reduced to the volarmedial fragment, which is

Fig.  2.9  Arthroscopic view from the 4–5 portal of a rotated volar medial fragment (Copyright by Slutsky [23])

utilized as a landmark. A small locking dorsal plate can be applied at this point, or alternatively, the distal screws of the volar plate can be used to lag the volarmedial and dorsomedial fragments. In this event, one or more of the distal screws should be placed in a nonlocking fashion to help compress the fragments. Wiesler et  al. however have described a method for

2  Portals and Methodology

treating four-part fractures arthroscopically. After a Freer elevator is introduced dorsally to disimpact the fragments, a nerve hook is used to reduce the volar lunate facet which is then pinned to the radial styloid. The remaining fragments are reduced with interfragmentary pin fixation, and the reconstructed articular surface is then pinned to the radial metaphysis [27].

25

understanding of the topographical and internal ­anatomy of the wrist are integral to minimizing complications while maximizing the chances for a successful outcome.

References Ulnar Styloid Fractures Peripheral TFCC tears are assessed arthroscopically. In a study of arthroscopically-treated distal radius fractures, Lindau found that 10/11 with complete peripheral TFCC tears had DRUJ instability at the 1 year followup examination compared with 7 of the 32 patients with only partial or no peripheral tears. Patients with instability of the DRUJ had a worse Gartland and Werley wrist score [12]. In this regard, large TFCC tears may be repaired with open or arthroscopic technique at the preference of the surgeon. The diagnosis of a foveal detachment of the deep fibers of the TFCC requires a high index of suspicion. Arthroscopic confirmation is difficult, since the fovea cannot be seen through the standard radiocarpal portals. Berger has described using a probe to pull on the TFCC in multiple directions in an attempt to elicit the displacement of the triangular fibrocartilage which he believes is indicative of a foveal disruption [25]. Atzei and Luchetti describe the hook test which consists of applying traction to the ulnar-most border of the TFCC with the probe inserted through the 4–5 or 6-R portal. The test is positive when the TFCC can be pulled upwards and radially towards the center of the radiocarpal joint [2]. Basi-ulnar styloid fractures with initial displacement of more than 2 mm should be repaired if there is residual DRUJ instability following fixation of the radius. It is my preference to use either 2 K-wires with tension band wiring or headless screw fixation. (see also Chap. 6).

Summary The use of wrist arthroscopy continues to expand the indications and treatment options for distal radius fractures. A systematic approach and a thorough

1. Abrams RA, Petersen M, Botte MJ. Arthroscopic portals of the wrist: an anatomic study. J Hand Surg [Am]. 1994;19: 940–4 2. Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008;12:226–35 3. Balogh B, Valencak J, Vesely M, Flammer M, Gruber H, Piza-Katzer H. The nerve of Henle: an anatomic and immunohistochemical study. J Hand Surg [Am]. 1999;24: 1103–8 4. Botte MJ, Cohen MS, Lavernia CJ, von Schroeder HP, Gellman H, Zinberg EM. The dorsal branch of the ulnar nerve: an anatomic study. J Hand Surg [Am]. 1990;15: 603–7 5. DaSilva MF, Moore DC, Weiss AP, Akelman E, Sikirica M. Anatomy of the palmar cutaneous branch of the median nerve: clinical significance. J Hand Surg [Am]. 1996; 21: 639–43 6. del Piñal F, Garcia-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg [Am]. 2007;32:119–23 7. Dicpinigaitis P, Wolinsky P, Hiebert R, Egol K, Koval K, Tejwani N. Can external fixation maintain reduction after distal radius fractures? J Trauma. 2004;57:845–50 8. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intraarticular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg Am. 1999; 81:1093–110 9. Gelberman RH, Panagis JS, Taleisnik J, Baumgaertner M. The arterial anatomy of the human carpus. Part I: the extraosseous vascularity. J Hand Surg [Am]. 1983;8: 367–75 10. Kamei K, Ide Y, Kimura T. A new free thenar flap. Plast Reconstr Surg. 1993;92:1380–4 11. Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients. J Hand Surg [Br]. 1997;22:638–43 12. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg [Am]. 2000;25:464–8 13. Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. J Hand Surg [Am]. 1985;10:522–6

26 14. Martin CH, Seiler JG III, Lesesne JS. The cutaneous ­innervation of the palm: an anatomic study of the ulnar and median nerves. J Hand Surg [Am]. 1996;21:634–8 15. McCabe SJ, Kleinert JM. The nerve of Henle. J Hand Surg [Am]. 1990;15:784–8 16. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach. J Bone Joint Surg Br. 2000;82: 79–86 17. Omokawa S, Ryu J, Tang JB, Han J. Vascular and neural anatomy of the thenar area of the hand: its surgical applications. Plast Reconstr Surg. 1997;99:116–21 18. Ruch DS, Vallee J, Poehling GG, Smith BP, Kuzma GR. Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures. Arthroscopy. 2004;20:225–30 19. Slutsky D. Wrist arthroscopy: portals and procedures. In: Trumble T (ed). Hand surgery update IV. American Society for Surgery of the Hand; 2007 20. Slutsky DJ. Wrist arthroscopy through a volar radial portal. Arthroscopy. 2002;18:624–30

D. J. Slutsky 21. Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy. Tech Hand Up Extrem Surg. 2004;8: 229–38 22. Slutsky DJ. The use of a volar ulnar portal in wrist arthroscopy. Arthroscopy. 2004;20:158–63 23. Slutsky DJ. Wrist arthroscopy portals. In: Slutsky DJ, Nagle  DJ, editors. Techniques in hand and wrist arthroscopy. Amsterdam: Elsevier; 2007 24. Steinberg BD, Plancher KD, Idler RS. Percutaneous Kirschner wire fixation through the snuff box: an anatomic study. J Hand Surg [Am]. 1995;20:57–62 25. Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg [Am]. 2007;32:438–44 26. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg [Am]. 1997;22:57–65 27. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10: 139–44.

3

Management of Simple Articular Fractures Ferdinando Battistella

Introduction Wrist arthroscopy is a continuously expanding field, bringing up new controversies and challenges. The use of new portals (both dorsal and volar) means that the wrist joint can be viewed from virtually any perspective (“box concept”). Indications for wrist arthroscopy continue expanding and include diagnostic and reparative procedures, and more recently, reconstructive, soft tissue, and bony procedures. Recent advances in wrist arthroscopic surgery techniques and instrumentation have enabled the surgeon to improve the treatment of intraarticular distal radius fractures. The clinical outcome of an intraarticular distal radius fracture will be affected by the amount of radial shortening, residual extraarticular angulation, joint congruity (radiocarpal and ulnocarpal joints), and associated soft-tissue injuries [6, 17]. Arthroscopicassisted treatment of the distal radius fracture will be useful only if it is able to influence these factors. The potential advantages of arthroscopic technique over more traditional techniques include: 1. Accurate assessment of the status of the articular surface by direct visual inspection, under a bright light and magnification, which is superior to fluoroscopy [12–18]. Particularly, rotation of the fracture fragments, which is difficult to judge under fluoroscopy, may be detected arthroscopically and corrected.

F. Battistella Clinical and Research Center of Upper Arm Disease, General Hospital Legnano, Via Torino 7/a, 20025 Legnano, Milan, Italy e-mail: [email protected]

2. Identification and repair of chondral and ligamentous lesions, which have been shown to occur with distal radius fractures. 3. Washing out of fracture hematoma and debris may allow for improved range of motion [2]. 4. Minimally invasive technique causing less tissue damage (skin, tendons, capsule, and fewer fracture fragments will be devitalized). The potential disadvantages of arthroscopic-assisted management may be that it is technically demanding, and in some cases, it does not allow for rigid stable fixation.

Fracture Classification A number of authors have proposed systems for the classification of fractures of the distal aspect of the radius, such as the Mayo [3], Melone [13], Fernandez [7] (Fig.  3.1), and AO classification systems [14] (Fig. 3.2). They are helpful in describing the fractures but may not correspond directly to the status of intraarticular fragments, which is the key information required for accurate reconstruction of the distal aspect of radius. A system will be most useful if it can describe the relative severity of the fracture and the corresponding treatment options. In other words, the principal significance of any classification is to provide guidelines for treatment as well as to facilitate evaluation and comparison of results. Complete understanding of the detailed status of distal radius surface, such as the direction and degree of displacement or comminution, is of vital importance to any well-ordered reduction and immobilization. Unfortu­ nately, most of the existing classification systems focus

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_3, © Springer-Verlag Berlin Heidelberg 2010

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F. Battistella

Fig. 3.1  The classification of Fernandez addresses the mechanism of injury. Bending: Type 1, one cortex of the metaphysis fails due to tensile stress (Colles and Smith fractures) and the opposite undergoes a certain degree of comminution. Shearing: Type 2, fracture of the joint surface – Barton’s, reversed Barton’s, styloid process fractures, simple articular fracture. Compression: Type 3, fracture of the surface of the joint with impaction of subchondral and metaphyseal bone (die-punch fracture), intraarticular comminuted fracture. Avulsion: Type 4, fracture of the ligament attachments of the ulnar and radial styloid process, radiocarpal fracture dislocation. Combinations: Type 5, combination of types, high velocity injuries

only on the mechanism of injury or the geometry of the fracture and are based only on radiography. Computerized tomography and a newly developed 3-dimensional reconstruction technique (3D CT) solve the limitation of plain radiography. On the basis of preoperative 3D CT scanning, Doi et al. classified intraarticular distal radial fractures into 2, 3, and 4-part types, according to the number of main fracture fragments involved in the joint surface [5]

(Fig. 3.3). Two-part fractures had three subtypes, based on the direction of the fracture line (vertical, horizontal, or at the dorsal rim). Three-part fractures are composed of a significant radial styloid fragment and two main fragments in the lunate facet. A 4-part fracture involves two main fragments in both the lunate and scaphoid fossae. Severe comminuted cases, namely AO type C3 fractures, are categorized as 4-part fractures in this system. Compared with other

3  Management of Simple Articular Fractures

Fig. 3.2  Müller AO classification. Group B partial articular fracture. B1 radius, sagittal; B2 radius, frontal, dorsal rim; B3 radius, frontal, volar rim. Group C complete articular fracture of radius. C1

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articular simple, metaphyseal simple; C2 articular simple, metaphyseal multifragmentary; and C3 articular multifragmentary

Fig. 3.3  The classification of Doi: 2-part fractures. (a) Vertical line; (b) horizontal line; (c) dorsal rim; (d) 3-part fractures; and (e) 4-part fractures

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classifications, this system simply and accurately describes the status of the joint surface, thereby providing an intuitive and practical guideline for the arthroscopy and reduction-fixation procedure.

Indications and Contraindications Relative indications include: 1. Age between 16 and 65 years without evidence of metabolic bone disease. 2. A 2, 3, or 4-part type fracture of the distal radius with an articular step-off of equal to or greater than 1  mm that remains irreducible after adequate attempts at closed reduction. 3. Additional fracture patterns include lunate diepunch fractures. 4. Radiographic signs of concomitant injury, including diastasis of intercarpal joint spaces, subluxation of distal radioulnar joint, or a broken carpal arch. 5. The best time interval after injury is within 3–7 days. If reduction is attempted earlier than 2 days, bleeding from the fresh fracture may potentially complicate the procedure; and furthermore, the fresh fracture and ligament tears may precipitate the extravasation of arthroscopic fluid into soft tissues. After 7  days postinjury, the fracture fragments would have started to consolidate and may become too difficult to manipulate. If a dry technique arthroscopy is used [4], the waiting period can be reduced to 0 days. Relative contraindications include: 1. Marked metaphyseal comminution or radial styloid comminution. These were considered classically as contraindications, but indications have now widened as shown in Chap. 4. 2. Infection. 3. Open injuries. Again this is a relative contraindication if the dry technique is used. 4. Extensive soft-tissue damage. 5. Unreduced carpal dislocations were also considered as a contraindication, but again, views have changed dramatically in recent years (see Chap. 11). 6. Median nerve involvement. This is not a contraindication when using the dry technique.

F. Battistella

7. Compartment syndrome in the forearm or hand. 8. Associated injuries or fractures of the upper arm that do not allow traction of the wrist or the vertical or horizontal position for arthroscopy.

Surgical Technique The 2-part type fractures with three subtypes are the more common articular fractures of the wrist. Preoperative planning is based on X-ray and CT scan, which is indispensable to assess the 3D picture of the displaced fragments (frontal, sagittal, and axial planes) and 3D reconstruction for classification. Arthroscopy is usually performed under axillary block or general anesthesia; the choice is based on patient’s and anesthesiologist’s preference. Vertical and horizontal traction may be used. We use a traction system that we had customized, that allows us to change from vertical to horizontal easily and with no surrounding impediments, in order to facilitate the simultaneous performance of arthroscopic instrumentation and fluoroscope transillumination. This system allows the surgeon to flex, extend, and radial and ulnar deviate the wrist while keeping constant traction. When the best position to reduce the fractured fragment is achieved, the wrist is blocked (Fig. 3.4). Longitudinal traction is applied with the wrist in a slightly flexed and ulnar-deviated position, with the amount of traction slightly more than normally used for wrist arthroscopy, as this was found to facilitate reduction via the effects of ligamentotaxis. The use of traction with a tower or another system for wrist arthroscopy helps reduce the fracture and achieve the right length of the radius [9]. A pneumatic tourniquet is applied on the upper arm and inflated to 250 mmHg when the arthroscopic procedure starts. Before prepping and draping, we use fluoroscopy to control the traction (maximum 5–6 kg) of the wrist. It must not be too much because we may overreduce the fragments. The normal bony landmarks for the portals are often distorted as a result of swelling in distal radial fractures, and so, it is helpful to place an 18-gauge needle into the joint before making the skin incision to locate the portal. Furthermore, fluoroscopy may be needed in the more complicated cases to avoid entrance into the fracture itself.

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introduced via the trocar of the arthroscope. Lowpressure mechanical pumping is used to facilitate irrigation and space expansion, but the intraarticular pressure is kept as low as possible to avoid extravasation and the risk of compartment syndrome. Having cleared the view, the examination of the wrist starts by performing radiocarpal assessment of the injuries to the scapholunate (SL) and lunotriquetral ligaments and classification of the injuries to the triangular fibrocartilage complex (TFCC). This procedure is required in order to plan the surgery time. Then the degree of comminution, separation, and depression of the fracture fragments are assessed. It is not uncommon to find that the fragments are tilted in the sagittal plain, but this is not appreciated on lateral fluoroscopy because of the overlap of the ulna, scaphoid, and lunate fossae and the biconcave configuration of the distal radius [19]. In addition, gap separation and step-off displacement can be accurately evaluated with the tip of the probe.

Reduction of the Fracture Fig.  3.4  Author’s system of traction provides stable traction with virtually unrestricted access to the wrist during arthroscopic and fracture reduction procedures. The system can be easily maneuvered to allow fluoroscopic imaging, and can be tilted or rotated down to a horizontal position to support management of fractures

Precautions are applied to minimize arthroscopic fluid extravasation into the soft tissues: (1) the forearm is wrapped in a compressive dressing, (2) irrigation and washing is controlled by the use of pressurized pump inflow and outflow at 20 mmHg, and (3) the portals are created just slightly larger than standard arthroscopic procedure, so that the water can go out easily without extravasation into soft tissues. The fracture is approached initially from the dorsal side, the 3–4 portal is preferred for initial visualization (2.7 mm/30° small joint arthroscope) along with the 4–5, and 6-R portals for instrumentation (2.7 mm arthroscopic shaver/probe and punch for the removal of hematoma and fragments). During the arthroscopic procedure, the viewing portal may be changed to the 6R if needed. Blood clot, debris, and detached synovial tissue that obstruct full visualization with the arthroscope are cleared away using arthroscopic aspiration, shaver, and punch. Continuous inflow with saline solution is

The technique varies according to the fracture type.

Two-Part Fractures The simple 2-part type fracture can sometimes be easily reduced by traction with the tower and manual compression because radial styloid is normally reduced through ligamentotaxis while the arm is suspended in the traction tower, and the quality of reduction is controlled with arthroscopy. Next, the fracture is fixed with Kirschner wire (K-wire) and cannulated screw (Figs. 3.5 and 3.6). Sometimes, this technique is not sufficient, and so we need to add percutaneous K-wire manipulation. The K-wires are placed into the fracture plane under fluoroscopy. These wires elevate, reduce, and buttress the distal fragment. K-wires are driven into larger fragments, such as the radial styloid, acting as joysticks. In these techniques, the wires are positioned under fluoroscopy and then manipulated as the distal articular surface of the radius is arthroscopically assessed. The wires are advanced once anatomical reduction is obtained and if the fracture needs compression we insert a cannulated screw (Fig. 3.7).

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a

F. Battistella

b

c Fig. 3.5  (a) Two-part fracture vertical rim. (b) The reduction is made by ligamentotaxis with the traction system and with external compression with surgeon’s thumb. (c) The fracture is fixed

Fig. 3.6  Fluoroscopic final control, before removing the temporary K-wire that was inserted to avoid the rotation of the fractures’ fragment driving the screw

with K-wire and cannulated screw while the reduction is controlled by arthroscopic view

It is important that while the screw is inserted into the styloid, the K-wire used before as a joystick must be advanced temporarily into the ulna to avoid the rotation of the fragment. The best portal to view the rotation of the radial styloid fragment is 4–5 or 6R. The volar fragment of the 2-part type fracture with a horizontal rim tends to rotate dorsally during traction because of ligamentotaxis. Longitudinal traction is released slightly, and the wrist is placed in slight flexion. The fracture is reduced using a target compass (Fig. 3.8) to get the right position of the K-wire and to make compression of the fragments. The fragments are gently compressed together and maintained with the tip of the compass, while oblique K-wires are placed to fix intraarticular fragments to the radial shaft (Fig. 3.9). If the volar fragment is elevated or dislocated we use arthroscopic manipulation. An arthroscopic probe or elevator is used to manipulate bony fragments via the

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Fig. 3.7  (a) Two-part fracture vertical rim that was not possible to reduce only with legamentotaxis. (b) Percutaneous K-wire manipulation: the K-wire is used like a joystick to reduce the fragment under fluoroscopic control and arthroscopic view. (c) Final arthroscopic control

a

b

c

Fig. 3.8  Compass. It is used to drive the K-wires exactly where we need in easy way and contemporarily to compress the fractures’ fragment. The target compass reduces the time to use the fluoroscopy

instrumental portal, particularly those involving the lunate fossa. Once acceptable realignment is achieved, K-wires are introduced percutaneously for fixation (Fig. 3.10). In case of 2-part type subgroup dorsal rim, the fragment is difficult to view from the dorsal portals even by moving the scope from 3 to 4 portal to 6R. In such cases we need to add a volar portal. This is done under direct vision through a 1 cm longitudinal skin incision between the flexor carpi radialis tendon and the radial artery. The volar aspect of the capsule is exposed after blunt dissection, and a small (3 mm) incision is made parallel to the capsular fibers (Fig. 3.11). The arthroscope is therefore placed through the volar portal (Fig. 3.12), and the dorsal rim fragment is reduced

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a

F. Battistella

b

Fig.  3.9  (a) Two-part fracture horizontal rim. (b) Reduction with the tip of compass and contemporarily external compression with surgeons’ thumb and internal cannulated cylinder of

a

b

c the compass. (c) The K-wire is placed to fix the articular fragment to the radial shaft

c

Fig.  3.10  (a) Two-part fracture horizontal rim with elevated volar fragment. (b) Arthoscopic manipulation of the articular fragment using elevator. (c) Positioning the K-wire while the

reduction of the volar fragment is maintained by the elevator and the fracture is compressed by the compass

by dorsal compression with the wrist in slight flexion, and a single K-wire is used with the aim of percutaneus manipulation and immobilizing the dorsal die-punch fragment (Fig. 3.13). In case of a large dorsal die-punch fragment a cannulated cancellous screw is used.

percutaneously under fluoroscopic visualization crossing the fracture line by only 6–7 mm to obtain a temporary stabilization. The radial styloid fragment is used as an intraarticular landmark to elevate arthroscopically the depressed lunate facet fragments with the arthroscopic probe. Then, using the compass guide, a K-wire is placed into the bone under the depressed volar lunate fragment and is used to elevate the fragment percutaneously. When the depressed fragment is leveled and the reduction of the volar lunate fragment is judged arthroscopically acceptable, the K-wire is pushed through the styloid and fixed to the radial cortex, and the volar lunate fragment is fixed definitively. Then, the dorsal lunate fragment is reduced and pinned in the same way. The use of a compass guide is useful not only for the easy and correct positioning of the

Three-Part Fractures Reduction of articular congruity is initiated by the elevation of the die-punch fragments and depression of the articular surface, and by the control of the mobility of the articular fragment. We start reducing the radial styloid fragment in the same way as 2-part fractures. The styloid is pinned

3  Management of Simple Articular Fractures

Fig.  3.11  Skin incision for arthroscopic radial volar portal between the flexor carpi radial (FRC) and radial artery (RA)

a

b

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Fig. 3.12  Arthroscopic radial volar access between the flexor carpi radial (FRC) and radial artery (RA)

c

Fig. 3.13  (a) Two-part fracture dorsal rim. (b) The volar radial portal is relatively easy to use and is an ideal portal for evaluation and to assist the reduction of the dorsal fragment of the

fracture. The reduction is made using a K-wire with joystick technique and external compression with the surgeons’ thumb. (c) The dorsal articular fragment is fixed with K-wire

K-wire, but also to reduce any sagittal gap that may exist between the radial styloid and depressed lunate facet fragment (Fig. 3.14). In fact, the external blunt tip of the compass is placed on the radial styloid and the internal tip is placed on the border of the lunate facet fragments to close the sagittal gap. If the size of the articular fragment of the styloid is not big enough to obtain a good reduction and a rigid

stabilization, we use a modification of Piñal’s technique [15]. (see also Chap. 4). We start with the position of the arm in the traction system in horizontal way with only 3 kg of traction. The approach to the radial is with the open standard volar technique. The volar locking plate is placed and fixed temporarily only with a screw placed in the elliptical hole; this will allow us some adjustment at the time of

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F. Battistella

a

d

b

e

c

f

Fig.  3.14  (a) Three-part fracture. (b) Percutaneous K-wire manipulation: the K-wire is used like a joystick to reduce the styloid fragment under fluoroscopic control and arthroscopic view. Temporary stabilization with the K-wire that cross the fracture plan only of 6–7 mm. (c) The volar lunate fragment is elevated using an elevator and the reduction is checked with the radial styloid fragment as an inside articular landmark. (d) The

volar lunate fragment is reduced using the arthroscopic probe. (e) A K-wire is positioned, with the use of compass, into the bone of volar lunate fragment and the final reduction of the fragment is made with little movement of the K-wire. Then the K-wire that temporarily fixed the radial styloid is pushed on and fixed to the radial cortex; and (f) the dorsal lunate fragment is reduced and fixed with K-wire

final plate positioning. The manual reduction of the fracture is performed using a progressive traction and volar flexion using the traction system, and then, the wrist is positioned in 5–7 kg of traction and light (10°) flexion. The articular fracture fragments are preliminary fixed with two K-wires to the plate under fluoroscopic control through the auxiliary holes. It is important to control that the plate is not positioned too distally or too proximally because this will also condition the correct positioning of the screws or pegs in the subcondral bone and to control that the traction is not too much to avoid displacement of the articular dorsal fragments caused by overdistraction. Then, we move the traction system from horizontal to the vertical position and start the arthroscopic procedure performing 3–4 portal for the scope and 6R for the motor and probe. When the joint is washed and a clear view of the joint is achieved, all articular fragments are evaluated. Then, we move the scope from 3 to 4 to the 6R portal. We perform arthroscopic fine-tuning of the reduction starting from

the ulnar side of the radial fracture using the tip of the arthroscopic probe or elevator and using the K-wire as a joystick, backing out or advancing as needed to move the related articular fragment, and moving the plate a few degrees with external dorsal compression with the thumb of surgeon. When the reduction is judged optimal, at least another screw is inserted into the stem of the plate to lock it well in its final position. Then, while the reduction is maintained or using the dedicated compass, the first and second K-wires are pushed onto the dorsal cortex and locking pegs or locking screws are positioned under arthroscopic control (Fig. 3.15).

Four-Part Fractures Four-part fractures are always managed through a combination of open reduction for placing the volar locking plate with arthroscopic-assisted reduction of

3  Management of Simple Articular Fractures

a

d

37

b

c

e

f

Fig.  3.15  (a) Three-part fracture with small articular styloid fragment. (b) Open surgery: the volar locking plate is placed and fixed temporary only with a screw in the elliptical hole and the articular fragments are fixed to the plate with two K-wires through dedicated holes. (c) Arthroscopic-assisted reduction of the articular fragments moving the two K-wires or the plate.

(d) Arthroscopic fine-tuning, the reduction of the two fragments of lunate fossae is maintained using a compass while the two K-wires are pushed on to the dorsal cortex of the radius. (e) Locking screws are driven into the bone. (f) Final arthroscopic control when all screws are placed

articular fragments. The technique is similar to those explained in “Three-Part Fractures” but more complex because of the four articular fragments and because some are depressed and some are elevated and the precise placement of the volar plate is much more important for the reduction and for fixation of the fragments (see also Chap. 4).

at the time of fracture, involving not only the surrounding fractured radius but also the intercarpal joints. SL ligament disruption results from an avulsion fracture of the radial styloid process due to ulnar deviation of the wrist (Fig. 3.16a) or a trauma force that is “used” to break the distal radius due to carpal supination (Fig.  3.16b). For management of associated injuries see Chap. 8.

Associated Injuries Articular distal radial fractures exhibit a high incidence of associated injuries: chondral and soft tissue injuries, interosseous ligament injuries, and TFCC lesions [8]. The most commonly associated injury of a 2-part type fracture is SL ligament injury (average 31%), [11] because of the great transmission of energy to the joint

Complications Complications of arthroscopic-assisted treatment secondary to the arthroscopy itself are minimal in reported cases. However, potential complications include: (1) settling of the fracture fragments resulting in loss of reduction (2) pin track infection, (3) pin loosening, and (4) sensory nerve irritation.

38 Fig. 3.16  (a) Scapholunate disruption caused by avulsion fracture of styloid. (b) Scapholunate disruption caused by carpal supination

F. Battistella

a

b

Results

Clinical Experience and Personal Results

Several studies [1, 9, 18] have evidenced the effectiveness and safety of arthroscopic-assisted treatment of articular distal radius fractures even if there are no prospective randomized double-blind studies. In 1999, Doi et al. reported a long-term outcome of arthroscopically-assisted reduction of intraarticular fractures of the distal end of the radius, and demonstrated better range of motion and grip strength than those treated by conventional procedures [5]. In 2004, Ruch et al., in a prospective cohort study, evidenced that the arthroscopic-assisted (A.A.) reduction and fixation permits a more thorough inspection of the ulnar-sided components of the injury. At follow-up evaluation, patients who underwent AA procedures had a greater degree of supination, flexion, and extension than those undergoing fluoroscopically assisted (FA) surgery [16]. In 2007, Hattori, in a clinical study, reported the result on 28 patients older than 70 years with AO type C fracture of the distal radius that were treated with arthroscopically-assisted reduction combined with volar plating or external fixation. The study concluded that arthroscopically-assisted reduction combined with volar plating or external fixation is one of the useful options for the treatment of a displaced intraarticular fracture of the distal radius in elderly patients who are physiologically young or active [10]. In 2008, Varitimidis, in a randomized prospective study, reported that the patients who underwent arthroscopically-assisted treatment had significantly better supination, extension, and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both the groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant [18].

From 2001 to 2008, we treated 124 patients with arthroscopic-assisted technique for distal articular radius fractures. On the basis of our prospective comparative study, we found that the arthroscopicallyguided procedure was superior to the conventional open procedure with regard to several parameters. Specifically, the scores for outcome as assessed with the system of Gartland and Werley and the modified system of Green and O’Brien, the range of flexionextension and that of radial-ulnar deviation of the wrist, and the grip strength were better in the group managed with the arthroscopically-guided procedure.

Conclusion Traditional methods of traction and ligamentotaxis cannot control and elevate the die-punched fragments and correct the articular step-off. Conventional open reduction and internal fixation generally yields poor functional outcome. An arthroscopically-guided operation achieves an accurate reduction of intraarticular fractures of the distal aspect of the radius and treats associated lesions, both of which are necessary for regaining anatomic structure and satisfactory function. Minimal capsular and adjacent soft-tissue scarring reduces postoperative contracture, which improves the overall functional results. Arthroscopically-guided reduction is a feasible procedure, but it requires meticulous technique, and despite a steep learning curve, is an invaluable method. We recommend arthroscopically-assisted technique for any active patients, not only for young adults but also for all the patients who have an intraarticular

3  Management of Simple Articular Fractures

fracture of the distal part of the radius with more than 1 mm of displacement on plain radiographs.

References   1. Chen AC, Chan YS, Yuan LJ, Ye WL, Lee MS, Chao EK. Arthroscopically assisted osteosynthesis of complex intraarticular fractures of the distal radius. J Trauma. 2002;53(2): 354–9   2. Cognet JM, Martinache X, Mathoulin C. Arthroscopic management of intra-articular fractures of the distal radius. Chir Main. 2008;27(4):171–9   3. Cooney WP. Fractures of the distal radius: a modern treatment based classification. Orthop Clin North Am. 1993;24: 211–6   4. Del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg. 2007;32A:119–23   5. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intraarticular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg. 1999;81A: 1093–110   6. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg. 1991;16A:375–84   7. Fernandez DL, Geissler WB. Percutaneous and limited open reduction of the articular surface of the distal radius. J Orthop Trauma. 1991;5(3):255–64   8. Forward DP, Lindau TR, Melsom DS. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg. 2007;89A:2334–40

39   9. Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005;21:407–16 10. Hattori Y, Doi K, Estrella EP, Chen G. Arthroscopically assisted reduction with volar plating or external fixation for displaced intra-articular fractures of the distal radius in the elderly patients. Hand Surg. 2007;12(1):1–12 11. Kordasiewicz B, Pomianowski S, Orłowski J, Rapała K. Interosseous ligaments and TFCC lesions in intraarticular distal radius fractures - radiographic versus arthroscopic evaluation. Ortop Traumatol Rehabil. 2006;8:263–7 12. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach. J Bone Joint Surg. 2000;82B: 79–86 13. Melone CP. Articular fractures of the distal radius. Orthop Clin North Am. 1984;15:217–36 14. Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. New York: Springer; 1990 15. Piñal F. Dry arthroscopy of the wrist: Its role in the management of articular distal radius fractures. Scand J Surg.2008; 97:298–304 16. Ruch DS, Vallee J, Poehling GG, Smith BP, Kuzma GR. Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures. Arthroscopy. 2004;20(3):225–30 17. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg. 1994;19A:325–40 18. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg. 2008;90B:778–85 19. Wiesler ER, Chloros GD, Mahirogullari M, Kuzma GR. Arthroscopic management of volar lunate facet of distal radius fractures. Tech Hand Upper Extrem Surg. 2006;10(3): 139–44

4

Treatment of Explosion-Type Distal Radius Fractures Francisco del Piñal

We have defined explosion-type distal radius fracture (DRF) as any fracture with more than four articular fragments, or in any case where there was a single, free (central) osteochondral fragment (Fig. 4.1). This group is more difficult to approach from an arthroscopy point of view, and has been considered as the “last frontier” [13, 14, 21, 28]. By the same token, in our opinion, it is the one that benefits the most from improving its dim prognosis as arthroscopy may allow to achieve anatomic reduction of the articular surface. As a matter of fact, much of the low popularity of AARIF (arthroscopic-assisted reduction and internal fixation) of wrist fractures is due to the fact that many surgeons started their training dealing with this most difficult group, thinking that the fracture that benefited the most because of control of the articular surface was this group. Although the rationale was correct, trying to climb the highest mountain without experience had a detrimental effect. On one hand, the end result of these first encounters was frustration, and, on the other, the surgeons became convinced that the technique was not useful. Intuitively, one would always think that complicated methods in inexperienced hands will provide poorer results than when those surgeons use safer methods. By the same token, only skilled surgeons will get consistently good results in the most severe fractures using the most complicated techniques. So, although much of the information concerning the way I manage explosion fractures is useful to deal with the simpler type, I would like to stress again that explosion fractures are not for a novice in arthroscopy, unless one is looking for a reason to give up AARIF.

F. del Piñal Head of Hand and Plastic Surgery, Private practice Hospital Mutua Montañesa, Calderón de la Barca 16-entlo, 39002-Santander, Spain e-mail: [email protected]

Fig. 4.1  An explosion-type distal radius fracture (DRF) that has more than four articular fragments and also a free osteochondral fragment. (1: volar rim of the scaphoid fossa; 2: dorsal rim; 3: posterior lunate (dorso-ulnar) fragment; 4: anterior lunate (volarulnar) fragment; 5: free osteochondral fragment at the scaphoid fossa) (Copyright by Dr. Piñal, 2009)

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_4, © Springer-Verlag Berlin Heidelberg 2010

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AARIF in explosion-type fractures is a lengthy operation and all personnel should be appropriately trained in order not to run out of tourniquet time and overstress. By paying attention to logistics and keeping order in this seemingly chaotic procedure, it can be transformed into a friendly exercise. The first rule (common to all fracture types) is never to carry out a definitive fixation until after an arthroscopic control of the reduction has been performed. In this sense, another of the most common causes of frustration and finding the AARIF useless is to introduce the arthroscope at the end of the operation once all the rigid fixation has been done in order “to confirm the anatomic reduction.” At this stage, correcting any misplaced fragment and achieving stable fixation is a nearly impossible endeavor, leaving the surgeon with the difficult decision of accepting an inaccurate reduction or having to transform the ideal “rigid” fixation into a voodoo-type exercise, with Kirschner-wires (K-wires) maintaining a tenuous fixation. This problem underscores how important logistics are, more so the more complex the fracture is. It is imperative to follow the correct sequence in order to be able to modify the fixation should the need arise. We suggest the following: preliminary volar locking plate application, reversible fixation (K-wires though the plate), arthroscopic (dry) tuning, and then stable (locking pegs) fixation under arthroscopic guidance.

The Dry Technique In the author’s opinion, a key factor in making this operation friendlier is to carry out the arthroscopic part of the procedure without infusing water inside the joint, the so-called dry arthroscopy [7]. Not only will one avoid the risk of compartment syndrome [1], but much more importantly, the soft tissue extravasation is eliminated, facilitating any combined open surgery as the tissues maintain their original properties. Additionally, portals can be made much larger, and the constant loss of vision due to leakage and bubbles is avoided. The main shortcoming comes from the fact that if one is not able to get rid of the blood and splashes that obscure vision in an expeditious manner, the surgery will be a nightmare and one will give up the dry technique. Intuitively, one would think that removing the scope and wiping off the lens with a wet sponge is a good way of having a clear vision. Although effective, this maneuver is time consuming and, in a fracture,

F. del Piñal

there may be so much blood that the maneuver may need to be repeated an exasperating number of times. Based on our experience with more than 500 dry wrist arthroscopies, but more important seeing how others in the laboratory struggle with the same difficulties over and over, I can recommend the following tips that are critical for a smooth procedure: • Keep the valve of the sheath of the scope open at all times as to allow the air to circulate freely inside the joint. Otherwise, either the suction of the shaver will not function properly or the capsule will collapse in by the power of the suction, blocking vision. Hence, in classic wet arthroscopy, a common source of obscure vision is leaving the water closed; here it is the opposite. The valve should be left open at all times (Fig. 4.2). • After a fracture, there is a fair amount of blood and clots that need to be removed before the articular fragments are identified. Although one can patiently aspirate all the debris with the synoviotome, it is both slow and cumbersome to do it dry. A much quicker method of doing so is to connect a syringe with 5–10 mL of saline into the side valve of the scope and then aspirate it with the synoviotome. Pressure on the plunger of the syringe is unnecessary, as the negative pressure exerted by the shaver will suck the saline into the joint. Once all the water has been aspirated, the syringe is removed, and again the suction power of the shaver is enough to dry out the joint sufficiently to allow the surgeon to work on the reduction. This maneuver should be repeated as necessary

Fig. 4.2  The importance of keeping the valve of the sheath of the arthroscope open at all times to allow free circulation of air cannot be overemphasized

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•

•

•

Fig. 4.3  Method used to wash out the joint and clear it of blood. Notice that the negative pressure exerted by the shaver is sufficient to aspirate the saline without extravasation of water

throughout the procedure, as it is much quicker than struggling with blood in the joint (Fig. 4.3). • If an absolute dry field is needed, as to see a gap or a step, we then recommend to dry out the joint. For this we use small (13 × 13  mm) or medium (25 × 25 mm) surgical patties (Ref: 800–04000. size: ½″ × ½″, Ref: 800–04003. size: 1¢ × 1¢ (25 × 25 mm) Neuray™, Xomed, Jacksonville, FL). The small patty can be directly rolled and introduced into the joint by a grasper. The large patties have to be slightly modified by cutting them into the shape of a triangle, which facilitates removal from the joint. If the patties become entangled, they can be removed by pulling on the tail or by retrieval with a grasper (Fig.  4.4). I must underscore that we now rarely resort to this technique. In order to reduce operative time, we trust more the irrigation–suction just explained above, and accepting a poorer vision. • Avoid getting too close with the tip of the scope when working with burrs or osteotomes in order to avert splashes that might block your vision. It is preferable to first inspect the area of interest and

•

then slightly pull the scope back prior to inserting your working instrument. For the same reason, avoid touching the tip of the scope with your instruments (probe, synoviotomes). In case a minor splash at the tip of your scope blocks the vision, it can be removed by gently rubbing the tip of scope on the local soft tissue (capsule, fat…). This maneuver will clear the view sufficiently. If the arthroscopy is carried out immediately after elevating the tourniquet, vision can be poor, as condensation appears at the tip of the scope. This is due to the difference of temperature between the room temperature (usually 21–23°C) and the still warm wrist. Although this improves as times goes by, as the exsanguinated limb cools down, a quick way of avoiding it is by immersing the tip of the scope in warm saline for few minutes before beginning the surgery. Alternatively, fogged vision can be accepted for a moment as the problem disappears once the joint is irrigated with room temperature saline. An important waste of time occurs when the synoviotome, burr, or any other instrument connected to a suction machine clogs because the aspirated debris dries out. When this happens, the operation has to be stopped in order to dismount and irrigate the synoviotome for dislodging the debris. This is to be avoided at all costs by clearing the tubing with periodic saline aspiration from an external basin, or irrigating the joint as explained above. Finally, one must understand that at most times the vision will never be completely clear but still sufficient to safely accomplish the goals of the procedure. Having a completely clear field except for specific times during the procedure is unnecessary and wastes valuable time. Actually, most of the times, particularly in fractures, we do irrigate with 3–5 mL, aspirate, and then work for sometime without any difficulty, and once the blood level rises in the joint, the irrigation–suction cycle is repeated. So, in truth, we have moved from wet arthroscopy to the dry, and now somewhat “moist arthroscopy” (so named after Tommy Lindau’s suggestion).

Management of the Fracture I have found delaying the operation neither necessary nor beneficial. Fractures with a delay in treatment longer than 3 weeks are considered healed [6, 18] and are managed

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Fig. 4.4  “Arthrosponge” and the effect in an operating arthroscopic field. (a) The neurosurgical patty is modified into an inverted arrow so as to allow easy removal from the joint. (b) For easy introduction into the joint it is rolled with the grasper. (c–f) Arthrosponge being introduced through the 6R portal and corresponding arthroscopic views

by arthroscopic-assisted osteotomy (see Chap. 14). As a matter of fact, we proceed as soon as the CT scan is available (immediately or some days after the accident). The CT is indispensable to assess the three-dimensional picture of the displacement (frontal, sagittal, and axial planes). The axial view is paramount to understand the position of each articular fragment (see Chap. 1). The operation is performed under axillary block on an outpatient basis, and preferably with the assistance of another surgeon. Admittedly, most hand surgery is carried out as a solo practice, and one may feel “crowded out” with another surgeon nearby. However, the help of

an experienced surgeon is invaluable for a smooth operation, until one is skilled in the procedure. Logistics are fundamental in this complex operation, and with minimal modifications the following steps should be followed at all times: (a) Volar locking plate application and manual reduction of the articular fragments (b) Preliminary fixation of the articular fracture with K-wires to the plate under fluoroscopic control (c) Arthroscopic fine-tuning of the reduction (d) Rigid articular fragment fixation under arthro­ scopic guidance

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(e) Final fixation with the hand lying on the operating table (f) Arthroscopic DRUJ and midcarpal exploration In essence, the operation can be divided into a “classic” and an “arthroscopic” part. It should be understood that the arthroscope is just a tool to improve the reduction, and expertise in the management of DRF treatment in a standard way is probably more important than the arthroscopic part itself.

a

Classic Part

b

The arm is exsanguinated and a tourniquet applied. For the most common explosion fracture, access to the radius is carried out through a 6–8 cm incision radial to the flexor carpi radialis sheath (FCR) with a 1  cm radial-directed back cut in the proximal wrist crease. By dissecting with a knife on the radial aspect of the FCR sheath, the sheath can usually be preserved intact, but more importantly, the radial artery will stay safely radial (Fig.  4.5a). The space between the FCR and radial vessels is developed. A large direct constant branch from the radial vessels to the radial aspect of the pronator quadratus should be identified and coagulated. In the distal aspect of the incision, a constant transverse carpal artery [19] similarly needs to be isolated and coagulated. The radial artery and its palmar branch can, and should, both be preserved. Dissection should expose distally the most distal aspect of the radius past the watershed area (a soft tissue interface distal to the pronator quadratus insertion) but obviously not violating the volar ligaments. The muscle is then sharply elevated subperiosteally and reflected ulnarly. Proximally, some fibers of the flexor pollicis longus are reflected ulnarly. A wide exposure of the fracture site, distally nearly up to the articular line, including the most ulnar volar corner of the radius, is required in order to accurately place the volar plate. A volar locking plate is provisionally applied and stabilized by inserting only the screw into the elliptical hole on the stem of the plate, as this will allow some adjustment at the time of final plate setting. The reduction of the volar metaphyseal fragments is done by standard maneuvers: traction and volar flexion. The dorsal fragments are manually compressed to the plate that acts as a mold. Customarily, several attempts and maneuvers are needed before the “best” reduction is

Fig. 4.5  (a) Close dissection with a knife will keep the sheath of the FCR intact (asterisks), and sufficient fat will be provided for protection of the radial artery (arrow). (b) Reduction of the metaphyseal component has to be assured prior to insertion of the Kirschner wire (K-wire) to the plate. The fracture with the screws inserted in the stem and the K-wires (two or more) maintaining the articular reduction are now ready for arthroscopic fine-tuning

obtained, as judged by fluoroscopic views, and by direct observation of the metaphyseal component of the fracture. The articular fragments are then secured to the transverse component of the plate by inserting K-wires through the auxiliary holes (Fig. 4.5b). Once the reduction is considered ideal and/or that no improvement is attainable without carrying out an arthrotomy, the surgeon should proceed to assess the joint under arthroscopy (Fig. 4.6). Prior to suspending the hand, however, and in order to avoid secondary displacement by traction of the plate, at least another screw should be inserted in the stem of the plate to lock it in position. Although it may be considered a waste of space to expend a paragraph on plate placement in an arthroscopy book, I should underscore that there is not much room for error in the placement of a volar locking plate in an explosion-type DRF. If the plate is not in the right spot, there are likely to be problems in fixation and

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Fig. 4.6  Two K-wires maintain the fragments temporarily reduced in this explosion-type DRF. From a fluoroscopy standpoint, the reduction can be considered anatomically reduced. See also Fig. 4.9 (DVR® plate. Hand Innovations) (Copyright by Dr. Piñal, 2009)

in the end result. One should pay particular attention to the position of the distal edge of the plate in relation to the rim of the radius. If the plate is too distal, the screws may be lodged inside the joint and/or the flexor tendons irritated by the edge of the plate. On the other hand, if placed too proximally, the locking screws/pegs will sit too far from the subchondral bone, providing minimal support to the articular fragments. Subsidence of the fragments will be more likely if more comminution exists, as is the case in this type of fracture. Similarly, the plate position should also be checked in relation to the lateral and medial aspect of the epiphysis. It should not surpass the radius ulnarly, as the pegs will penetrate into the distal radio-ulnar joint. Nor should it surpass the radius radially, as it will be palpable and painful, requiring a further operation for plate removal.

Arthroscopic Part The hand is suspended from a bow, the fingers pointing to the ceiling, with a custom-made system that allows easy connection and disconnection from the bow without losing sterility (Fig.  4.7) [6]. Counter traction is usually 7–10 kg, but can be more in tight wrists. No adverse effects have been noticed perhaps because the traction is evenly distributed to all fingers. This system

has the advantage of its availability and price (8€ for each karabiner). Furthermore, it is very easy to fasten and unfasten for fluoroscopy checking. However, it requires, at times, a hand to stabilize the wrist. I personally prefer the 2.7  mm/30° angle scope for most of my cases. Seldom, in tight wrists, do I use a 1.9 mm/30° angle, as the field of vision is reduced. I start the procedure through a 3–4 portal. Portals after fractures are slightly more difficult to create than in a standard arthroscopy case. Deep palpation and bony landmarks recommended by Slutsky in Chap. 2 are used. To create my portals, I prefer small transverse incisions as they heal with a minimal scar and do not require suturing at the end of the operation. After enlarging the entrance with a mosquito forceps, the scope is introduced and directed ulnarly to establish the 6R portal. This portal is best made by inserting a needle percutaneously in the expected 6R position under arthroscopic control from the 3–4 portal. This trick is important, as sometimes detachment of the TFC directs the surgeon to the DRUJ instead of the radiocarpal joint. Although vision at this stage may also be obscured by blood, in general it is possible to see the needle introduced in 6R, assuring that one stays distal to the TFC. A straight hemostat is used to dilate the portal. Alternatively, if this proves unsuccessful, the surgeon might go blindly making the portal radial to the ECU, just proximal to the triquetrum, and directing the hemostat radially inside the joint.

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Fig. 4.7  The sequence of suspending the hand from the pole is shown from left to right. The pink ring (circled) is unsterile and will be stabilized by the OR personnel for the surgeon (hidden behind the operating field, arrow). The upper karabiner is considered unsterile from the moment of hooking to the ring. The upper ring of the figure-of-eight, although probably sterile at all times, is considered contaminated too. However, the lower ring of the figure-of-eight and the karabiner closer to the hand are

sterile throughout the procedure. At this lower position, the hand may be released from and hooked to traction as many times as required during the operation. In the far right picture, the radiocarpal portals have been established and the joint has been cleared of blood as can be seen on the monitor screen. Notice that the whole process, including pictures, has taken less than 5  min on the OR clock! (Karabiners and figure-of-eight are available in any climbing shop, for around 8€ each)

A 2.9 mm shaver is inserted in 6R to aspirate blood and debris. As stated before, the valve on the arthroscope sheath should be left open at all times to allow the air to circulate freely in the joint and avoid capsular collapse while suctioning. The joint can be washed of blood as required during the procedure by connecting a 10 mL syringe to the valve of the scope. The negative pressure exerted by the shaver will suck the saline from the syringe without extravasation of fluid outside the joint. Once the elements that need to be mobilized are identified from the 3–4 view, the scope is swapped to 6R,

where it will stay until the entire fixation is done. In this position, on top of the ulnar head, the scope will have a steady point to rest upon, and will not impede reduction or displace reduced fragments (Fig. 4.8 left). If the scope is left in the 3–4 (or 4–5) portal, it will rest upon an unstable point, will create space conflict during the reduction, and will tend to displace the reduced fragments (Fig. 4.8 right). Although useful for assessing the dorsal rim fractures, the volar-radial portal can be supplanted by the 6R portal. The scope simply needs to be put volarly, and from there, pointed dorsally. Doing so avoids changing

Fig. 4.8  If the scope is placed in 6R, it will rest on top of the ulnar head providing a stable platform from which to work, thus avoiding conflict with the reduction (left). Instability of the scope and conflict of space during the reduction (yellow and red arrows) are inevitable when the scope is placed in any other portal (right) (Copyright by Dr. Piñal, 2009)

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of portals, and the risk of redisplacement of reduced (but not yet rigidly fixed) volar fragments. With the scope inside and with a clear view of the joint, the surgeons can face three situations.

pler fracture cases, but has never been found in our controlled series of explosion fractures [8] (Fig. 4.9).

2.  One or Two Fragments Displaced 1.  Joint Acceptably Reduced In this most ideal scenario, there would be no fragment to be reduced. The fracture has to be stabilized by introducing the pegs in the plate under arthroscopic control. The operation follows by assessing now the ulnar part of the joint, by swapping the scope to the 3–4 portal, and resting on the unyielding reduced and fixed radius. Finally, the midcarpal joint is explored, and the whole joint is irrigated abundantly and the water suctioned with the shaver. I must warn that this ‘idyllic’ scenario can be seen in sima

Most frequently, one or two fragments need to be specifically addressed. Depressed, elevated, or free osteochondral fragments (FOFs) may need attention. (a) Depressed fragments represent most of the displaced cases and can be relatively easy to manage. Most respond to hooking them with the tip of a shoulder or knee arthroscopy probe introduced from the 3–4 portal and pulling distally (Fig. 4.10). The mechanics of the reduction is always the same no matter whether the misplaced fragment is located b

Fig. 4.9  Corresponding arthroscopic view of the case shown in Fig.  4.6. Notice there that the joint appeared to be correctly reduced under fluoroscopy. (a) The antero-ulnar fragment is depressed in relation to the dorsal fragment and elevated in relation to the central lunate fragment in the background on the right

(the scope is in 6R looking dorsally in this left wrist). (b) Looking volarly now: the probe is now passing underneath the anterior fragment to highlight the deformity (FOF free osteochondral fragment) (Copyright by Dr. Piñal, 2009)

Fig. 4.10  Reduction of a depressed fragment in the scaphoid fossa (same patient as in Fig. 4.1). From left to right: The shoulder probe is gauging the step-off (3 mm), hooking the depressed fragment, elevating it, and leveling it to the rest of the joint

(scope in 6R, viewing radially in a right wrist. 1: volar rim of the scaphoid fossa; 2: dorsal rim; 5: scaphoid fossa) (Copyright by Dr. Piñal, 2009)

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Fig. 4.11  Author’s technique to reduce depressed fragments (see text for details) (Copyright by Dr. Piñal, 2009)

radially or ulnarly (Fig. 4.11). The fragment is released from the plate by backing out the specific K-wire that kept it secured, and then hooked and lifted with the shoulder probe, slightly overreducing it. At this point, the surgeon maintains the reduction by compressing volarwards the reduced fragment with the thumb while the other surgeon pushes in the K-wire slowly to the dorsal cortex, taking care not to impale the extensor tendons (or the other surgeon’s thumb!) (Fig.  4.12). The remaining part of the procedure, common to all fracture types, consists of maintaining the reduction with a bone clamp while locking pegs/half screws are inserted under arthroscopic control. (b) Elevated fragments nearly always correspond to dorsal rim fragments that due to the effect of ­traction are overdistracted (Fig. 4.13). More rarely, the whole radial styloid may behave similarly as a consequence of the rich ligament insertions on it. Overdistracted fragments are easily repositioned by decreasing traction while the surgeon levels them with the probe or a Freer elevator. Once the fragment is reduced, it is held in position with a bone tenaculum or the surgeon’s thumb, and stabilized by pushing the corresponding K-wire in the plate again (Fig.  4.14). At times, when large enough, rim fragments can be stabilized by the locking pegs/screws of the plate itself, or by the pressure exerted by the extensor tendons, when very small. If they still remain unstable, one should avoid using the pegs or screws to engage them as even minimally proud screws or pegs may create

Fig.  4.12  The critical moment of stabilizing a reduced ­fragment is shown in this figure. Surgeon #1 is maintaining a fragment reduced that has been elevated with the shoulder probe, right hand, while with his left thumb is pushing it against the volar fragment (arrow). At the same time, Surgeon #2 is holding the scope introduced in 6R with his right hand, while pushing in the K-wire to fix the reduced fragment with his left hand

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Fig. 4.13  Technique of arthroscopic reduction of elevated dorsal rim fragments. Notice that a Freer elevator is used to level the fragment, while with the thumb the surgeon closes the gap

to avoid skin irritation (Fig. 4.15). The addition of extra fixation can be considered a less elegant procedure than direct fixation by the locking pegs, but one should be very cautious as fluoroscopy has been found ­inaccurate to assess peg length in relation to the dorsal rim of the radius. In fact the pegs should always be about 2  mm shorter than measured to avoid dorsal cortex penetration [27]. It is very important to stress that large dorsal fragments that look distracted on fluoroscopy are rarely so. What in fact happens is that the anterior fragment (generally the volar-ulnar fragment) remains dorsally rotated. Clues to recognize this deformity are the absence of collapse in the dorsal cortex, and the loss of angulation of the so-called Medoff’s teardrop angle [20] (Fig. 4.16). It is imperative that in those cases the anterior fragment is derotated and elevated to the dorsal fragment rather than depressing the dorsal one in an attempt to level the joint. This is done in a similar way as to that used for dorsal depressed fragments (see Fig.  4.11), but obviously the K-wire should be removed completely from the plate before this anterior fragment can be mobilized (Figs. 4.17 and 4.18). Fig. 4.14  Fixation of a rim fragment. The bone is held by a bone clamp and the probe while a K-wire is being introduced (in this case all instruments were introduced through the 3–4 portal)

extensor tendon irritation and rupture. We prefer hence specific fragment fixation with K-wires introduced dorsal to the palmar. These K-wires are left percutaneously and are removed in the office at 3 weeks. In aftercare, wrist flexion is encouraged, but extension is avoided until the K-wire is removed

(c) FOF (Free ostechondral fragments) are extremely unstable and when repositioned, sink into the metaphyseal void. To prevent this from occurring, we create a supporting hammock by inserting the distal layer of locking pegs in the plate. The fragments are kept slightly overreduced, and then impacted by using a Freer elevator, or by releasing the traction and using the corresponding carpal bone as a mold. A grasper can be useful to grab and twist a severely displaced fragment (Figs. 4.19 and 4.20).

4  Treatment of Explosion-Type Distal Radius Fractures

a

b

51

c

d

Fig. 4.15  (a) The posterior ulnar (PU) fragment could be easily stabilized by the plate pegs. However, the dorsal central rim fragment (corresponding approximately to Lister’s tubercle (L)) and the small rim fragments (r) are too small to be fixed by the pegs without incurring risky dorsal penetration. (b) The frag-

ment “L” was fixed with a K-wire, while “r” was stable at the end of the fixation. (c, d) Flexion of the wrist and extension to neutral are encouraged despite the K-wire being percutaneously located (arrow) (2 weeks postoperative)

Fig. 4.16  (a) Fluoroscopic view of a pseudoelevated dorsal fragment creating a step-off at the lunate facet (arrows). Notice, however, that the dorsal cortex is restored without gaps and that the “teardrop angle” is slightly increased, both of these pointing to a malrotated volar fragment. (b) After the anterior ulnar fragment was derotated, anatomic restoration of the lunate fossa was achieved (normal “teardrop angle”) (Copyright by Dr. Piñal, 2009)

3.  Many Fragments Remain Unreduced This fortunately occurs rarely even in the most comminuted cases. Backing out all the K-wires and attempting to reduce and fix all fragments at the same time is an impossible endeavor in our hands. We recommend a step-by-step procedure beginning from ulnar to radial

(Fig.  4.21). With the scope sitting on top of the ulnar head, the keystone lunate fossa is first re-reduced. At this stage only the K-wires of the lunate fossa are backed out, the radial ones are left in place, because although imperfect they serve as a much better reference than if all the fragments are free. The technique for reducing the lunate fossa is similar to that for a single fragment reposition:

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Fig. 4.17  Author’s technique for reduction of an anterior malrotated fragment. Notice that reduction of this fragment requires complete removal (not just partial backing out) of the corres ponding K-wire (see text for details) (Copyright by Dr. Piñal, 2009)

Fig. 4.18  Correction of a pseudoelevated dorsal fragment. (a) Despite the fact that the dorsal lunate fossa fragment is apparently elevated and responsible for a step-off of about 3 mm, the displacement is actually due to malrotation of the anterior ulnar fragment of the lunate fossa (AU) and less so of the anterior

central lunate fossa (AC). (b) With a shoulder probe inserted through the 3–4 portal, the anterior fragment is being derotated. (c) The two volar components of the lunate fossa (AU, AC) are now leveled to the dorsal fragment (see Fig. 4.17 and text for technical details) (Copyright by Dr. Piñal, 2009)

backing out the corresponding K-wire, arthroscopic reduction, and pushing in the K-wire (Fig. 4.21a). Before the scope is advanced radially, the lunate fossa is made stable by inserting one or two locking pegs in the ulnar part of the plate (Fig.  4.21b). The radial part of the joint is now fine-tuned under arthroscopic guidance (Fig.  4.21c). Once reduced, locking screws are inserted to stabilize the scaphoid fossa, providing a stable articular surface (Fig. 4.21d). Inserting locking pegs/screws into critical spots under arthroscopic guidance is paramount in order to achieve a stable joint, and this has to be done before the ulnar joint is explored. This part of the operation is quite awkward as the flexor tendons are in tension blocking the vision of the plate. The task may be somewhat eased by an assistant retracting the tendons

ulnarly, while reducing the traction to release tension in the flexor tendons (Fig. 4.22). As soon as the major articular fragments are stable to probe palpation, the hand is released from the traction, and laid flat on the operating table, as in this position the rest of the pegs and screws can be inserted expeditiously. In my experience, I rarely start the reduction from radial to ulnar, unless the degree of comminution is minor radially and a stable foundation can be created there. In those cases, the scope is inserted in the 3–4 portal, directing the reduction from radial to ulnar. As explained before I also rarely use a volar portal [9, 26]. Bone graft was not used in any of these patients, as it is our belief that a locking plate provides sufficient support. Once the radius fixation is finished, the hand is again put in traction to explore the ulnar part of the

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Fig. 4.19  Management of FOFs according to the author’s technique (see text for details) (Copyright by Dr. Piñal, 2009)

a

b

c

Fig. 4.20  (a) A FOF has sunk into a metaphyseal void in the scaphoid fossa. After several attempts of reduction, without support, the fragment did not resist the stress of the probe, and sank

again every time. (b) After a supporting hammock of locking pegs had been created, the FOF is now shown overreduced prior to being leveled by the probe (c)

joint, by inserting the arthroscope in the 3–4 portal and the working instruments in 6R. Whatever work that needs to be done there can now be safely carried out as the radius is firmly fixed (Fig. 4.23). Similarly, midcarpal portals are established to rule out interosseous ligament injuries. Throughout the procedure the hand is released from traction, and fluoroscopy is used as necessary before definitive fixation is carried out. Similarly, the joint is flushed as required with the method presented (Fig.  4.3) as minimal extravasation is expected with the dry arthroscopy technique (Fig. 4.24). The pronator quadratus is sutured radially to its remnants or to the brachioradialis tendon with two or three resorbable stitches. The volar skin is closed in a single layer with a subcuticular 3/0 nylon.

Aftercare The operations are carried out as an outpatient procedure. Twenty-four to forty-eight hours later the splint is removed, and self-directed active and assisted exercises are encouraged. A removable plastic splint is fabricated, to be worn only when at risk of further trauma. After 4 or 5 weeks any limitation of arc of motion is addressed by assisted exercises under the supervision of a physiotherapist. Exceptions are made in the cases of additional fixation required for dorsal rim fixation where 3 weeks of extension blocking is required. Other exceptions are the associated distal radio-ulnar derangement where my preference is a sugar-tong splint, blocking prono-supination but leaving the radiocarpal joint free (Fig. 4.25).

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Fig. 4.21  (a–d) Technique for reduction when many fragments remain unreduced (see text)

Special Situations So far the standard management of an explosiontype DRF has been presented. Quite frequently, however, special situations challenge the most experienced surgeons. Associated metaphyseal comminution, localized comminution at the scaphoid fossa, the control of small volar-ulnar fragments, and management of loose osteoligamentous fragments are among some of them. Other considerations such as management of the carpal tunnel are also discussed in this section.

Severe Metaphyseal Comminution Volar locking plates act as internal fixator devices, making the use of an external fixator unnecessary in the aftercare of a DRF. Nevertheless, the use of a

temporary external fixator (intraoperatively) may prove extremely valuable in severely comminuted metaphyseal fractures (C32 of the AO classification) to avoid loss of the extra-articular reduction during the operation. Under those circumstances, the metaphyseal support may be so feeble that the K-wires may pull through the comminuted metaphyseal fragments and/ or the whole epiphysis–K-wire complex may toggle on the plate, during the arthroscopy. The stage is set for disaster when the surgeon only pays attention to the articular component, and inserts the locking pegs and screws distally on the plate without fluoroscopic control (Fig. 4.26). The end result will be a reasonable articular reduction but a poor metaphyseal reduction, and a too prominent distal edge of the plate (quite a worrying scenario for the flexor tendons) (Fig. 4.27). To avoid this complication, a simple frame external fixator is installed temporarily as recommended by Fernandez and Jupiter [12]. Alternatively, a locking

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The Small Volar-Ulnar Fragment

Fig.  4.22  While the surgeon (red gloves) is maintaining the reduction with the help of a bone clamp and the shoulder probe, the other surgeon (green gloves) is inserting “critical” locking pegs into the plate

peg (rather than a K-wire) can be inserted in the less comminuted part of the metaphysis under fluoroscopy. This peg will support all the reconstruction, and during the arthroscopy, the surgeon will build up the joint to this fixed portion.

Fig. 4.23  Ulnar exploration is carried out with the scope in 3–4 and the instruments in 6R once the radius is firmly fixed. Right: corresponding ulnar view of the patient shown in Figs. 4.6 and 4.9, where an I-A tear is evident (left wrist)

The volar-ulnar fragment was a source of major problems and sequelae in DRFs. Melone drew attention to the importance of detecting malrotation of this fragment [22]. Apergis et al. [3], on the other hand, showed that even deceptively small fragments can cause late volar radiocarpal dislocation if not appropriately addressed. The typical volar-ulnar fragment of the four-parttype articular fracture responds well to the protocol reported previously. It can be easily reduced from the incision used to place the plate and, after arthroscopic fine-tuning, can be rigidly fixed with the pegs of the plate. The difficulty comes when the fragment has a small metaphyseal component. In those instances, the plate offers little support, risking surpassing the distal edge of the plate (Fig. 4.28). Although the loss of reduction can occur with any small metaphyseal fragment all along the volar rim of the radius, the consequences are particularly grave when this takes place in the volar-ulnar corner of the radius: volar dislocation of the carpus and incongruence at the lunate fossa [15]. In order to fix these small fragments with the available locking plates, one would need to place the plate too distally and ulnarly, risking both tendon irritation and DRUJ penetration by the pegs [2]. Orbay modified his original plate by creating a small tongue that extends distally and ulnarly. However, in my experience this improvement is still insufficient for fragments with a small metaphyseal component. My preference is to fix these small volarulnar fragments with an independent K-wire, with a procedure derived from Fernandez and Geissler’s

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Fig. 4.24  Notice that minimal swelling is evident at the end of the operation. The transverse portals do not require suturing (same patient as in Figs. 4.1 and 4.10)

Fig. 4.25  Author’s preferred splint after a DRF associated to a DRUJ derangement. Flexion and extension of the wrist is encouraged from the first day. A compressive dressing is needed distal to the wrist in order to avoid distal swelling (range of motion at 4 weeks)

original technique [11, 12]. They use a formal volarulnar approach to apply a plate or at times a K-wire, but such a large incision is not required when a volar locking plate is inserted radially. A 1.5 cm incision is made radially to the ulnar neurovascular bundle at the distal wrist crease level (Fig.  4.29). With a Stevens tenotomy scissors, the space between the flexor tendons and the ulnar pedicle is developed. Gentle retraction will permit us to reach the ulnar corner of the radius and to place there a protective soft-tissue guide.

The volar-ulnar fragment is now reduced from the radial approach and stabilized with a bone hook, and at the same time the surgeon exerts pressure on the drill guide to keep it stably reduced. Flexion of the wrist at this stage is recommended in order to relax the short radiolunate ligament. The K-wire is introduced and left percutaneously. The operation continues as usual, i.e., volar plate application, arthroscopy etc. At 4 weeks the Kirschner is removed in the office, and a range of motion started (Fig. 4.30).

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Fig. 4.26  The possibility of intraoperative collapse during arthroscopic reduction is particularly feasible when metaphyseal comminution exists and frequent fluoroscopic controls are not made (see text for details)

Fig. 4.27  (a–c) The extra-articular reduction was lost during the arthroscopic part of the operation in this patient who had a severe C32 fracture. Despite the correct articular reduction,

both shortening (arrow) and dorsal tilting negatively influenced the clinical outcome

Scaphoid Fossa Comminution

the other subtypes are challenging for the experienced arthroscopist. An exact assessment of the areas involved is paramount for the appropriate treatment of these fractures. However simple or uncomplicated fractures may appear to be at first sight, in my experience, both preoperative CT scan and intraoperative arthroscopy are fundamental in the decision making process. For the single fragment situation I prefer cannulated screws inserted under arthroscopic guidance (Fig. 4.31a). A 2  cm transverse incision slightly distal to the radial styloid is made. Two K-wires are preplaced under fluoroscopic control, with the hand lying flat on the operating table, on each side of the first extensor compartment.

Styloid fractures represent an extremely wide group ranging from truly simple fractures (B11of the AO classification) [23] to more complex fractures that involve the scaphoid fossa only (B12), or the volar or dorsal rim of the radius in combination with the styloid itself (variations of types B31 and B33, and B22, respectively). Recognition of the subtypes bears a critical importance for the treatment as it is, in my view, responsible for some of the bad results of the styloid fracture (Fig. 4.31). In fact, while simple styloid fractures are readily accessible to arthroscopic treatment and ideal for beginners,

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Fig. 4.28  Volar-ulnar fragments with a small metaphyseal component (m) bear a high risk of volar radiocarpal dislocation

The hand is now suspended and under arthroscopic guidance (scope in 6R working instruments in 3–4), reduction of the fragment is carried out with a shoulder probe and manual external pressure. A bone clamp maintains the reduction while the K-wires are pushed in. The hand is taken out from traction and cannulated screws are inserted with the hand flat on the table (Fig. 4.32). As the comminution increases, and the fracture pattern gets more intricate towards a mixture of styloidvolar or dorsal Barton’s fracture, the approach presented before will bring about untoward deformity: compression directed ulnarly by the screws will cause “crumbling” of the central fragments (Fig. 4.31b). This can be managed arthroscopically by a combination of K-wires, bone graft supporting the reduction, and an external fixator to avoid early collapse. My preferred fixation method, however, is buttressing plates that allow a fixation rigid enough to start early range of motion without the need of bone graft support. Unfortunately, available radial volar-locking plates at best send two pegs to the styloid providing a poor fixation when there is severe comminution of the scaphoid

fossa. My first choice is a classic 2.7  mm AO steel plate (which has a very low profile) applied with the buttressing principle, much the same as that recommended by Jupiter et al. for volar Barton fractures [16]. I use an L- or a T-shaped plate depending on the configuration of the fracture. The idea is that the volar fragments are supported by the distal component of the plate, the latter being placed as proximal as possible as to avoid flexor tendon irritation (Fig. 4.31c). Through a limited radial approach, the most distal portion of the pronator quadratus is reflected ulnarly. Manual reduction of the fragments is carried out, and the plate is applied over the area of comminution, trying to encompass all the metaphyseal fragments with its distal limb (Fig. 4.33). Minimal shaping is required, except molding of the distal edge to avoid flexor tendon irritation, as the more separated the plate is at its center the more pressure it will exert as the central screws are tightened. It is important to take into account that the distal edge of the plate will recede several millimeters when the central screw is tightened as the plate has to adapt to the

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Fig. 4.29  Intraoperative picture and artistic redemption of the technique proposed in the text for fixation of a small volar-ulnar fragment. The fragment is reduced under visual control from the radial incision and stabilized with a bone hook. A small ulnar incision, radial to the ulnar neurovascular bundle, allows the introduction of a drill guide to insert a K-wire

a

c

d

b

Fig. 4.30  (a, b) Explosion-type DRF. The volar-ulnar fragment is displaced into the middle of the lunate fossa (arrow). On the sagittal section, it is clearly seen that it has a 90° rotation. Reduction will not be a problem from the radial incision but

fragments with such a little metaphyseal component (m) cannot be appropriately addressed with the available locking plates. (c, d) Radiological result. Notice that the proximal rim of the fragment is actually distal to the plate

concavity of the radius. To compensate for this proximal migration, the plate should be placed slightly distal to the intended area of fixation. Once the plate is applied and the middle screw starts to get hold of the fragments, the hand is then placed in traction, and the joint explored with the arthroscope inserted in a portal away from the area affected, so as not to disturb the reduction (Scope in 6R or 4–5 portals;

instruments in 3–4 portal). The screw is loosened just enough to enable manipulation of any misplaced fragments. Usually, there may be a combination of depressed and elevated fragments. For the former, we use a shoulder probe, and for the latter, a Freer elevator that keeps the fragments reduced while the central screw is tightened. Once the articular surface is reduced and supported by this screw, the surgeon tests the

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Fig. 4.31  The treatment of a “styloid fracture” varies according to the degree of comminution and the presence of an intact dorsal radial rim. While single fragments respond well to cannulated screws (a), a stable surface is required for this fixation method as otherwise compression will increase the articular deformity (b). A buttress plate is an ideal option when comminution exists, provided the dorsal radius is intact (c). Notice that the lack of a sturdy dorsal cortex contraindicates the use of a buttress plate, as it will cause dorsal collapse of the scaphoid fossa (d) (see text for details)

rigidity of the fixation. If satisfactory, the rest of screws are introduced with the hand on the operating table (Fig.  4.33). Despite the apparent fragility of these plates, they provide sufficiently rigid fixation to allow

early range of motion, in a much less invasive manner than a standard volar-locking plate (Fig. 4.34). A supporting bony structure is needed opposite the plate for the buttress principle to take effect. When

4  Treatment of Explosion-Type Distal Radius Fractures

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Fig. 4.32  Author’s preferred approach for a simple styloid fracture. (a) The cannulated screw is being inserted volar to the abductor pollicis longus, and the other guide wire is dorsal to the extensor pollicis brevis. (b) Fluoroscopic view prior to insertion of the second cannulated screw

comminution also affects the dorsal rim of the scaphoid fossa, use of an under-contoured volar buttress plate will lead to dorsal displacement of the whole scaphoid fossa complex (Fig.  4.31d). For this scenario, our preference is a standard volar-locking plate. The latter is not ideal, as it requires a larger approach, is more expensive, and provides a more tenuous fixation as referred to above. Nevertheless, this option is, in our opinion, better than the external fixator and K-wires alternative. Some subsidence of the smaller styloid fragments is sometimes unavoidable, but probably is inconsequential (a similar effect to a stylodectomy) provided the main fragments of the scaphoid fossa remain reduced (Fig. 4.35).

Osteochondral Fragments with Attached Ligaments Severely displaced “osteochondral fragments with attached ligaments” are commonly seen after radiocarpal dislocations; they are responsible for persistent dislocations if not specifically addressed (see Chap. 11). [10, 17]. When the bone portion is sizable, a screw or a K-wire would be appropriate as mentioned previously

for the dorsal rim fractures. When the fragment is small and contains a major articular fragment or a major ligament portion, however, all efforts have to be made to achieve fixation and avoid the risk of redislocation. Chin and Jupiter recommended reattaching such rim fragments by means of a figure-of-eight wire suture in order to minimize manipulation and osteonecrosis [4]. The technique we have used is to spear the fragment by means of an epidural-type needle (Touhy or Rodiera’s needle) inserted from the 3–4 portal (Figs.  4.36 and 4.37). The needle is loaded with the thread from the volar-radial incision (needed for the plate). Now the needle is slowly withdrawn and, once in the joint, the fragment is speared again and the needle pushed volarly. In this way, a mattress stitch will be located intraarticularly, while both suture ends will be located palmarly, ready to be tied.

Preventive Opening of the Carpal Tunnel Minimal swelling is seen after a dry arthroscopy (Fig. 4.24). Our policy is not to open the carpal tunnel unless preoperatively there were symptoms that pointed to an acute carpal tunnel syndrome. Additionally, all our

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Fig. 4.33  (a–c) Comminuted scaphoid fossa with a depressed free fragment (F) but an intact dorsal rim to apply counter pressure (arrows). (d) A 2.7 mm plate was applied with the principle

Fig. 4.34  The incision required to fix a styloid fracture with a volar buttress plate has been highlighted with dots. Notice that the transverse back-cut is slightly longer and the longitudinal part of the incision much shorter than in the standard radial approach. The fixation with a 2.7 mm buttress plate is stable enough to allow early range of motion (result at 8 weeks) (same patient as in Fig. 4.33)

F. del Piñal

of buttressing, and an additional screw was used for the larger styloid fragment

4  Treatment of Explosion-Type Distal Radius Fractures

Fig. 4.35  (a, b) Comminuted scaphoid fossa with involvement of the dorsal rim of the radius (arrowheads) that contraindicates the use of the buttressing principle (Fig.  4.31d). (c) A volar

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l­ocking plate supports a major portion of the scaphoid fossa, but some subsidence is at times unavoidable

Fig. 4.36  Artistic representation of the technique for osteochondral reattachment

patients are interrogated preoperatively for symptoms that could indicate a minimally symptomatic carpal tunnel syndrome history (awakening at night with tingling, or numbness in the median nerve distribution). Only those patients will have their carpal tunnels opened. Otherwise, these minimally symptomatic patients may undergo a painful postoperative period, with reflex sympathetic dystrophy symptoms that will not ease up until after the median nerve is decompressed. In all these cases, the volar retinacular ligament is opened through a minimal distal incision (Raimondi, Piero,MD. Milan (Italy). Personal communication; 2001). The latter is never connected to the

ulnar approach (when needed) in order to minimize linear scarring.

Clinical Experience We have operated more than 200 articular DRFs under arthroscopic control. None of our cases were considered a failure nor did the arthroscopy had to be abandoned. In order to test the feasibility and outcome of the above protocol, we extracted a subgroup of the 16 consecutive most comminuted fractures [5, 8]. They all had explosion

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Fig. 4.37  Fixation of a volar osteoligamentous fragment with the technique shown in Fig. 4.36 (left wrist, scope in 6R). (a) A fragment containing the short radio-lunate ligament (SRL) remains unstable at the end of the fixation with a volar locking plate. The unloaded Touhy needle is ready to penetrate the

f­ ragment. (b) The needle has been pulled back now loaded, and is ready to spear the fragment again. (c) The final reduction is shown after the suture has been tied volarly. The horizontal mattress stitch has been marked by an arrow

fractures: more than five articular fragments and/or a FOF. After a minimum interval of 2 years, they were called back for the purpose of this study. Except in one case where the extra-articular reduction was lost, in the rest, the radiographic parameters were satisfactorily maintained. Range of motion was 105° of flexion-extension, grip strength was 85% of the contralateral, and a DASH of 6. This study confirms that (dry) arthroscopy is feasible in the most severely articular comminuted C3 fractures, and our results compare favorably with other similar case series [24, 25]. In a more recent case, out of the study group, one patient suffered collapse of the lunate fossa and required radiolunate arthrodesis.

  5. del Piñal F. Dry arthroscopy of the wrist: Its role in the management of articular distal radius fractures. Scand J Surg. 2008;97:298–304   6. del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Regalado J, Cerezal L. Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique. J Hand Surg. 2006;31A:1029–234   7. del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg. 2007;32A:119–23   8. del Piñal F, Studer A, García Bernal FJ, Regalado J, Cagigal L, Thams C. Explosion type articular distal radius fractures: technique and results of volar locking plate under dry arthroscopic guidance. FESSH Congress. Poznan, Poland. 2009   9. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intraarticular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg. 1999;81A: 1093–110 10. Dumontier C, Meyer zu Reckendorf G, Sautet A, Lenoble E, Saffar P, Allieu Y. Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases. J Bone Joint Surg. 2001;83A:212–18 11. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg. 1991;16A:375–84 12. Fernandez DL, Jupiter JB. Surgical techniques. In: Fractures of the distal radius. A practical approach to management. 2nd ed. New York: Springer; 2002. p. 71–127 13. Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005;21:407–16 14. Guofen C, Doi K, Hattori Y, Kitajima I. Arthroscopically assisted reduction and immobilization of intraarticular fracture of the distal end of the radius: several options of reduction and immobilization. Tech Hand Up Extrem Surg. 2005;9:84–90

References   1. Adolfsson L, Jörgsholm P. Arthroscopically-assisted reduction of intra-articular fractures of the distal radius. J Hand Surg. 1998;23B:391–5   2. Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg. 2006;31A: 892–5   3. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the ulno-palmar distal radial fragment. J Hand Surg. 2002;27B:139–45   4. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg. 1999;24A:525–33

4  Treatment of Explosion-Type Distal Radius Fractures 15. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg. 2004;86A:1900–8 16. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg. 1996;78A: 1817–28 17. Lozano-Calderón SA, Doornberg J, Ring D. Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation. J Bone Joint Surg. 2006; 88A:1486–93 18. Marx RG, Axelrod TS. Intraarticular osteotomy of distal radius malunions. Clin Orthop. 1996;327:152–7 19. Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid nonunion. J Hand Surg. 1998;23B:318–23 20. Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin. 2005;21:279–88 21. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach. J Bone Joint Surg. 2000;82B: 79–86

65 22. Melone CP Jr. Distal radius fractures: patterns of articular fragmentation. Orthop Clin North Am. 1993;24:239–53 23. Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. New York: Springer; 1990 24. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg. 2004;86-A:1646–52 25. Rogachefsky RA, Lipson SR, Applegate B, Ouellette EA, Savenor AM, McAuliffe JA. Treatment of severely comminuted intra-articular fractures of the distal end of the radius by open reduction and combined internal and external fixation. J Bone Joint Surg. 2001;83A:509–19 26. Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy. Tech Hand Up Extrem Surg. 2004;8:229–38 27. Thomas AD, Greenberg JA. Use of fluoroscopy in determining screw overshoot in the dorsal distal radius: a cadaveric study. J Hand Surg. 2009;34A:258–61 28. Wiesler ER, Chloros GD, Mahirogullari M, Kuzma GR. Arthroscopic management of distal radius fractures. J Hand Surg. 2006;31A:1516–26

5

Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability Alejandro Badia

Introduction Fractures of the distal end of radius account for nearly 20% of all fractures seen in a routine emergency room and are commonly associated with intercarpal ligamentous injuries and other soft tissue disruptions [6]. The structure most frequently injured in distal radial fractures is the triangular fibrocartilage complex (TFCC) [15, 21, 24, 27]. In one cadaveric study where a hyperextension force was applied to cadaveric wrists until a distal radial fracture occurred, an injury to the TFCC occurred in 63% of the specimens followed by injuries to scapholunate ligament (32%) and to lunotriquetral ligament (17%) [20]. The TFCC consists of the central fibrocartilage, the dorsal and palmar distal radioulnar ligaments, the sheath of extensor carpi ulnaris tendon, the ulnar collateral ligaments, and the ulnocarpal ligaments. It works as a single unit that aids in movements, stability, and load sharing at the wrist. The central area of TFCC is avascular and called the debridement zone, whereas, the peripheral zone enjoys an extensive blood supply and is termed the repair zone [25] (Fig. 5.1). Anatomic reduction of the articular surface of the distal radius and treatment of the associated injuries are the primary goals when treating fractures of distal radius. Appropriate assessment of intraarticular reduction and of the associated injuries is difficult when performing open reduction and internal fixation without having to open the joint capsule. Arthroscopy provides excellent direct visualization of the entire joint, allows

A. Badia, MD, FACS Badia Hand to Shoulder Center, Baptist Hospital of Miami, 3650 NW 82nd Ave. Suite 103, Doral, Florida 33166, USA e-mail: [email protected]

thorough evaluation of the articular comminution, and facilitates correction of gaps and/or step-offs with minimal disruption of soft tissues [1, 2, 3, 10–12, 16, 23, 29]. Blood, debris, and small loose bodies can be identified and removed with arthroscopy. Moreover, it is also possible to identify and treat injuries of TFCC and intercarpal ligaments during the same sitting [13, 15, 18]. This chapter focuses on arthroscopic management of TFCC injuries, without distal radioulnar joint (DRUJ) instability, while surgically treating the ubiquitous distal radial fracture.

Indications for TFCC Repair Central tears of TFCC warrant simple debridement and perhaps radio frequency shrinkage to further stabilize tissues and minimize redundancy, while in a peripheral tear

Fig. 5.1  Histologic coronal view of the TFCC anatomy showing the deep fibers (ligamentum subcruentum) and superficial (capsular insertion) fibers of the articular disc. Lesion to the latter is the subject of current discussion. Note the proximity of the lunotriquetral ligament

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_5, © Springer-Verlag Berlin Heidelberg 2010

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with the loss of the trampoline effect on disc palpation, a suture repair is indicated [5]. A Palmer 1B [19] tear is the most frequent indication, and the size of the tear determines the number of sutures to be placed. Repair of radial sided tears (1D) is controversial since the blood supply in this region of the TFCC articular disc is tenuous. This matter will be discussed in Chap. 7.

Contraindications for TFCC Repair A grossly unstable DRUJ with obvious complete loss of foveal attachment will require a more aggressive repair and will not be addressed in the current discussion. This requires reattachment of the entire TFCC complex to the fovea using bone anchor or drill holes. An arthroscopic-assisted technique for this is possible, but the standard repair of the 6th compartment floor (as described herein) is not adequate for this profound instability (see Chap. 6). Central tears are of course not repaired due to the lack of propensity for healing. Debridement of central tears, as for any degenerative TFCC lesion, should be down to stable edges taking care not to disrupt the critical volar and dorsal radioulnar ligaments. This can be best accomplished using radiofrequency which can provide a more stable edge after initial mechanical debridement. There is also a relative contraindication that ultimately relies upon the surgeon’s judgment and perspective when discussing TFCC lesions associated with wrist fractures that is in the small peripheral tear that has equivocal instability, or loss of trampoline like tension. It is the author’s opinion that smaller peripheral tears may not require peripheral suture repair since the very environment of a healing fracture may provide the necessary hyperemia to augment healing of smaller cartilage lesions, given no gross instability, of course. The act of debridement alone will certainly promote fibrous healing of the torn edge and the surgeon must decide intraoperatively if suture repair is truly necessary. One must remember that the distal radius fracture itself will also be immobilized postoperatively; hence, further healing is generated in this scenario. This may explain why many patients with significant fractures in the past have not had ulnarsided wrist issues in the long term despite the correlation of TFCC lesions, now found arthroscopically, as

A. Badia

per the previously mentioned authors. Therefore, one can likely conclude that arthroscopic-assisted TFCC debridement alone may suffice for many of the previously unrecognized lesions, but suture repair should be performed in the large tears that may also explain the occasional persistent ulnar wrist pain in prior patients, despite a well-healed fracture and adequate rehabilitation. Large tears can be defined as the ones where there is a loss of the trampoline effect of the articular disc, or a sizeable defect remains after debridement that cannot be expected to heal without approximating the edges (Fig.  5.2). Small peripheral lesions can be expected to heal when the edges present no diastasis (Fig. 5.3). Arthroscopy now gives us the

Fig. 5.2  Large peripheral tear of the articular disc (arrows) with subsequent loss of the trampoline effect. One must confirm that the deeper fibers are not torn via physical examination and possibly DRUJ undersurface arthroscopy

Fig. 5.3  Small peripheral tear with minimal displacement has good propensity to heal due to visible vascularity, minimal gapping, and period of immobilization implicit in managing the concomitant distal radius fracture

5  Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability

tool to improve our outcomes in this common, but troublesome, fracture.

Surgical Technique The patient is placed in the supine position and a shoulder support is secured to the surgical table on the ipsilateral side of the injured wrist. The senior author prefers to use a regional block, using the three nerves blocking technique at the elbow level. This prevents complications caused by the use of axillary blocks [7, 26]. Once anesthetized, we hold the wrist in supination and a nonsterile tourniquet is applied to the upper arm, along with a strap to provide countertraction. The upper extremity is prepped, draped, and then exsanguinated with an Eschmarch and the tourniquet is inflated to 250  mmHg. Intravenous sedation is used for tourniquet pain. As a part of my surgical protocol, endoscopic carpal tunnel release using the single portal technique (Microaire, Carpal Tunnel Release System, Charlottesville, VA) is performed at this time if displacement of the metaphyseal fragment is not severe [2, 4]. However, if the displacement and deformity are severe, the carpal tunnel is released after the fracture is reduced, to facilitate safe placement of the scope within the canal. This carpal tunnel release is performed to not only decompress the median nerve, but also to release the flexor tendons which are also under pressure with the tunnel, particularly in the scenario of an articular distal radius fracture where blood is often seen within the carpal tunnel. The author notes that this may decrease the incidence of painful dystrophies in his experience and the issue of late posttraumatic CTS is, of course, resolved during the index procedure. Future prospective studies would be useful to determine the place for carpal tunnel prophylactic release in the setting of distal radius fractures, particularly intraarticular fractures. Via a separate incision, the extended flexor carpi radialis approach is used for distal radius open reduction and subsequent fixation [17]. Once the fracture has been securely stabilized, longitudinal wrist traction is achieved by placing finger traps on the index and middle fingers along with 10  lb of weight suspended through a pulley system, which is secured to the shoulder holder. We do not use the traction tower because almost always there will be a need to use fluoroscopy

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throughout the procedure and it can be more cumbersome. An 18-gauge needle is then used to identify the radiocarpal joint, because Lister’s tubercle is usually displaced and hence cannot be reliably used as an anatomic landmark. The 3–4 portal is utilized to introduce either the 2.4 or 2.7  mm scope. A full radius shaver placed through the 4–5 or 6R portal is used to remove blood clots and small intraarticular fragments to complete reduction of the joint surface. A small probe is used to palpate the joint surface in search of articular gaps and/or step-offs and to test the integrity of the carpal ligaments and the TFCC.

Management of a TFCC Tear Type IB tears [19] (ulnar avulsion with or without ulnar styloid fractures) of the TFCC are usually seen in significant fracture displacement. Small central tears are managed with debridement, and larger tears with the loss of the trampoline effect require percutaneous suture repair. A 0.5 cm longitudinal incision is made directly over the area of TFCC detachment as determined by external palpation and arthroscopic visualization. A needle is passed through this incision and a small joint grasper is inserted to retrieve the suture. It is important to extend longitudinally and ensure the safety of dorsal sensory branch of the ulnar nerve. The TFCC perforation and suture passing can be performed with commercially available instruments or a simple 18-gauge needle. The needle is passed within the longitudinal incision, into the tear and then across the edge of the visualized TFCC detachment in a proximal to distal direction. The more volar edge is first perforated and a 2–0 pds suture is passed through this needle and retrieved more distally above the disk with a small joint grabber or small straight clamp. It is important to pull out the 18-gauge needle before retrieving the suture, while grabbing the suture, to avoid cutting it on the bevel of the needle. Once a simple suture is passed, traction is applied and the second needle is more easily passed through the now taut TFCC disk. This second suture is passed more dorsally and that is usually all required to close the defect. Both these sutures pass just volar to the sixth compartment and additional sutures, if required should be passed across the floor of the compartment by opening the

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A. Badia

sheath and retracting the extensor carpi ulnaris tendon volarly (Fig. 5.4a). Two 2–0 pds sutures are now spanning the tear and tension should be applied to them (Fig. 5.4b), while the wrist is held in full supination, since the ulnar head will sit more ventrally within the sigmoid notch in supination and this allows for a tighter repair of the detached disk. This is an important maneuver as it allows the wrist to be in an advantageous position of supination during the healing process, while shoulder abduction can be used to compensate for the limited pronation during the rehabilitation period. The sutures are manually tied so that the knots sit on the floor of the sixth extensor compartment and are generally not an issue. However, due to occasional complaints of subcutaneous knot irritation, a novel technique of suture welding has been used [5] (Fig. 5.5). At the time of this publication, the technology of ultrasound suture welding is being reviewed and is currently not commercially available. Thermal welding has been considered, allowing a variety of suture material to be used, and is in the investigational phases.

Regardless of the suture securing method used, a sugar-tong plaster splint is then applied over generous cast padding while the wrist is held in supination with elbow in 90° flexion (Fig. 5.6). TFCC simple debridements, without suture repair, are immobilized in a simple volar splint, allowing early pronosupination. In the recovery room, immediate digital flexion/extension is encouraged. One week after the surgery, the splint is converted to a muenster-type fiberglass cast in supination to permit some elbow flexion/extension while

a

Fig. 5.5  Suture welding technique which eliminates subcutaneous knots that often cause irritation

b

Fig.  5.4  (a) Arthroscopic view showing sutures spanning the TFCC tear, without tension and loss of trampoline effect. (b) Arthroscopic view showing suture spanning the tear, now under tension. Note the loss of concavity on the disc signifying the restoration of trampoline effect

Fig.  5.6  Intraoperative sugar-tong splint holding the wrist in supination at the time of TFCC suture repair

5  Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability

restricting pronation/supination in TFCC repair protocols. Cast removal 5 weeks later should be followed by 4–8  weeks of physical therapy with active range of motion and strengthening. In cases of TFCC debridement alone, the short arm cast is usually removed between 3 and 5  weeks depending upon the fracture stability after fixation.

Discussion The operative management of distal radial fractures continues to evolve and the recent research is focused on anatomic congruency, TFCC injuries, and resultant DRUJ instability. Many studies have suggested that arthroscopic-assisted fixation of distal radial fractures is the best alternative to assess the joint surface and residual step-offs once reduction and fixation have been obtained Moreover, associated intercarpal and ligamentous injuries can also be assessed and managed [1, 2, 10–13, 15, 16, 18, 23, 29]. Arthroscopy has been demonstrated to be more reliable for the diagnosis and treatment of such injuries when compared to cinearthrography [28] and MRI [22] with minimal disturbance of the soft tissues. A prospective cohort study by Ruch et  al. [23] showed that the patients who underwent assisted arthroscopic procedures had a greater degree of supination, flexion, and extension than the patients undergoing fluoroscopicassisted surgery. Better management of associated injuries influences the outcome to a great extent. Lindau et  al. performed a prospective study on 51 patients with displaced distal radius fractures [14]. Arthroscopy at the time of fracture showed complete or partial TFCC tears in 43 patients (24 peripheral tears, 10 central perforations, and 9 combined tears). At 1-year follow-up, 10 patients with complete peripheral TFCC tears and 7 with partial or no peripheral tears had DRUJ instability. Shih et  al. [24] reported their results using arthroscopy to treat 33 patients of distal radius fractures with soft tissue injuries. In their series, the TFCC was torn in 18 patients. All the peripheral TFCC tears were repaired and the cases with SL instability were treated by arthroscopic debridement and transfixation of the joint interval with Kirschner wires. At final follow-up, 11 patients achieved excellent results and 22 patients had good results according to the Mayo modified wrist score.

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Osterman and Vanduzer in their series of 56 patients reported restoration of 95% of rotational arc at 5 years of follow-up [18]. Cheng et  al. [9] concluded that healed radial fractures were often complicated by chronic debilitating wrist pain and one of the important causes being TFCC tears with or without DRUJ instability. Bohringer et al. [8] concluded that arthroscopic treatment of TFCC tears in acute radius fractures is possible with good results. Varitimidis et  al. [27] in their prospective study concluded that addition of arthroscopy to the fluoroscopically-assisted treatment of intraarticular distal radius fractures improves the outcome. They further commented that the effective management of intraarticular injuries could be the key to the successful outcome. Acknowledgement  The author acknowledges Dr. Prakash Khanchandani assistance in reviewing the literature and writing this article.

References   1. Abboudi J, Culp RW. Treating fractures of the distal radius with arthroscopic assistance. Orthop Clin North Am. 2001;32:307–15   2. Agee JM, McCarroll HR Jr, Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg Am. 1992;17A:987–95   3. Auge ANX, Velasquez PA. The application of indirect reduction techniques in the distal radius: the role of adjuvant arthroscopy. Arthroscopy. 2000;16:830–5   4. Badia A. Median nerve compression secondary to fractures of distal radius. In: Luchetti R, Amadeo P, editors. Carpal tunnel syndrome. Berlin: Springer; 2006   5. Badia A, Jimenez A. Arthroscopic repair of peripheral triangular fibrocartilage complex tears with suture welding: a technical report. J Hand Surg Am. 2006;31A:1303–7   6. Badia A, Khanchandani P. Volar plate fixation. In: Slutsky DJ, Osterman AL, editors. Distal radial fractures and carpal injuries: the cutting edge. Philadelphia: Elsevier; 2008   7. Bouaziz H, Narchi P, Mercier FJ, Khoury A, Poirier T, Benhamou D. The use of a selective axillary nerve block for outpatient hand surgery. Anesth Analg. 1998;86(4):746–8   8. Bohringer G, Schadel-Hopfner M, Junge A, Gotzen L. Primary arthroscopic treatment of TFCC tears in fractures of the distal radius [German]. Handchir Mikrochir Plast Chir. 2001;33(4):245–51   9. Cheng HS, Hung LK, Ho PC, Wong J. An analysis of causes and treatment outcome of chronic wrist pain after distal radial fractures. Hand Surg. 2008;13(1):1–10 10. Doi K, Hattori Y, Otsuka K, Abe Y, Yammamoto H. Intraarticular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open

72 reduction and internal fixation. J Bone Joint Surg. 1999;81A: 1093–110 11. Edwards CC, Harszti CJ, McGillivary GR, Gutow AP. Intraarticular distal radius fractures: arthroscopic assessment of radiographically assisted reduction. J Hand Surg Am. 2001; 26A:1036–41 12. Geissler WB, Freeland AE. Arthroscopically assisted reduction of intraarticular distal radius fractures. Clin Orthop Relat Res. 1996;327:125–34 13. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78A(3):357–65 14. Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients. J Hand Surg Am. 1997; 22B:638–43 15. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radius fractures. J Hand Surg Am. 2000;25A:464–8 16. Mathoulin C, Sbihi A, Panciera P. Interest in wrist arthroscopy for treatment of articular fractures of the distal radius: report of 27 cases [French]. Chir Main. 2001;20(5): 342–50 17. Orbay JL, Badia A, Indriago IR, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg. 2001;5(4):204–11 18. Osterman AL, Vanduzer ST. Arthroscopy in the treatment of distal radial fractures with assessment and treatment of associated injuries. Atlas Hand Clin. 2006;11:231–41 19. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am. 1989;14A:594–606

A. Badia 20. Pechlaner S, Kathrein A, Gabl M, et  al. Distal radius ­fractures and concomitant lesions. Experimental studies ­concerning the pathomechanism. Handchir Mikrochir Plast Chir; 2002; 34:150–7 21. Richards RS, Bennett JD, Roth JH, et al. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am. 1997;22(5):772–6 22. Rominger MB, Bernreuter WK, Kenney PJ, et al. MR imaging of anatomy and tears of wrist ligaments. Radiographics. 1993;13(6):1233–48 23. Ruch DS, Valle J, Poehling GG, et al. Arthroscopic reduction versus flouroscopic reduction in the management of intra-articular distal radius fractures. Arthroscopy. 2004;20: 225–30 24. Shih JT, Lee HM, Hou YT, et al. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue management of distal radius. Hand Surg. 2001;6(2):127–35 25. Shih JT, Lee HM, Tan CM, et al. Early isolated triangular fibrocartilage tears: management by arthroscopic repair. J Trauma. 2002;53:922–7 26. Stark RH. Neurologic injury from axillary block anesthesia. J Hand Surg Am. 1996;21(3):391–6 27. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME, Bargiotas K, Malizos K. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction. J Bone Joint Surg Br. 2008;90(6):778–85 28. Weiss APC, Akelman E, Lainbiase R. Comparison of the findings of triple injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg. 1996;78A: 348–56 29. Wolfe SW, Easterling KJ, Yoo HH. Arthroscopic-assisted reduction of distal radius fractures. Arthroscopy. 1995;11(6): 706–14

6

Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears Andrea Atzei

Introduction Distal radius fractures (DRF) are usually the result of a high-energy injury to the whole wrist joint. The wrist is a complex joint: not only is it composed of the distal radius and ulna, of eight carpal bones (including the pisiform), and multiple articular surfaces, but also of as many as 28 intrinsic and extrinsic ligaments along with the triangular fibrocartilage complex (TFCC), all within a 5-cm interval. For this reason, DRF are frequently associated to intraarticular soft-tissue injuries that, when overlooked, often lead to more problems than the fracture itself. As recognized by many authors [18, 32], distal radioulnar joint (DRUJ) dysfunction is one of the most frequent complaints following DRF. Among the different causes of DRUJ dysfunction, DRUJ instability was a relatively uncommon finding when DRF were treated by prolonged long arm cast immobilization, but it became a more common problem after the introduction of new fixation devices, especially volar locking plates, and more aggressive postoperative protocols [7]. Recent acquisitions on the anatomy of DRUJ stabilizing mechanism and on the pathomechanics of the hyperextension injury of the wrist have improved the management of DRUJ instability, in terms of early recognition and efficacy of its treatment. Nakamura et  al.’s [10, 22, 23] anatomical studies showed that the proximal part of the TFCC, also described with the term ligamentum subcruentum [14], is made up

A. Atzei, MD Hand Surgery Unit, Policlinico “G.B. Rossi”, P.le L.A. Scuro, 10, 37100 Verona, Italy e-mail: [email protected]

of the DRUJ ligaments and that most of their insertion is located in the fovea ulnaris rather than in the styloid. These studies confirm the role of the proximal part of the TFCC as the main stabilizer of the DRUJ, as opposed to the distal part, which consists of the distal hammock structure and the ulnar collateral ligament (Fig. 6.1). It also implies that DRUJ instability may occur regardless of the presence of an ulnar styloid fracture, and on the contrary, that DRUJ may remain stable even when the ulnar styloid is fractured [10]. Pathomechanics of DRF were simulated using a materials testing machine on 63 prepared cadaver wrists that were subsequently examined by conventional radiology and computer tomography and by dissection [23]. DRUJ

Fig. 6.1  Artist’s rendering of the ulnar portion of the TFCC. It is separated into the “distal component” (dc-TFCC) formed by the UCL and the distal hammock structure, and the “proximal component” (pc-TFCC), represented by the proximal triangular ligament, or ligamentum subcruentum, which originates from the ulnar fovea and the proximal styloid and stabilizes the DRUJ

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_6, © Springer-Verlag Berlin Heidelberg 2010

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instability was the concomitant lesion most frequently found (44.5%). It resulted from a complete or partial laceration of the proximal part of the TFCC at its ulnar insertion: either in the form of an ulnar styloid fracture (19 cases, 67.8% of all DRUJ instability), or an ulnar avulsion of its ligamentous insertion (8 cases, 28.6% of all DRUJ instability); in only one case was the disk sheared from its radial insertion. DRUJ instability resulted from the pressure-related widening of the wrist, with maximum rotation and deviation of the forearm. Poor bone quality, as in older specimens with demineralized bone, correlated to the presence of an ulnar styloid fracture, rather than TFCC tearing. Other laboratory cadaver studies [33] demonstrate that following DRF with the ulnar styloid and TFCC intact, the distal radius can achieve only certain losses of radius length, palmar tilt, angle of inclination, or all the three. Only when ulnar styloid was cut through its base (and the TFCC detached consequently), the fractured distal radius achieved displacement greater than: 1. 4 mm of shortening 2. 0° of radial inclination 3. 10° of dorsal tilt (Fig. 6.2)

Fig. 6.2  Disruption of DRUJ stabilizing mechanism usually follows fracture displacement greater than (1) 4 mm of shortening, (2) 0° of radial inclination, and (3) 10° of dorsal tilt. It may be produced due to a pure ligamentous rupture or through the avulsion of the ulnar styloid

A. Atzei

This has important clinical implications, since it suggests that a DRF with metaphyseal collapse and shortening or dorsal tilt beyond the above values is most likely to be associated to DRUJ instability. This supposition is supported by the observation of Richards et al. [28], that injury to the TFCC was associated with greater shortening and dorsal angulation of the radius at the time of injury. A further corollary is that, in order to restore proper tension of the TFCC, the distal radius should be reduced to at least (1) 2 mm of shortening, (2) 10° of radial inclination, and (3) 0° of dorsal tilt. Fernandez [6] considered radiographic evidence of ulnar head subluxation or dislocation and intraarticular fracture of the sigmoid notch or ulnar head as key factors for a prognostic and treatment-oriented classification of DRUJ instability (Table 6.1). This classification system describes the pathoanatomy of the lesions, considering even the most severe cases of ulnar head and sigmoid notch explosion fracture, and provides prognosis and guidelines for a comprehensive treatment. Major implication of this classi­fication system is that DRUJ instability should be assessed after adequate restoration of the anatomic relationship between ulnar head and sigmoid notch, i.e., subsequent to DRF reduction and fixation. Presence of an ulnar styloid fracture is no longer considered as an absolute indicator of DRUJ instability, but only as a risk factor [17, 20, 31], regardless of fragment size and displacement. The supposition by Hauck [8] that DRUJ is unstable when the styloid is fractured at the base, and the opposite when the fracture is at the tip, is not confirmed by several arthroscopic studies [15–17, 28], that did not find any predictable correlation between ulnar styloid fractures and TFCC tears. Although ulnar styloid fracture is related to the pattern and magnitude of the injury sustained, it also depends on the bone quality and the relative strength of the ligaments. Thus, styloid fracture is more common in cases of an osteoporotic bone, giving reasons for the scarcity of isolated ligamentous injury in the elderly, compared to young active patients, in which DRUJ instability often results from a midsubstance tear of the TFCC [23]. In very rare cases, DRUJ instability results from the avulsion fracture of the TFCC foveal insertion and is associated to a small bony flake from the foveal area [12]. The variable combination of styloid fractures and ligamentous injuries of the ulnar side of the wrist has

6  Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears

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Table 6.1  Classification of DRUJ lesions associated to DRF according to Fernandez [6]. The pathoanatomy of TFCC tear and ulnar head and sigmoid notch fracture is described, providing prognosis and guidelines for a comprehensive treatment Type Joint surface Prognosis Recommended treatment involvement Type I Stable (following reduction of the radius, the DRUJ is congruous and stable) A: fracture of the ulnar styloid tip

None

Good

A + B: functional after treatment Encourage early pronation– supination excercises Note: extraarticular unstable fractures of the ulna at the metaphyseal level or distal shaft require stable plate fixation

None

Chronic instability

A: closed treatment reduce subluxation. sugar tong splint in 45’ supination 1–6 weeks A + B: operative treatment repair triangular fibrocartilage complex or fix ulnar styloid with tension band wiring Immobilize wrist and elbow in supination (cast) or transfix ulna/radius with K‐wire and forearm cast

B: stable fracture of the ulnar neck

Type II Unstable (subluxation or dislocation of the ulnar head is present) A: tear of TFCC and/or palmar and dorsal capsular ligaments

Painful limitation of supination if left unreduced

B: avulsion fracture of the base of the ulnar styloid

Possible late arthritic changes

Type III Present

Potentially unstable (subluxation possible)

A: intraarticular procedure at a later date fracture of the sigmoid notch

B: intraarticular fracture of the ulnar head

been explained recently by del Piñal [24] and defined as a “constellation” of ligamentous, osseous, and capsular damage [25]. A special condition is represented by the Galeazzi fracture-subluxation. When the fracture is localized

Dorsal subluxation

A: anatomic reduction of palmar and dorsal sigmoid notch fragments if residual subluxation tendency is present immobilize as in type II injury B: functional after treatment Possible together to enhance remodeling of with dorsally displaced die punch ulnar head or dorso‐ulnar fragment If DRUJ remains painful: Risk of early partial ulnar resection, degenerative changes and severe Darrach or Sauve–Kapandji procedure at a later date limitation of forearm rotation if left unreduced

within 7.5  cm of the distal epiphysis of the radius, DRUJ instability is frequently associated and requires repair [27]. Radiographic measurement of distal radius displacement, presence of DRUJ widening, or ulnar styloid

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A. Atzei

Table  6.2  Risk factors for DRUJ disruption as seen on plain radiographs of acute DRF Distal radius dislocation [33] greater than   4 mm of shortening   0° of radial inclination   10° of dorsal tilt DRUJ Intraarticular fracture [6] involving   Sigmoid notch   Ulnar head Presence of ulnar styloid fracture   Dislocated more than 2 mm [20]   Larger than 75% of styloid height [31] Avulsion fracture at the fovea ulnaris [12] Galeazzi fracture – subluxation [27]   Radius fracture within 7.5 cm from the distal epiphysis After fracture reduction and fixation, the actual presence of DRUJ hypermobility should be confirmed by the intraoperative ballottement test

fracture, may only give a hint of an associated DRUJ instability (Table 6.2). However, DRUJ instability still remains a challenging issue complicating DRF, especially in young patients, in whom preoperative clinical assessment and imaging often fails to provide reliable indications. When arthroscopic evaluation is performed during DRF treatment, a more accurate definition of the TFCC ruptures may be obtained, whether they are isolated or associated to osseous avulsions, either from the radius or ulna. The aim of this chapter is to illustrate the arthroscopic management of DRUJ instability following TFCC ulnar tears.

Clinical Assessment and Arthroscopic Findings After reduction and stable fixation of any DRF, either intraarticular or extraarticular, it is strongly recommended that DRUJ laxity is assessed intraoperatively by the ballottement test (Fig. 6.3) that has proven to be simple and reliable [21]. This test consists of the passive anteroposterior translation of the ulna on the radius in neutral rotation, full supination, and pronation. Abnormal translation in neutral rotation suggests complete TFCC disruption. If the translation is abnormal when the forearm is held in full supination, then the dorsal DRUJ ligament is ruptured. On the other hand, when the translation is abnormal in full pronation, then

Fig. 6.3  The “ballottement test” is a stress test to evaluate DRUJ stability. The radius is grasped by the examiner and the distal ulna, fixed between the examiner’s thumb and index finger, and moved in dorsal and palmar directions with respect to the radius. If the ulna shows an increased displacement relative to the contralateral side associated with a “soft” end-point resistance, it is likely to develop a symptomatic DRUJ instability, i.e., cause patient’s complaint when left untreated

the palmar DRUJ ligament is incompetent. The increased amount of radioulnar translation is compared to the opposite side and may be graded as: slight, when less than 5  mm; mild, when 5–10  mm; and severe, when greater than 10 mm. Evaluation of the resistance at the end point of the increased translation is of utmost importance, since its loss correlates with clinical DRUJ instability. Though hyperlax, the DRUJ showing a “firm” end point is unlikely to progress toward a clinically symptomatic instability. However, the DRUJ showing an increased passive anteroposterior laxity with a “soft” end-point resistance is prone to develop a clinical instability, i.e., cause a patient’s complaint when left untreated. TFCC laceration may occur either at its radial insertion, or more frequently, at its ulnar end. (Radial tear of the TFCC will be discussed in Chap 7). Ulnar disruption can result from a midsubstance tear, commonly in

6  Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears

the young patient, or from an avulsion fracture of the bony insertion, i.e., ulnar styloid fracture, or a combination of both, depending on the direction and severity of traumatic forces acting across the wrist [24]. Therefore, when the ballottement test is positive, regardless of the radiological evidence of a concomitant ulnar styloid fracture, arthroscopy of the radiocarpal joint is advisable to evaluate the extent of TFCC involvement. Arthroscopic exploration of the wrist is recommended to assist operative treatment of DRF in order to improve reduction of intraarticular step-offs, or to detect chondral and ligamentous lesions. Arthroscopy permits accurate definition of the different conditions affecting the TFCC. According to Palmer’s classification of TFCC tears, a type 1-B injury (ulnar detachment) should be visualized from the 3–4 portal in the dorsoulnar edge of the TFCC. The TFCC tension is evaluated by the trampoline test [11] and the hook test. The trampoline test assesses the TFCC tautness by applying a compressive load across it with the probe (Fig. 6.4). The test is positive

Fig. 6.4  The trampoline test: the probe inserted through 6-R (or 4–5) portal applies a pressure across the TFCC and shows lack of the normal resilience when the TFCC is lacerated. This test may be misleading when using the dry technique, probably due to the lack of fluid distention that reduces TFCC resilience

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when the TFCC is soft and compliant and suggests a peripheral TFCC tear. The hook test is a less known test whose use has been advocated to evaluate foveal avulsion of the proximal component of the TFCC [2, 5, 29]. It consists of applying traction to the ulnar-most border of the TFCC with the probe inserted through the 4–5 or 6-R portal, and is considered positive when the TFCC can be lifted distally and radially toward the center of the radiocarpal joint (Fig. 6.5). In my early experience with this test, I used DRUJ arthroscopy to confirm the foveal disruption of the proximal component of the TFCC and found a high correspondence between the positive hook test and the proximal detachment of the TFCC. Thus, in my practice, the positive hook test is a consistent indicator of TFCC foveal avulsion, and a confirmatory DRUJ arthroscopy is no longer required. However, DRUJ arthroscopy is still advisable to detect any posttraumatic chondromalacia or even cartilage loss of the distal ulna

Fig. 6.5  The hook test: the probe is inserted through 6-R portal into the prestyloid recessus in an attempt to pull the TFCC in multiple directions. The TFCC can be displaced towards the center of the radiocarpal joint only when the proximal component of the TFCC is torn or avulsed from the fovea. In this case, the test is considered positive

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or sigmoid notch that may be the cause of a poor outcome after TFCC foveal repair [1, 4]. Assessment of TFCC disorders includes preoperative evaluation of normal X-rays that may show an ulnar styloid with no/tip or basilar fracture and considers the following intraoperative parameters: Clinical DRUJ laxity: the ballottement test allows grading as none, slight, mild, and severe laxity. Soft or firm end-point resistance is also evaluated. Arthroscopic assessment of the TFCC distal component: as visualized through the 3–4 portal during radiocarpal arthroscopy, that may show either an intact surface or a tear usually on the dorsoulnar edge of the TFCC. Arthroscopic assessment of the TFCC proximal component: according to the hook test, that may show either an intact (negative hook test) or a torn proximal TFCC (positive hook test). DRUJ arthroscopy – through the Distal DRUJ portal – may help doubtful cases. Correlation of radiographic, clinical, and arthroscopic findings associated to fresh DRF allow to arrange different conditions in a treatment-oriented classification, which results from the outline proposed for chronic peripheral TFCC tears [1] (Table 6.3). Generally speaking, in fresh DRF, the TFCC tear is easily reducible and shows a good healing. However, following high-energy injuries or due to the coexistence of previous TFCC disorders, radiocarpal arthroscopy may show TFCC extensive laceration or frayed edges that cannot be repaired in the acute setting. In addition, high-energy injuries may cause cartilage loss or posttraumatic chondropathy of either the sigmoid notch or the ulnar head, whose presence should be investigated by DRUJ arthroscopy, as they may be responsible for a poor long-term outcome [16].

Indications In most instances, anatomic reduction of the distal radius, especially arthroscopically assisted, permits restoration of DRUJ stability, regardless of the presence of any ulnar styloid fracture. In this case, the ballottement test may still show slight increase of radioulnar translation, but the surgeon can clearly appreciate a “firm” endpoint resistance, witnessing ligament tautness. No further treatment is required in Class 0 lesions (Table 6.3), unless wrist arthroscopy discloses a sizeable laceration

A. Atzei

of the distal portion of the TFCC (Class 1) that should be treated with arthroscopic suture of the peripheral TFCC to the ulnar wrist capsule (see Chap. 5). However, a ballottement test showing an increased radioulnar translation with a “soft” end-point resistance reveals an actual insufficiency of the stabilizing structures. The latter condition is produced as a result of variable pathoanatomy and requires appropriate treatment to prevent the development of symptomatic DRUJ instability. Wrist arthroscopy permits precise visualization of the ruptured structures and reliable testing of its tautness, notably by the hook test, and hence it is decisive in the definition of appropriate treatment strategy (Table 6.3.). DRUJ laxity, as defined by a positive ballottement test, correlates to a positive hook test and may have arthroscopic evidence of a peripheral TFCC tear on radiocarpal exploration. This condition follows a complete peripheral TFCC tear, i.e., involving both the proximal and distal components of the TFCC, and the ulnar styloid may be intact, have a tip fracture, or a large styloid fracture (Class 2). The last setting, in which the TFCC is avulsed from the fovea and the ulnar styloid, fractured at its mid- to proximal-height, retains only a few ligamentous fibers, represents a particular condition that I call “floating styloid.” In Class 2 lesions, the TFCC should be repaired to the fovea, and the floating styloid (the large styloid fragment with few ligamentous attachments), may require styloid excision. Alternatively, though with a positive ballottement and hook test, radiocarpal arthroscopy may show no TFCC tear, regardless of the type of ulnar styloid fracture. These conditions are the consequence of an isolated tear of the proximal portion of the TFCC (Class 3), whose diagnosis is often challenging. In Class 3, when the ulnar styloid shows no or a tip fracture or when it shows limited size or quality to retain any fixation device, TFCC foveal refixation is recommended, by transosseous sutures or suture anchor, and the smaller or comminuted ulnar styloid is left in situ and rarely removed. Although it may develop a radiographic appearance of nonunion, when DRF reduction is acceptable and DRUJ instability is restored, the nonrepaired ulnar styloid is seldom the cause of pain and should eventually be treated when it becomes symptomatic (see Chap. 13). However, when the ulnar styloid is fractured closer to its base, usually

Negative

Taut (negative)

Ulnar tear

Slight laxity (hard end point)

Loose (positive)

Mild to severe laxity (soft end point)

(Floating styloida)

Intact

Class 3-Ab avulsion fracture of TFCC insertion

–

Ulnar tear

Variable

Variable

Variable

Suggested None TFCC suture TFCC foveal repair Styloid fixation Tendon graft after Arthroplasty treatment fracture healing when symptomatic Two basic conditions are defined according to the radiographic evidence of the ulnar styloid showing no or tip fracture and a basilar fracture. After fracture reduction and fixation, residual DRUJ instability is tested by the ballottement test and TFCC is evaluated by arthroscopic inspection and the hook test. Treatment is suggested according to the different classes a Class 2 “floating styloid” may require styloid excision b Class 3-A requires ulnar styloid fixation by K-wires and tension band or cannulated headless mini-screw fixation

Proximal TFCC tension (hook test)

Intact Distal TFCC appearance (RC arthroscopy)

Intraoperative ballottement test

Ulnar styloid basilar fracture

Ulnar styloid intact or tip fracture

Table 6.3  Comprehensive classification of TFCC peripheral tears and associated ulnar styloid fractures considers radiographic, clinical, and arthroscopic findings Class 0 Class 1 Class 2 Class 3 Class 4 Class 5 No TFCC tear Distal Complete Proximal Nonrepairable DRUJ TFCC tear TFCC tear TFCC tear TFCC tear Isolated styloid Fx Chondral loss – arthritis

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due to an avulsion mechanism by the TFCC itself, and therefore retains TFCC insertion (Class 3-A), it should be fixed with a small cannulated screw, K-wires and/or tension band. Extensive TFCC laceration or lack of adequate healing capacities (Class 4) requires reconstruction with tendon graft, which should be postponed after complete fracture consolidation and restoration of wrist range of motion. Acute DRUJ cartilage loss or severe contusion (Class 5) do not represent an actual contraindication to TFCC refixation; however, the surgeon should be aware of the likelihood of poor results, due to the development of an early DRUJ arthritis.

Technique Operative Setup and Diagnostic Arthroscopy Repair of DRUJ instability associated to DRF is an essential part of the surgical treatment of DRF and is performed using the same operative setup as arthroscopic-assisted DRF reduction and fixation. The wrist is suspended by finger traps using a wrist traction tower in a standard arthroscopic setup ([3], see also Chaps. 2 and 3). Joint distension is usually not required and the use of the dry technique [26] is advisable, since it benefits complex and long-lasting procedures. The wrist is systematically evaluated by radiocarpal arthroscopy using a 2.7-mm arthroscope as a routine, reserving the 1.9-mm arthroscope for smaller wrists. The scope is introduced through the 3–4 portal and care is taken to detect any associated disorders of the intercarpal ligaments. Tears of the distal component of the TFCC are seen on the dorsal-ulnar aspect, and depending on the delay of treatment, are frequently covered by coagulated hematoma or granulation tissue, which is removed with a shaver. A probe is inserted in the 6-R portal to assess the tension of the TFCC using the trampoline test and especially the hook test. My experience agrees with that of del Piñal [24], that the trampoline test is often misleading, especially when using the dry technique, probably due to the lack of fluid distention of the ulnar wrist that reduces TFCC resilience. Therefore, my diagnosis of TFCC peripheral

Fig. 6.6  Arthroscopic portals required for complete exploration of the wrist and foveal repair of the TFCC. R-MC radial midcarpal portal; U-MC ulnar mid-carpal portal; D-DRUJ distal DRUJ portal; and DF direct foveal portal

tear, particularly foveal avulsions, relies on the positivity of the hook test, even when the radiocarpal exploration shows an intact distal component of the TFCC. According to the approach suggested in Table 6.3, repair of DRUJ instability is performed by direct reattachment of the proximal component of the TFCC into the fovea, with a suture anchor or screw in Class 2 and 3, or by ulnar styloid refixation with a small cannulated screw, K-wires, and/or tension band in Class 3-A. Arthroscopic reattachment of the foveal insertion of the TFCC requires a separate portal to provide access to the fovea ulnaris. A dedicated working portal named the direct foveal (DF) portal [5] has been devised to debride the coagulated hematoma and ligamentous remnants from the foveal area, prepare the bone, and to drill and insert the suture screw or anchor (Fig. 6.6).

Direct Foveal Portal The DF portal is located approximately 1 cm ­proximal to the 6-U portal and is performed with the forearm in

6  Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears Fig. 6.7  Artist’s rendering of the anatomical relationship of the ulnar wrist in neutral prono-supination (a) and full supination (b). Following supination (b), the ulnar styloid and the ECU tendon displace dorsally and the fovea and the ulnar-most area of the distal ulna become subcutaneous. Full forearm supination is required to create the direct foveal (DF) portal

a

Fig.  6.8  The direct foveal (DF) portal is located about 1  cm proximal to the 6-U portal and allows exposure of the basistyloid and foveal area. It can also be prepared as a mini-open approach through an oblique skin incision between the ECU and FCU tendons, protection of the dorsal branch of the ulnar nerve, and splitting of the extensor retinaculum

full supination, because this produces dorsal displacement of the ulnar styloid and the ECU tendon and uncovers the palmar aspect of the distal ulna (Fig. 6.7). The fovea and the basi-styloid area of the distal ulna become subcutaneous and can be easily exposed [5]

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(Fig. 6.8). The DF portal is easier than the volar ulnar portal [30], but it is used only as a working portal. After confirming the 6-U portal with an 18-gauge needle, the DF portal is created with a mini-open exposure of the ulnar wrist. A 2- to 2.5-cm oblique skin incision is made between the ECU and the flexor carpi ulnaris that extends proximally to the 6-U portal. The dorsal sensory branches of the ulnar nerve (DSBUN) are identified by subcutaneous dissection and protected by two small Ragnell’s retractors. The risk of damaging the nerve is further reduced by forearm supination because the nerve is displaced palmarly. The extensor retinaculum is exposed and split along its fibers. The DRUJ capsule is incised longitudinally to reach the distal articular surface of the ulnar head under the TFCC. The fovea is located palmarly at the base of the ulnar styloid, just lateral to the capsule as an area of soft bone. Through the DF portal, a small shaver or curette is used to debride the torn or avulsed ligament, remove adherent clots from the fovea, and prepare it for suture, screw, or anchor insertion. Curettage of the fovea can also be performed as an arthroscopic procedure, with the scope viewing through the distal DRUJ portal (Fig. 6.9).

Technique of Suture Anchor Foveal Repair In order to pass a suture through each limb of the ligament, a screw or anchor with a pair of sutures is preferred. Using two sutures will also recreate a broader

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footprint for a faster healing of the proximal component of the TFCC [19]. In fresh TFCC avulsions, I prefer to use a 2.8 or 3.2 titanium screw with two preloaded nonabsorbable 2-0 ultrabraid sutures (Twinfix, ref. 72202067, Smith &

Fig.  6.9  The direct foveal (DF) portal is a working portal to provide access to the area of the ulnar styloid and fovea. With the scope in the distal DRUJ portal, a small shaver is inserted through the DF portal to debride the torn/avulsed ligament and the fovea

Fig. 6.10  The suture screw is inserted through the DF portal into the fovea, which is located palmarly at the base of the ulnar styloid, just lateral to the capsule as an area of soft bone. The sutures exit from below the TFCC

A. Atzei

Nephew, Andover, MA) because of the low friction of the sutures inside the eyelet, that reduces the risk of suture breakage during knot-tying, and the high tensile strength of the suture material. After the suture screw is inserted, the forearm is placed in neutral rotation, so that the screw head lies under the TFCC’s ulnar-most part and the sutures exit the DF portal from under the TFCC (Fig. 6.10). With the scope in the 3–4 portal, the sutures are inserted in an outside-in fashion from the DF portal, using the suture loop technique [2, 9], in which the suture end is inserted into the tip of a 25-G hypodermic or Tuohy needle so that it creates a loop inside the joint (Fig. 6.11). The first suture is placed close to the TFCC’s palmar edge to hold the palmar limb of the ligament, and the second one close to the TFCC’s dorsal edge to hold the dorsal limb. The sutures are retrieved with a grasper inserted through the 6-U portal (Fig. 6.12). The wrist traction is released and an assistant maintains the ulnar head in a reduced position with the forearm in neutral rotation. The sutures are tied under arthroscopic vision using a sliding knot and a small knot pusher (Fig. 6.13). Knots are located at the prestyloid recess or just outside the DRUJ capsule. Due to the ease of knot placement and reduced bulkiness, I favor the use of the SMC flip knot (Fig. 6.14) followed by two alternating half-hitch throws [13]. Complete tear closure is confirmed. Even in larger Class 2 TFCC peripheral tears, further ligament-to-capsule sutures are seldom necessary to repair the distal

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Fig. 6.11  The extremity of the first suture is introduced into the tip of a 25-G Tuohy needle. With the scope in the 3–4 portal, the needle is inserted outside-in via the DF portal to perforate TFCC’s palmar contour. The second suture is placed on TFCC’s dorsal contour using the same procedure Fig. 6.13  After the wrist traction is released, the forearm is held in neutral rotation and the ulnar head in reduced by the assistant, the sutures are tied using a sliding knot and a small knot pusher. At the end of the procedure, the probe assesses the restoration of proper tension of the TFCC (Hook test)

Fig. 6.12  A grasper is inserted through the 6-U portal and used to retrieve the sutures, so that one extremity of both the sutures exit from the 6-U portal and the other one from the DF portal

component of the TFCC. The DRUJ is assessed for the range of forearm rotation and residual laxity. The DRUJ capsule and the opening between retinaculum fibers are approximated and the skin is closed (Fig. 6.15).

Fig. 6.14  The SMC flip knot: a short post strand and a longer loop strand are prepared. The first underhand throw is made with the loop strand under both the loop and the post strands (a). The second underhand throw is made with the loop strand under the post strand (b). The loop strand is brought behind the second throw and an underhand throw is made with the loop strand under the post strand (c). By pulling the post strand, the knot is introduced into the joint without difficulty with the aid of a knot pusher. The post strand is tightened until the snug knot is established. Then, the loop strand is pulled until the locking loop is incorporated into the knot

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a

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f

Fig.  6.15  Illustrative case of the technique of arthroscopic refixation of TFCC foveal avulsion in DRF (a–h). A 26-year-old man suffered from an unstable AO type 3.2 fracture of the right distal radius (a). Arthroscopic exploration of the TFCC showed a complete peripheral tear (b) and a positive hook test (c). A Twinfix suture screw (Smith & Nephew, Andover, MA) was inserted through the DF portal using a mini-open approach (d). The two 2–0 ultrabraid sutures were introduced outside-in and

retrieved through the 6-U portal with a grasper (e). After knottying, proper tension of the suture on the palmar (black arrowheads) and dorsal DRUJ ligament (white arrowheads) restored TFCC tautness (f). Postoperative X-rays show fracture fixation with fixed-angle palmar plate (Matrix; Stryker) and proper placement of the Twinfix screw into the fovea ulnaris (g), with functional restoration of the pronosupination after 3 months (h)

6  Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears

g

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h

Fig. 6.15  (continued)

Technique of Styloid Fixation After arthroscopic-assisted reduction of the DRF and diagnostic arthroscopy confirming the Class 3-A lesion, the wrist is suspended by finger traps using a wrist traction tower in a standard arthroscopic setup [3], with an assistant holding the hand in supination, so that the distal ulna and the styloid become subcutaneous. The fracture site can be easily approached through an oblique skin incision between the ECU and FCU tendons, in a manner similar to the preparation of the DF portal, only slightly dorsal and proximal (Fig. 6.16). Great care must be taken to protect the DSBUN, which courses very close to the level of the ulnar styloid. The extensor retinaculum is split along its fibers, and then the distal ulnar styloid, the fracture line, and a few millimeters of the distal ulna are exposed subperiosteally. Gentle traction is exerted on the styloid to confirm if it is still firmly attached to the TFCC (Class 3-A) and exclude the presence of a Class 2 “Floating styloid.” In Class 3-A lesion, the styloid is reduced with the aid of a skin hook and temporarily stabilized with a K-wires under fluoroscopy. Definitive fixation is achieved by multiple K-wires and/or tension band or by a cannulated mini headless screw (Fig.  6.16a and b). DRUJ translation returns to normal ranges and the

ballottement and hook tests become negative (Fig. 6.17). On the contrary, in Class 2, styloid refixation is not effective on DRUJ stability and the ballottement and hook tests still remain positive after fixation. In this case, TFCC refixation with a suture screw is recommended, eventually associating styloid resection.

Aftercare The patient is placed in a long arm splint in neutral forearm rotation for the first week, and a Munster-type splint (a short arm splint that extends to the epi­condyle, allowing elbow flexion and extension but restricted forearm rotation) is worn day and night for another week, to be removed only for physical therapy. Two weeks after the operation and according to the postoperative protocol of the DRF, wrist flexion/extension is allowed. Gentle forearm rotation in a painless range of motion may be started as early as 2 weeks postoperatively, as tolerated by the patient. The splint is still worn between exercises for another week, after which it is reduced to a wrist splint and the patient is instructed to wear the splint the following week, when in public

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Fig. 6.16  Exposure of the styloid fracture through an ulnar approach between the ECU and FCU tendons, just dorsal and proximal to the mini-open preparation of the DF portal. Care is taken to protect the dorsal branch of the ulnar nerve, coursing very close to the ulnar styloid. The technique of tension band wiring (a) or cannulated headless mini-screw (b) can be used to fix the ulnar styloid

a

b

a

b

c

Fig. 6.17  Illustrative case of the technique of ulnar styloid fixation in DRF. Stable fixation of the complex TFC-ulnar styloid by a cannulated mini headless screw, allowed immediate ROM with this clinical result at 4 weeks. (Courtesy dr. F. del Piñal)

6  Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears Fig. 6.17  (continued)

d

or sleeping. Recovery of full range of motion is progressively achieved in the next 6 weeks, during which resisted movements are not permitted. Finally, progressive resisted wrist and hand strengthening exercises are begun. Return to full work duties or contact sports is not allowed for 3 months postoperatively.

References   1. Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur 2009;5:582–591   2. Atzei A, Luchetti R, Garcia-Elias M. Lesioni capsulelegamentose della radio-ulnare distale e fibrocartilagine triangolare. In: Landi A, Catalano F, Luchetti R, editors. Trattato di Chirurgia della Mano. Italy: Verduci Editore Roma; 2006. p. 159–87   3. Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusa M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25:S131–44   4. Atzei A, Corain M, Lavini F, et al. Treatment of distal radius fractures with arthroscopic assistance. J Orthop Traumatol. 2007;8:S36   5. Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008;12:226–35   6. Fernandez DL. Treatment of articular fractures of the distal radius with external fixation and pinning. In: Saffar P, Cooney WP, editors. Fractures of the distal radius. London: Martin Dunitz; 1995. p. 210–28   7. Geissler WB, Fernandez DL, Lamey DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clin Orthop Relat Res. 1996;327:135–46   8. Hauck MR. Ulnar styloid fractures: a review. Curr Opin Orthop. 2005;16:227–30   9. Haugstvedt JR, Husby T. Results of repair of peripheral tears in the triangular fibrocartilage complex using an arthroscopic suture technique. Scand J Plast Reconstr Hand Surg. 1998; 33:439–47

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10. Haugstvedt JR, Berger RA, Nakamura T, et al. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg Am. 2006;31:445–51 11. Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am. 1991;16:340–6 12. Kikuchi Y, Nakamura T. Avulsion fracture at the fovea of the ulna. J Hand Surg Br. 1998;23:176–8 13. Kim SH, Ha KI. The SMC knot – a new slipknot with locking mechanism. Arthroscopy. 2000;16:563–5 14. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am. 2007;32:1086–106 15. Lindau T. Treatment of injuries to the ulnar side of the wrist occurring with distal radial fractures. Hand Clin. 2005;21: 417–25 16. Lindau T, Arner M, Hagberg L. Chondral and ligamentous wrist lesions in young adults with distal radius fractures. A descriptive, arthroscopic study in 50 patients. J Hand Surg Br. 1997;22:638–43 17. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am. 2000;25:464–8 18. Lindau T, Aspenberg P, Adlercreutz C, et al. Instability of the distal radioulnar joint is an independent worsening factor after distal radial fractures. Clin Orthop. 2000;375: 229–35 19. Lo IKY, Burkhart SS. Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff. Arthroscopy. 2003;19:1035–42 20. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg Am. 2002;27:965–71 21. Moriya T, Aoki M, Iba K, et al. Effect of triangular ligament tears on distal radioulnar joint instability and evaluation of three clinical tests: a biomechanical study. J Hand Surg Eur Vol. 2009;34:219–23 22. Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg Br. 2001;26:446–54

88 23. Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex. J Hand Surg Br. 2000;25:479–86 24. del Piñal F. Dry arthroscopy of the wrist: its role in the management of distal radius fractures. Scand J Surg. 2008;97(4): 298–304 25. del Piñal F. The type 1-B constellation. Presented at the EWAS meeting. Poznan, June 2009 26. del Piñal F, Garcia-Bernal FJ, Pisani D, et al. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am. 2007; 32:119–23 27. Rettig ME, Raskin KB. Galeazzi fracture dislocation: a new treatment-oriented classification. J Hand Surg Am. 2001;26: 228–35 28. Richards RS, Bennett JD, Roth JH, et al. Arthroscopic diagnosis of intraarticular soft tissue injuries associated with distal radial fractures. J Hand Surg Am. 1997;22: 772–6

A. Atzei 29. Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures. Arthroscopy. 2003;19:511–6 30. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Up Extrem Surg. 2007; 11:38–44 31. Souer JS, Ring D, Matschke S, et al. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-andscrew fixation of a distal radial fracture. J Bone Joint Surg Am. 2009;91:830–8 32. Stoffelen D, De Smet L, Broos P. The importance of the distal radioulnar joint in distal radial fractures. J Hand Surg Br. 1998;23:507–11 33. Viegas SF, Pogue DJ, Patterson RM, et al. Effects of radioulnar instability on the radiocarpal joint: a biomechanical study. J Hand Surg Am. 1990;15:728–32

7

Radial Side Tear of the Triangular Fibrocartilage Complex Toshiyasu Nakamura

Introduction Distal radius fracture induces various soft tissue disruptions. Radial tear of the triangular fibrocartilage complex (TFCC) is a typical soft tissue injury associated with the distal radius fracture. The radial tear of the TFCC includes fibrocartilage central tear and dorsal or palmar rim tear; the latter two may induce distal radioulnar joint (DRUJ) instability [3]. Intrafibro­ cartilage tear of the TFC may not be associated with DRUJ instability. When the DRUJ indicates severe instability in the radial tear of the TFCC, the rim area must be repaired, as opposed to the tear inside the fibrocartilage area which just needs arthroscopic partial resection.

(Fig. 7.1). The TFCC has an important role in the stability between the ulnocarpal and DRUJs, distribution of load between ulna and ulnar carpus and smooth wrist motion and forearm rotation [7, 12]. Connection from the hyaline cartilage of the radius to the TFC indicates decrease of the cartilage cells and matrix, indicating a rather weaker connection histologically than the ligament–bone connection (Fig. 7.2a) [6, 9]. The radioulnar ligaments rise nearly vertically from the fovea and the base of the styloid process of the ulna, and after coalescing, bifurcate dorsally and palmary to pass on the proximal side of the TFCC. Finally, they insert in the very dorsal and very palmar

Anatomy of the TFCC The TFCC consists of the triangular fibrocartilage (TFC), meniscus homologue, ulnar collateral ligament, radioulnar ligament, ulnolunate ligament, and ulnotriquetral ligament [6, 7, 9–11]. The TFCC is a three-dimensional structure, where the distal portion is a hammock-like structure supporting the ulnar carpus, the proximal portion is the radioulnar ligament, direct primary stabilizing ligament of the DRUJ, and the ulnar portion is a functional ulnar collateral ligament consisting of the sheath floor of the extensor carpi ulnaris (ECU) and the thickened ulnar joint capsule corresponding to the 6-U portal

T. Nakamura, MD, PhD Department of Orthopaedic Surgery, School of Medicine, Keio University, 35, Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan e-mail: [email protected]

Fig. 7.1  Three-dimensional structure of the TFCC consists of a distal hammock-like structure, radioulnar ligament, and functional ulnar collateral ligament including ECU sheath floor

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_7, © Springer-Verlag Berlin Heidelberg 2010

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90 Fig. 7.2  Histological section of the radial side of the TFCC. (a) The area between the radius and triangular fibrocartilage (TFC) includes transition from hyaline cartilage to fibrocartilage, and an increase of fibers with decrease of hyaline cartilagematrix. It is a rather weak connection. (b) The dorsal margin of the sigmoid notch of the radius demonstrates direct bone-ligament connection with Sharpey’s fiber fashion between the radius and the RUL. (c) The palmar margin of the sigmoid notch of the radius again indicates direct bone-ligament connection. Both the dorsal and palmar marginal area of the TFCC to the sigmoid notch are considered to be strong

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edge of the sigmoid notch of the radius with Sharpey’s fibers (Fig. 7.2b, c). The meniscus homologue is just the internal wall of the distal hammock-like structure made of the synovial tissue, which can be easily elongated and folded with radial and ulnar deviation motion. The prestyloid recess is a pit between the apex of the TFC and meniscus homologue, which functions as an absorber of the deformity occurred around the TFC during forearm rotation.

Classification of the Radial Tear of the TFCC Palmer [10] classified TFCC injury into two classes, traumatic (Class 1) and degenerative (Class 2), and further subdivided traumatic tears according to their

site of injury: a central slit as 1A, ulnar tear as 1B, distal tear as 1C, and radial tear as 1D. The radial tear of the TFCC is usually found as a small slit on the radiocarpal arthroscopy [2, 13], rather than what was represented in the figure of Palmer’s classification [10], where the 1D tear was showed as a wide radial avulsion injury with or without a fragment of the sigmoid notch of the ulna. In my experience, the radial tear of the TFCC can be subdivided into: (a) fibrocartilage tear between the hyaline cartilage of the sigmoid notch of the radius and TFC (Fig. 7.3a), (b) dorsal edge tear between the dorsal edge of the sigmoid notch of the radius and dorsal portion of the radioulnar ligament (Fig.  7.3b), (c) the palmar edge tear between the palmar edge of the sigmoid notch of the radius and palmar portion of the radioulnar ligament (Fig. 7.3b), (d) combination of (a) + (b) (Fig. 7.3c), (e)

7  Radial Side Tear of the Triangular Fibrocartilage Complex Fig. 7.3  Classification of the radial-sided TFCC tear. (a) Type (a) is the radial slit or flapped tear limited to the fibrocartilage area, which is most commonly seen in the radiocarpal arthroscopy. (b) Type (b) is the dorsal rim tear with/without avulsion fracture of the dorsal margin of the sigmoid notch, which indicates DRUJ instability. Type (c) is the palmar-radial avulsion tear of the TFCC with/without avulsion fracture of the palmar margin of the sigmoid notch of the radius. (c) Type (d) is a combination of the radial TFC tear with dorsal avulsion of the TFCC from the sigmoid notch of the radius. (d) Type (f) is the total avulsion of the TFCC from the radius

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combination of (a) + (c), and (f) complete detachment of the TFCC from the sigmoid notch of the radius (Fig. 7.3d). As the strong connection of the TFCC and radius was found in the very dorsal and palmar edges of the sigmoid notch of the radius [4, 6, 8], the type 1D-a may not be associated with DRUJ instability, while type 1D-b–f can induce DRUJ instability.

Mechanism of the Radial Side of the TFCC The common radial-sided TFC tear is considered to be detached from the radius when the wrist is in extended and/or ulnar deviated position on the ground with axial load applied and supination/pronation force is applied from the body during the fall [1]. In this position, the TFC is pressed between the lunate and ulna. Different directional force may be applied both on the proximal and distal surfaces of the TFC, i.e., flexion-extension or radial-ulnar deviation forces may come from the carpal side and a rotational force may come from the

ulnar head. Avulsion fracture of the sigmoid notch of the radius is extremely rare; only the dorsal side of the sigmoid notch has been reported [4]. The radioulnar ligament was outstretched from the dorsal side of the radial sigmoid notch by a pronation force with flexion, extension or rotational force, a small bone fragment of the radial sigmoid notch had been avulsed from its dorsal edge, while the palmar over half of the TFCC remained attached to the radius. Total avulsion of the TFC from the radial sigmoid notch with or without sigmoid notch fracture may occur with compression forces on the ulnocarpal joint with twisting torque from the rotating ulnar head with the outstretched wrist.

Diagnosis and Evaluation with Physical Examination Radiographs cannot demonstrate any injury of the TFCC directly, because it is a soft tissue. If the radial side of the TFCC is completely ruptured, radioulnar

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a

b Fig. 7.5  Arthrogram indicates radial avulsion tear of the TFCC. The dye intrudes from the radiocarpal joint to the DRUJ through the radial slit tear of the TFCC

Fig. 7.4  (a) Radiograph of the avulsion fracture of the dorsodistal part of the sigmoid notch of the radius. (b) CT finding of the avulsion fracture of the dorsal margin of the sigmoid notch of the radius. White arrow indicates fragment

dissociation may occur resulting in a widening of the DRUJ in the radiograms. The avulsion fracture of the sigmoid notch can be recognized with careful checking of the radiograph, or CT (Fig. 7.4a, b) [4]. Diagnosis of the radial avulsion of the TFCC without the avulsion fracture is very difficult.

Classic arthrogram is useful to demonstrate the radial tear of the TFCC (Fig.  7.5). The dye intrudes from the radiocarpal joint into the DRUJ through the radial slit. In the case of fresh distal radius fracture, however, the dye expands into the fracture and it is difficult to clearly demonstrate the radial tear. Recent advances in high-resolution MRI now make it possible to delineate the fine structures inside the joint [8, 14]. The TFCC is demonstrated as a low signal intensity between the ulna, radius, lunate, and triquetrum [8, 12] (Fig. 7.6). Radial slit tear is delineated with a line close to the high signal intensity area of the hyaline cartilage of the sigmoid notch of the radius. Arthroscopy is a very useful tool for diagnosing the radial-sided TFCC tear. It provides a direct view of the TFCC. Probing of the torn TFCC is also useful to test the tension of the TFC, which is closely related with DRUJ instability. After exploration of the TFCC,

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the TFCC is an avascular area, with minimal healing potential. Although some have recommended repair of the radial-sided TFCC tear [1, 2], in my opinion, the flapped or irregular margin of the radial tear of the TFCC can be debrided or excised arthroscopically [1, 2]. The scope is inserted through the 3–4 portal, and the instrument is inserted through the 4–5 or 6R portal. First, the loss of tension of the TFC is confirmed with a probe (Fig.  7.7a). Then the basket punch is used to resect the flapped area of the fibrocartilage from the tear site of the TFC. The resected area should be kept to a minimum, avoiding injury to the DRUJ ligaments. A shaver or electric high-frequency probe is finally used to smooth the rough surface of the disc (Fig. 7.7b–d).

Avulsion Fracture of the Dorsal Sigmoid Notch of the Radius Including the Dorsal Radioulnar Ligament

Fig. 7.6  T2* weighted MRI delineates the TFCC well as a low signal structure between the radius, ulna, lunate, and triquetrum. White arrow indicates radial slit tear of the TFCC. Do not confuse the high signal area of the hyaline cartilage of the radial sigmoid notch with the radial slit tear of the TFCC

depending on the findings, one may opt to undertake an arthroscopic debridement or repair of the TFCC.

Treatment Treatment of the radial tear of the TFCC depends on the tear location.

Fibrocartilage-Radius Interface Tear Seldom will this type of TFCC tear induce DRUJ instability, because the radioulnar ligaments are not found in this location. The radial side of the fibrocartilage area of

The peripheral attachment of the TFCC is important for the DRUJ stability, because it includes the dorsal radioulnar ligament [4]. When the fragment of the dorsal sigmoid notch, including the dorsal side of the TFCC, is found on plain radiographs (Fig. 7.8a, b) or on CT (Fig. 7.8c, d), fixation of the fragment through the 4–5 or 6R portal can be possible through the radiocarpal arthroscopy (Fig. 7.8e–g). The dorsal rim can at times be very difficult to assess from the radiocarpal or DRUJ arthroscopic exploration. In these cases, open repair and internal fixation is recommended. In the dorsoradial avulsion of the TFCC, the tension of the TFC decreases, and obvious avulsion fragment at the dorsal margin of the radius is seen (Fig. 7.8e). Through the radiocarpal dry arthroscopy, the avulsion fragment, including the dorsal side of the TFCC from the radius, can be reduced (Fig.  7.8e–g) and fixed with the K-wire from the 4–5 or 6R portal (Fig. 7.8h, i). If there is simple avulsion of the TFCC from the radial sigmoid notch, this area can be sutured with a suture anchor. After arthroscopic reduction and internal fixation of the dorsoradial fragment of the sigmoid notch, there should be no instability of the DRUJ with full range of rotation (Fig. 7.8j, k). When an open repair is judged necessary the ­incision is made on the dorsal side of the TFCC (Fig.  7.9). The fifth compartment is opened and the

94 Fig. 7.7  (a) Arthroscopic findings of the radial flap tear of the fibrocartilage area of the TFCC. Arrows indicate TFCC tear. (b, c) Shaver or radiofrequency probe can easily debride the TFC. (d) After the partial resection of the TFCC, loss of tension area is removed

T. Nakamura

a

c

extensor digitorum quinti (EDQ) is removed from the compartment. After a longitudinal incision on the radial sheath floor of the EDQ is made, the dorsal rim area of the TFCC, including the avulsion fracture of the sigmoid notch of the dorsal radius, is revealed (Fig. 7.9e). The avulsed fragment can be repaired with a pull-out soft wire or a suture anchor to the original side of the sigmoid notch (Fig. 7.9f). If the dorsal tear of the TFCC is present, open repair of the TFCC can be done in the same fashion.

Avulsion Fracture of the Palmar Sigmoid Notch of the Radius Including Palmar Portion of the Radioulnar Ligament There is no report of this avulsion tear in the literature. In theory, when the palmar avulsion of the sigmoid notch of the radius is recognized, the carpal tunnel is opened [5] and the palmar portion of the TFCC can be repaired with a bone anchor.

b

d

Combination Injury of the Fibrocartilage Tear and either the Dorsal or Palmar Rim Avulsion of the TFCC Including Avulsion Fracture of the Sigmoid Notch of the Radius There is also no report of this type injury in the literature. The radial avulsion of the TFC can be sutured arthroscopically and 6  weeks of immobilization may induce repair of the rim tear, or open repair of the dorsal or palmar avulsion is needed.

Total Avulsion of the TFCC at its Radial Insertion Although Palmer described total avulsion of the TFCC (Fig. 7.3d), this tear is very rare. The TFC area is very difficult to repair in open fashion, and so, the author recommends arthroscopic repair of the total radial avulsion of the TFCC.

7  Radial Side Tear of the Triangular Fibrocartilage Complex Fig. 7.8  (a, b) Preoperative X-rays: apart from the obvious styloid fracture, a concomitant avulsion of the dorsal radioulnar ligament from the radius exist (marked with arrows) (c) In the CT scan, the avulsion of a small dorso-ulnar fragment on the radius (white arrow) that is displaced ulnarly (black arrow) is evident in the coronal view. (d) The defect on the radius surface (limited by arrows) is visible in the axial view. The incompetency of the dorsal radioulnar ligament causes dorsal subluxation of the ulna. (e–g) Arthroscopic reduction of the postero-ulnar (PU) fragment was done. (The scope is in 3–4 looking radially, the probe comes from 6R, the radius-TFC junction has been marked with dots). (h, i) Postoperative X-rays. The percutaneous K-wire was removed at 3.5 weeks and unrestricted pronosupination allowed. (j, k) Pronosupination 9 weeks after the operation. (Courtesy of Dr. Piñal)

95

a

b

c

e

d

f

g

96 Fig. 7.8  (continued)

T. Nakamura

h

j

A small 1–2  cm longitudinal incision is carried out on the radial side of the radius, between the first and second compartment. Careful attention is paid to avoid any damage on the sensory branch of the radial nerve. The tip of the targeting device is set on the torn surface of the sigmoid notch of the radius through the 4–5 portal, then the base of the targeting device is attached to the radial cortex of the radius, the 1.2 mm K-wire is passed from the radial cortex of the radius to the sigmoid notch (Fig. 7.10a) to make a tunnel (Fig.  7.10b). The 21G needle with a loop stitch is inserted into the same bone tunnel to the

i

k

radiocarpal joint (Fig. 7.10c). The needle is pushed forward to penetrate the radial side of the TFC (Fig.  7.10d). This step is repeated four times from different, but close positions, on the radial cortex of the radius to the different position of the sigmoid notch of the radius (Fig.  7.10e). Four loop stitches are then pulled out from the radiocarpal joint through the 4–5 portal with forceps. 3-0 braided polyester stitches are switched back to the tunnel with loop stitches induced to outside-in repair of the TFC. The TFCC is then tightened up to the sigmoid notch (Fig. 7.10f).

7  Radial Side Tear of the Triangular Fibrocartilage Complex

b

97

c

a

d

e

f

Fig. 7.9  (a) The radiocarpal arthroscopic view of the TFCC in the dorsal avulsion fracture of the sigmoid notch of the radius case. Only the loss of tension of the central TFC is recognized. No positive findings of the dorsal margin of the TFCC is noted. (b) Open exploration of the dorsal side of the DRUJ. The EDQ tendon is removed from the fifth compartment. (c) After the

EDQ sheath floor is cut, avulsion of the TFCC from the dorsal margin of the sigmoid notch is recognized. (d) Arrow indicates avulsed fragment of the sigmoid notch of the radius. (e) Avulsion fracture of the sigmoid notch can be repaired with bone anchor, or (f) pull-out wiring method

Postoperative Care

is strongly recommended) is adequate followed by a 3 week short arm casting. After the removal of the cast, active ROM exercise begins for 2 weeks, then passive ROM exercise of flexion-extension, and pronation– supination. The author usually asks the patient not to ulnar deviate the wrist in the immediate postoperative period (usually up to 4 weeks).

The arthroscopic partial resection may not need cast immobilization, because it is not related with DRUJ instability or radioulnar ligament tear. When the TFCC is repaired either arthroscopically or in an open fashion, a 2–3 week upper arm casting (sugar tongs plaster

98

T. Nakamura

a

b

c

d

e

f

Fig. 7.10  In the total avulsion of the TFCC from the sigmoid notch of the radius, arthroscopic repair is an option. (a) The targeting device is set on the sigmoid notch of the radius and the radial cortex of the radius. (b) K-wire (1.2  mm ) is useful to make a bone tunnel from the radial side of the radius to the DRUJ. (c) A long needle with 4-0 monofilament nylon loop stitch is inserted into the bone tunnel from the radial cortex to

the DRUJ. (d) The needle penetrates the TFC. This process is repeated four times. (e) Two paired loop stitches are then pulled out from 4–5 or 6R portal. (f) Two 3-0 braided polyester stitches are introduced from the DRUJ to the radial cortex of the radius using nylon loop stitches, then the radial tear of the TFCC is repaired by the outside-in technique

Acknowledgment  The author appreciates Dr Yasushi Morisawa with his help.

  7. Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg. 1996;21B: 581–6   8. Nakamura T, Yabe Y, Horiuchi Y. Dynamic changes in the shape of the triangular fibrocartilage complex during rotation demonstrated with high resolution magnetic resonance imaging. J Hand Surg. 1999;24B:338–41   9. Nakamura T, Yabe Y, Horiuchi Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg. 2001;26B:446–54 10. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg. 1989;14A:594–606 11. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist – anatomy and function. J Hand Surg. 1981; 6:153–62 12. Skahen JR, Palmer AK, Levinsohn EM, et al. Magnetic resonance imaging of the triangular fibrocartilage complex. J Hand Surg. 1990;15A:552–7 13. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg. 1997;22A:57–65 14. Yoshioka H, Ueno T, Tanaka T, et al. High-resolution MR Imaging of triangular fibrocartilage complex (TFCC): comparison of microscopy coils and a conventional small surface coil. Skeletal Radiol. 2003;32:575–81

References   1. Cooney W, Linscheid R, Dobyns J. Triangular fibrocartilage tears. J Hand Surg. 1994;19A:143–54   2. Fellinger M, Peicha G, Seibert FJ, et al. Radial avulsion of the triangular fibrocartilage complex in acute wrist trauma: a new technique for arthroscopic repair. Arthroscopy. 1997;13: 370–4   3. Kihara H, Short WH, Werner FW, et  al. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg. 1995;11A:798–804   4. Morisawa Y, Nakamura T, Tazaki K. Dorsoradial avulsion of the triangular fibrocartilage complex with an avulsion fracture of the sigmoid notch of the radius. J Hand Surg. 2007; 32E:705–8   5. Moritomo H, Murase T, Arimitsu S, et al. Changes in length of the ulnocarpal ligaments during radiocarpal motion: possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg. 2008;33A:1278–86   6. Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. Ann Anat. 2000; 182:567–72

8

Arthroscopic Management of Scapholunate Dissociation Tommy Lindau

Introduction Radial styloid fractures may be relatively simple distal radial fractures or part of an incomplete or complete greater arch perilunate dislocation (Fig. 8.1a) [11]. If it is a part of a perilunate dislocation, all of us are aware about the need to assess and fully treat both the radial and ulnar-sided injuries. It is therefore surprising that we still struggle to identify associated injuries with all other distal radius fractures (Fig.  8.1a–d). These assumptions are supported by the fact that scapholunate (SL) disruptions are more common with displaced partial articular or intra-articular (AO B and C Types) than extra-articular fractures [6]. In fact, the prevalence of SL ligamentous injury in displaced distal radius fractures have been found to be as high as 85%, but also as low as 18% (Fig.  8.2) [9, 12, 16, 18]. The impact of intra-articular fracture distribution is further emphasized by the fact that late presenting symptomatic SL dissociations have been found in patients with arthroscopically-diagnosed grade 3 and 4 SL ligament tears at the time of the fracture (Table  8.1) [3]. Furthermore, there is a fourfold risk of such significant grade 3–4 SL tears with an ulnar variance of >2 mm on the initial radiographs [3]. Obviously, the outcome of associated carpal injuries in distal radius fractures will be improved with early recognition and treatment [21]. Historically, the majority of distal radial fractures have been treated with immobilization in plaster. The healing properties of SL ligament tears are unknown, but one assumption

T. Lindau, MD, PhD Pulvertaft Hand Center, Derbyshire Royal Infirmery London Road, DE 12 QY Derby, UK e-mail: [email protected]

has been that immobilization alone should be enough, at least for the partial tears. However, in contrast to such a theory, nearly 5% of the patients with distal radial fractures treated with cast immobilization presented with symptomatic SL instability 1 year following injury. Their functional scores were significantly worse than those who did not show signs of SL joint disruption on initial radiographs [20]. It is therefore obviously important to detect associated SL ligament injuries and manage them in an appropriate manner. Detecting SL ligament injuries should be part of a modern management of distal radius fractures. In every situation when various surgical treatment options are considered, something should be done to test the SL joint. In the absence of arthroscopy, at least radiographic imaging in radial and ulnar deviation (Fig. 8.3) and a traction view should be obtained as a part of intra-operative assessment. With external fixation, concerns have been expressed regarding distracting the carpus to achieve restoration of radial length, as this will compromise a carpal ligamentous injury if it would be present [15]. Recently, there has been a surge in internal fixation and early mobilization of displaced distal radial fractures, particularly in non-osteoporotic adults. These patients are more likely to have sustained a ligamentous injury as a consequence of a high energy injury [9]. Failure to diagnose or treat the disruption would render the patients vulnerable to the long-term adverse effects of SL instability. Therefore, whilst analyzing the radiographs of a distal radius fracture, one must not only look at the bony injury alone, but also consider soft-tissue disruptions of the carpus (Fig.  8.1c, d). Regardless of the choice of definitive treatment, failure to address concomitant SL instability would lead to inferior long-term outcome. Displaced distal radial fractures in non-osteoporotic patients are associated with SL ligament injuries

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_8, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 8.1  (a) Greater arch perilunate dislocation where a distal radial fracture of the radial styloid is clearly associated with a SL ligament injury. (b) Lesser arch perilunate dissociation where there is no radial fracture but an obvious SL-ligament injury. (c) Distal radial fracture with an associated SL ligament injury and an ulnar styloid fracture highlighting that the perilunate mechanism has injured radial sided and ulnarsided structures, but without the full blown perilunate dislocation. (d) Distal radial fracture through the radial styloid where an associated SL ligament injury seems very likely and has to be excluded

SL

4

a

b

d c

1

1

LT

in about 50% of the cases (Fig. 8.2) [9]. Of all these, SL tears grade 3 or 4, if left untreated, lead to SL dissociation and possibly later carpal instability [3, 16].

2 4

20

Anatomy and Biomechanics 13

TFCC

Fig. 8.2  SL ligament injuries were present in 50% of displaced distal radial fractures in non-osteoporotic patients [9]

The two rows of carpal bones are devoid of tendon insertions and are bound together by intrinsic and extrinsic ligaments. The scaphoid, lunate and triquetrum form the proximal row of the carpus and move as a unit in response to the movement of the

8  Arthroscopic Management of Scapholunate Dissociation

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Table  8.1  Radiological (scapholunate) dissociation 1 year after arthroscopic diagnosis at the time of a displaced distal radius fracture (Fisher’s exact test p = 0.006) [3] Radiological scapholunate Group I (scapholunate grade 3–4) Group II (scapholunate grade 0–2) dissociation (n = 10) (n = 41) None

4

36

Dynamic dissociation

4

 4

Static dissociation

2

 1

Fig.  8.4  The SL ligament has its most important component dorsally as opposed to the luno-triquetral ligament where the palmar part is most important (courtesy of Adams, USA)

a

b Fig. 8.3  (a) Radial deviation as a stress test for inter-carpal ligament injury. (b) Ulnar deviation as a stress test for inter-carpal ligament injury shows a widening of the SL joint diagnosing a SL ligament tear

c­ arpo-metacarpal joints where the tendons insert and thus function as an intercalated segment [10]. The SL joint is a key link in the kinematics of the carpal chain of the proximal row. Traumatic carpal instability is initiated in this joint [11]. The primary stabilizer of the SL joint is the dorsal part of the intrinsic SL ligament (Fig.  8.4) [1]. It resists distraction, traction and torsional forces. The membranous, proximal aspect of the SL ligament does not provide significant restraint. The palmar aspect is also thin and is believed to assist rotational stability [7]. The secondary stabilizers are the scapho-trapezial ligamentous complex, the volar radial extrinsic ligaments (radio-scapho-capitate, the long and short radiolunate) and the volar ulnar extrinsic ligaments (ulnolunate and ulnotriquetral) (Fig. 8.5). The scapho-trapezial ligament complex plays a major role in preventing flexion of the scaphoid (rotary subluxation) even when the SL ligament is disrupted [4]. SL joint disruptions, like distal radial fractures, occur from a fall on an outstretched hand. Hyperextension, ulnar deviation and supination of the carpus lead to failure of the SL ligament [11].

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Fig. 8.5  The SL joint has many important secondary stabilizing ligaments, mainly on the palmar aspect. The Scapho-TrapeziumTrapezoid ligament may prevent rotatory subluxation of the scaphoid even if the SL ligament is torn

Scapholunate Pathology It is important to distinguish between the terms “instability” and “laxity” or increased mobility. Instability is a symptom, whereas laxity and increased mobility are signs elicited when the patient is examined. There is a common tendency in the literature to use the term instability for descriptions and also in classifications. However, instability is in fact the patient’s subjective description of the problems they struggle with in routine activities or sports. Laxity or mobility is what we, as professionals, assess. We thereafter combine the history, our examination findings and radiological features into a description of the condition. We even classify the patient’s condition into those subgroups. In this respect, we tend to, inappropriately in our view, use the term “instability” when we should use increased mobility or laxity. In this chapter, we have decided to follow the general view, even if it is inappropriate, for the sake of simplicity. SL instability can be pre-dynamic, dynamic or static. In pre-dynamic instability, plain radiographs and clenched fist films and fluoroscopy are negative, but the SL instability/tear is diagnosed with arthroscopy.

Fig. 8.6  Wrist imaging with a stress series including a clenched fist view where the SL joint is widened as a sign of an SL tear (courtesy of Dr Borelli, Italy)

Dynamic instability is apparent on stress views (clenched fist views) (Fig. 8.6) and at dynamic fluoroscopic assessment (Fig. 8.3), but not evident on normal radiographs. Static instability is evident with SL gapping on plain radiographs.

Clinical Assessment In acute cases, clinical assessment of SL instability is precluded by the presence of the fracture. Hence, one has to rely on non-clinical investigations such as radiographic imaging or arthroscopic assessment. Unfortunately, some patients are diagnosed rather late, after the fracture has united. They commonly complain of painful clicking and weakness of grip. They may be tender at the dorsal SL interval, just distal to wrist joint line in line with Lister’s tubercle. Watson’s test is a useful provocative test, although it may be falsely positive in up to 30% of cases [7].

8  Arthroscopic Management of Scapholunate Dissociation

Radiographs A radial styloid fracture may represent a part of a greater arch mechanism in a perilunate dislocation (Fig. 8.1a, c, d). Therefore, such a fracture must lead the surgeon into suspecting a disrupted SL ligament. SL ligament disruption occurs as the initial part of the spectrum of trans-styloid perilunate injury arc and may stop short of perilunate dislocation (Fig. 8.1) [11]. SL ligament injuries grade 3–4 are four times as frequent if there is an increase in ulnar variance of >2 mm at the time of the injury, at least in the non-osteoporotic population [3]. Intra-articular fractures have also been shown to indicate SL ligament injuries grade 3–4 [3]. SL joint is best seen on the AP projection with the wrist supinated [19] or by obtaining a tangential view [14] It has been suggested that a separation of 3 mm at the SL joint is suggestive and 5 mm or more, diagnostic of joint disruption [17]. This has been shown to be unreliable with the improved diagnosis through arthroscopy [6]. Clenched fist (stress) views (Fig. 8.6) are useful in demonstrating dynamic instability but they may be impossible to obtain in acute cases. More significant injuries along the perilunate spectrum will involve the mid-carpal and lunatotriquetral joints and should always be kept in mind. SL dissociation, when clear as a static instability pattern, comes with particular radiographic findings. Rotatory subluxation of the scaphoid occurs with the loss of the secondary stabilizers and causes flexion of the scaphoid. A positive cortical ring sign on the PA view is due to the overlapping of the scaphoid tubercle in the flexed position (Fig. 8.1c). The lunate will assume a dorsiflexed position and the SL angle is increased. Other findings on the PA film include triangular-shaped lunate (looks like a D implying DISI deformity due to increased overlapping on the capitate) and a wider appearance of the triquetrum (the triquetrum dorsiflexes with the lunate). However, lesser degrees of injury are difficult to diagnose on plain radiographs.

CT and MRI Imaging CT arthrograms are more sensitive and specific than MRI but not practical in acute cases. It may be difficult to delineate SL ligament injury on the MRI scan in an acute setting due to the presence of soft-tissue swelling

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and bone bruising. MRI scans, with or without gadolinium enhancement, have a poor sensitivity and poor inter-observer reliability also in sub-acute and chronic cases [7].

Arthroscopy Arthroscopy is superior in assessing intra-articular congruency [12, 21]. Fluoroscan has been found to be inaccurate in assessing the correct closed reduction and Kirschner-wire fixation in distal radial fractures [2, 21]. Arthroscopy is also the gold-standard for the detection of SL ligament and other inter-carpal or distal radioulnar joint injuries [5, 7, 9]. It not only enables accurate assessment of concomitant carpal ligament injury, but is also helpful in treating the torn ligaments and confirms accurate restoration of intercarpal alignment.

Indications for Arthroscopy Many centres cannot perform wrist arthroscopy on every distal radial fracture in young and middle-aged patients. The main indications for arthroscopy in distal radius fractures are: • Features of static SL instability on radiographs (to grade and treat the specific injury and also to rule out ulnar-sided pathology as a possible part of a greater arch perilunate mechanism Fig. 8.1c). • Suspicious widening of SL interval on plain radiographs as, occasionally, the ligament has not been torn in spite of a slight gap on X-ray. • Ulnar positive variance of 2  mm or greater (preinjury) [3]. • Radial styloid fractures (AO Type B) as per greater arch mechanism (Fig. 8.1a, c, d). • Intra-articular fractures (AO Type C) as increased risk for grade 3–4 SL injury [3].

Technique Arthroscopy is performed with the wrist suspended in a traction device/tower. Assessment of SL tears should be done by combining radiocarpal visualization of the

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a

b

d c

Fig.  8.7  (a) Radiocarpal appearance of a torn scapholunate (SL) ligament where the extent of the tear can be assessed (Tables 8.2 and 8.3). (b) Mid-carpal assessment of SL mobility, which can be measured or described (Tables  8.2 and 8.3). Combined with the radiocarpal appearance the SL tear can be graded. (c) Mid-carpal assessment of the gap in between the scaphoid (right) and the lunate (left). The gap/diastasis as well as possible step can be measured or described (Tables 8.2 and 8.3).

In a grade 4 ligament tear, the scope can be passed from the midcarpal joint through this dissociation into the radiocarpal joint. This is called the “drive through sign”. (d) Radiocarpal assessment of a complete SL tear. Scope in 3–4 portal, scaphoid to the left and lunate to the right. The head of the capitate is seen through the dissociated SL joint because of the ligament tear. This is called the “drive through sign”

torn ligament (Fig. 8.7a, d) with mid-carpal assessment of the altered mobility in the SL joint as a consequence of the torn ligament (Fig. 8.7b, c) (Tables 8.2 and 8.3). The SL ligament is best viewed from the 3–4 portal at radiocarpal arthroscopy. The dorsal components should be inspected as this is the most important part (Fig. 8.4). In addition, the palmar and the central membranous portions are assessed. The ligament should be probed to establish continuity. The degree of tear will be registered. At mid-carpal arthroscopy, the diastasis and gap in the SL joint should be assessed and measured and registered (Fig. 8.7b, c) [6, 9]. A probe should be used to further assess the degree of mobility in between the two bones. In most cases, the traction should be released to be able to fully understand the amount of mobility. The combined radiocarpal appearance and mid-carpal mobility makes it possible to classify and grade the tear (Tables 8.2 and 8.3) [3, 6, 9].

SL Grading Arthroscopic examination of the SL joint can demonstrate a range of pathology to the SL ligament causing more or less damage to the constraints of the SL joint. The most popular classification is that of Geissler, who describes four types with increasing severity. His grading system is based on verbal descriptions of the tear; for instance, “the drive through sign” (Fig. 8.7d) (Table  8.2). That classification further suggests specific treatments for each grade, based on assumed consequences and reasonable treatment options [5, 6]. Geissler’s classification has been modified by quantifying the amount of mobility in between the scaphoid and the lunate as a consequence of the torn ligament [3, 9] (Table 8.3). This modified classification has, in longitudinal studies, shown that grade 1 and 2 injuries do not lead to any long-term problems, whereas grade 3 and 4 do (Table  8.1). [3]. Consequently, these

8  Arthroscopic Management of Scapholunate Dissociation

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Table 8.2  Geissler’s arthroscopic classification of carpal interosseous ligament tears Grade Description

Management

I

Attenuation/haemorrhage of interosseous ligament as seen from the radiocarpal joint. No incongruency of carpal alignment in mid-carpal space

Immobilization

II

Attenuation/haemorrhage of interosseous ligament as seen from the radiocarpal joint. Incongruency/step-off as seen from mid-carpal space. A slight gap (less than the width of a probe) between carpals may be present

Arthroscopic reduction and pinning

III

Incongruency/step-off of carpal alignment is seen in both the radiocarpal and mid-carpal space. The probe may be passed through the gap between carpals

Arthroscopic/open reduction and pinning

IV

Incongruency/step-off of carpal alignment is seen in both the radiocarpal and mid-carpal spaces. Gross instability with manipulation is noted. A 2.7 mm arthroscope may be passed though the gap between carpals

Open reduction and repair

Table 8.3  Modified Geissler grading of scapholunate ligament injury [9] Grade Radiocarpal ligament appearance Mid-carpal diastasis (mm)

Step-off (mm)

1

Haematoma or distension

0

 0

2

As above and/or partial tear

0–1

<2

3

Partial or complete tear

1–2

<2

4

Complete tear

>2

>2

findings have made the treatment options suggested by Geissler redundant. The European Wrist Arthroscopy Society (EWAS) has tried to include all SL pathology in a comprehensive classification, including acute, sub-acute and even chronic, which is under investigation by the EWAS study group for SL injuries [13].

Management of Scapholunate Injury Management of SL dissociation associated with distal radius fractures depends on the time since injury and the severity of disruption.

Acute Injuries It is commonly agreed that the healing potential of the SL ligament is best within the first week of injury and then decreasing up to 6 weeks after injury. After 6 weeks, the prospects for primary healing are poor. Although the deformity is reducible between 1 and 6 weeks, the capacity for primary healing is reduced due to retraction and/or necrosis of the ligament fibres.

It therefore follows that early detection and appropriate management of these injuries lead to improved outcome. This is corroborated by reports showing improved outcomes with early detection and stabilization [10, 22]. Improved range of movement and wrist scores have also been achieved with immediate treatment of carpal ligament injuries associated with distal radius fractures [21].

Grade I Injuries Grade I (Tables  8.2 and 8.3) injuries can be treated with immobilization only. This has to be borne in mind whilst planning rehabilitation after secure internal fixation. The temptation for early aggressive mobilization should be tempered with its potential adverse effects on the SL tear, which in grade I is minor (Table 8.1) [3].

Grade II Injuries Decision making is more difficult with grade II injuries (Tables 8.2 and 8.3). Immobilization is sufficient with this degree of SL tear as most patients are

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asymptomatic at 1 year [3]. An option is to reduce and pin the SL joint [5, 6], Long-term outcomes are needed to clarify the best form of management. Technique: A small incision slightly palmar to the anatomical snuff box is done. Care should be taken to avoid injury to the sensory branches of the radial nerve. A 14G venflon can be used to protect the soft tissues whilst drilling the K-wire across the joint. Two to three K-wires are inserted through and across the joint into the lunate (Fig.  8.8). It is important to be absolutely certain that joint alignment has been restored prior to K-wire stabilization as described above. Restoration of alignment can be achieved by inserting K-wires dorsally into the scaphoid and the lunate and using them as joysticks (Fig.  8.9). The location of the wires and carpal alignment can be confirmed by arthroscopy and fluoroscopy (Fig.  8.8). Additional stability can be obtained by inserting another K-wire across the scaphocapitate articulation. Stabilization of the joint with this technique has shown to yield good results [7]. a

T. Lindau

Grade III and Grade IV Injuries It has been shown that SL grade III and grade IV injuries (Tables 8.2 and 8.3) are likely to lead to chronic symptoms of carpal instability (Table  8.1) [3, 16]. Most experts now agree on immediate surgical intervention if such severe disruptions are noted acutely following distal radius fractures. Technique: The arthroscopically assisted technique, as described above, should be done with a special emphasis on the reduction of the SL joint. In some instances, it may be difficult to obtain an accurate reduction arthroscopically, particularly with grade 4 injuries. In such instances, open approach will be necessary. A direct open repair should be considered and the repair protected with K-wires as described above. Concomitant dorsal capsulodesis has shown to be useful in reinforcing the repair [8]. However, in our experience, it has a significant drawback by restricting palmar flexion. Occasionally, there may be a bony avulsion of the ligament from the lunate. In these instances, the avulsed fragment can be reattached using bone anchors [17].

Post-Operative Rehabilitation

b

The wrist should be immobilized in a splint until the removal of K-wires for 6–8 weeks. Our preference is 6 weeks. The wrist is further protected for another 4 weeks in a resting splint in between exercises with supervised hand therapy. Heavy activity and contact sports should be avoided for 6 months. Proprioceptive exercises are beneficial, particularly when dorsal SL ligament continuity has been restored.

Late Presentation (>6 Weeks)

Fig.  8.8  (a) AP fluoroscopic view of scapholunate (SL) pinning. (b) Lateral view of SL pinning

In symptomatic cases when the patient presents late (after 6 weeks), repair is less likely to be effective. Arthroscopic assessment can confirm the injury, show reducibility and will show whether the ligament can be used for a direct repair. It is still our preference to attempt a direct repair, depending on the reducibility of the joint. Autologous bone-ligament

8  Arthroscopic Management of Scapholunate Dissociation Fig. 8.9  (a) Scapholunate (SL) reduction can be done with a “joy stick” manoeuvre with a 1.5 mm K-wire in the scaphoid and the lunate. Scope in the UMC, ulnar mid-carpal portal. (b) Reduction is checked in the mid-carpal joint with a SL joint being level, with no step or gap. (c) Two K-wires are advanced over the SL joint. (d) An additional wire secures the scaphoid to the capitate joint

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a

b

c

d

bone grafts or dynamic ligament reconstruction should be considered. An ECRL tendon transfer is the dynamic option and a complete reconstruction with a 3 ligament tenodesis (3LT) procedure using the flexor carpi radialis tendon is the more permanent and static option [4]. Management of irreducible SL dissociations and the SLAC wrist is beyond the scope of this chapter. We recommend the reader to refer to the algorithm proposed by Garcia-Elias and colleagues [4].

Conclusions SL tears that lead to radiographic dissociations are devastating complications to distal radius fractures. They may be an obvious injury as in the greater arch trans-styloid perilunate injuries, but more often take the surgeon by surprise by being present at a late follow-up with incomplete recovery after the distal radius fracture they have been treated for (Fig. 8.10). It is our job to suspect such associated ligament injuries, detect them and decide how they should be managed in order

Fig.  8.10  Scapholunate ligament injury in the inappropriate management of a distal radius fracture

to have an overall satisfactory outcome after these complex wrist injuries,of which the distal radius fracture is the obvious one.

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References   1. Berger RA. The gross and histologic anatomy of the scapholunate ligament. J Hand Surg. 1996;21A:170–8   2. Edwards CE II, Haraszti CJ, McGillivary GR, et  al. Intraarticular distal fractures: arthroscopic assessment of radiographically assisted reduction. J Hand Surg. 2001;26A: 1036–41   3. Forward DP, Lindau TR, Melson DS. Intercarpal ligament injuries associated with fractures of the distal part of the radius. JBJS. 2007;89-A:2334–40   4. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique J. Hand Surg. 2006;31A:125–34   5. Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005;21:407–16   6. Geissler WB, Freeland AE, Savoie FH, et  al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. JBJS. 1996;78-A:357–65   7. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg. 2008;33A: 998–1013   8. Lavernia CJ, Cohen MA, Taleisnik J. Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. J Hand Surg. 1992;17A:354–49   9. Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients. JHS. 1997;22B:638–43 10. Linscheid RL, Dobyns JH, Beabout JW, et  al. Traumatic instability of the wrist: diagnosis, classification and pathomechanics. JBJS. 1972;54-A:1612–32 11. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. JHS. 1980;5A:226–41

T. Lindau 12. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach. JBJS. 2000;82 B:79–86 13. Messina J, Dreant N, Luchetti R, et al. Scapho-lunate tears: a new arthroscopic classification. Presented at FESSH 2009; Poznan, Poland 2009 14. Moneim MS. The tangential posteroanterior radiograph to demonstrate scapholunate dissociation. JBJS. 1981;63-A: 1324–6 15. Mudgal C, Hastings H. Scapho-lunate diastasis in fractures of the distal radius: pathomechanics and treatment options. J Hand Surg. 1993;18B:725–9 16. Peicha G, Seibert F, Fellinger M, et al. Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures. Knee Surg Sports Traumatol Arthrosc. 1999;7:327–33 17. Ruby LK, Cassidy C. Fractures and dislocations of the carpus. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma. vol 2. Philadelphia: Saunders; 2003 18. Shih JT, Lee HM, Hou YT, et al. Arthroscopically-assisted reduction of intra-articular fractures and soft-tissue management of distal radius. Hand Surg. 2001;6:127–35 19. Taleisnik J. Current concepts review – carpal instability. JBJS. 1988;70-A:1262–8 20. Tang JB, Shi D, Gu YQ, et al. Can cast immobilisation successfully treat scapholunate dissociation associated with distal radius fractures? J Hand Surg. 1996;21A: 583–90 21. Varitimidis SE, Basdekis GK, Dailiana ZH, et al. Treatment of intra-articular fractures of the distal radius. Fluoroscopic or arthroscopic reduction? JBJS. 2008;90-B:778–85 22. Whipple TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin. 1995;11(1): 37–40

9

Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures Didier Fontès

Introduction Distal radius fractures (both extra- and intraarticular types) have a high incidence of associated lesions, including chondral and soft-tissue injuries such as ­triangular fibrocartilage complex (TFCC), scaphol­unate interosseous ligament (SLIO), lunotriquetral interosseous ligament (LTIO) (Fig. 9.1), or extrinsic ligament tears. Final clinical result after a wrist fracture depends on the accuracy of articular reduction, reduction stability, and the initial management of associated lesions.

associated to an ulnar mechanism of impaction contemporary of the fracture impaction of the distal radius. But it has been shown by comparative prospective studies that arthrography has only a 60% sensitivity in

Incidence of Associated LTIO and Extrinsic Ligaments Lesions with Distal Radius Fractures By using arthrography, studies noted a high incidence of associated intrinsic ligament injuries. Specifically, in our first prospective series in 1992 [3], we performed a systematic operative wrist arthrogram (Fig. 9.2) during distal radius fractures in a group of 58 patients with a mean age of less than 50 years at a low risk of spontaneous degenerative ligamentous tears. TFCC was torn in twothirds of all type of fractures. Extraarticular radius fractures were associated with an intracarpal ligamentous tear in 25% and were always a lunotriquetral (LTIO) lesion type. In contrast, intraarticular and radius styloid fractures were frequently associated with a scapholunate lesion (SLIO). TFCC and LTIO ligament were regularly

D. Fontès, MD Sport’s clinic of Paris – CMC Paris V, 36, Boulevard Saint Marcel 75005 Paris, France e-mail: [email protected]

Fig.  9.1  Localization of lunotriquetral interosseous (LTIO) ligament tear

Fig.  9.2  Operative midcarpal arthrography showing a LTIO ligament tear

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detecting those ligament injuries compared with arthroscopy [31], which is now the gold standard of interosseous ligaments exploration. Arthroscopy provides the advantage of assessment of distal radius reduction and the status of the intercarpal ligaments under direct visualization and magnification and is currently the preferred imaging method of many surgeons. Several arthroscopic reports (Table 9.1) reveal the incidence of associated injuries occurring with distal radius fractures [4, 8, 12, 15, 20, 22]. Arthroscopy in distal radius fractures greatly enhances early recognition of these injuries so that prompt treatment may thus be performed avoiding unexpected sequelae regarding the fracture itself. A complete wrist arthroscopy with examination of both the radiocarpal and the midcarpal spaces is essential in evaluating SLIO and LTIO ligament lesions and carpal instability. Geissler and Freeland [9] proposed an arthroscopic classification of interosseous ligament injury that is commonly used in our clinical descriptions (see Table 8.2). Regarding extrinsic ligaments, arthroscopy is unquestionably the best assessment method even if 2D and 3D CT scan can give an orientation in the suspicion of osteoligamentous-associated lesions (Fig. 9.3).

Management of LTIO and Extrinsic Ligaments-Associated Lesions Lunotriquetral Ligament Lesions The Geissler classification system grades tears based on instability with a probe in the lunotriquetral joint through the midcarpal portal [8]. Grading of the ligament tear is done through the radiocarpal (Fig. 9.4a) and midcarpal portals (Fig.  9.4b). The primary treatment

for isolated, stable lunotriquetral ligament tears (more frequently the dorsal portion of the interosseous ligament) is conservative (Geissler grade 1–2). Cast immobilization in neutral alignment may result in healing of the ligament and pain relief. It is important to diagnose this associated lesion to avoid a too early mobilization of the wrist. For grade 2 to 3, arthroscopic debridement can be carried out through the 4–5 or 6R portal, scope in 3–4 portal after direct visualization of LTIO lesion through the ulnar side portal. The dorsal and membranous components of the ligament can be visualized and debrided (Fig.  9.4c) knowing that the volar part is most important for the stabilization of this articulation. Arthroscopic debridement alone of isolated lunotriquetral ligament tears may result in symptomatic improvement. Weiss et al. [32] reported that 43 of 43 patients with partial LT ligament tears had complete or improved symptoms after arthroscopic debridement alone. Ruch and Poehling [23] found excellent results in 13 of 14 patients with scapholunate or lunotriquetral ligament tears. However, Westkaemper et  al. [33] found poor results in 4 of 5 patients with debridement alone for lunotriquetral ligament tears. Debridement can be associated with a shrinkage using radiofrequency (RF) devices. Electrothermal shrinkage of the dorsal and palmar portions of the LTIO ligaments in patients with mild ligament instability has been reported with good results. Darlis et  al. [2] reported on arthroscopic debridement and thermal shrinkage using RF probes for 16 partial SLIO ligament injuries (Geissler grade 1 or 2) with a mean follow-up of 19 months. The outcomes were excellent or good in 88% of patients overall according to the Mayo wrist score. Shih and Lee [25] reported a 79% success rate at a minimum of 2 years’ follow-up in 19 wrists with SLIO ligaments treated with electrothermal

Table 9.1  Incidence of ligamentous lesions in wrist fractures Study Nb and type % TFCC

% SLIO

% LTIO

% Extrinsic 17

Fontès [4]

30 (intra and extraarticular)

70

40

17

Geissler et al. [8]

60 (intraarticular)

49

32

15

Lindau et al. [15]

50 (extra and intraarticular)

78

54

16

Richards et al. [22]

118 (extra- and intraarticular)

35 (intra) 53 (extra)

21 (intra)   7 (extra)

  7 (intra) 13 (extra)

Mehta et al. [20]

31 (intraarticular)

58

85

61

Hanker [12]

173 (intraarticular)

61

8

12

70 Dorsal capsule tear

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Fig. 9.3  2D and 3D CT scan can help in the evaluation of associated osteoligamentous extrinsic lesions

a

b

c

Fig.  9.4  Geissler grade 2 LTIO ligament lesion. (a) Fibro­ cartilage partial lesion of LTIO of a right wrist visualized from 4–5 radiocarpal portal. (b) Midcarpal stability testing through

RMC midcarpal portal (right wrist). (c) Arthroscopic debridement of fibrocartilage partial lesion of LTIO (left wrist, scope in 3–4 portal, full-radius shaver in 6-R portal)

shrinkage. It can be concluded that the electrothermal shrinkage may play a role in the management of partial tears of the SLIO and LTIO ligament. To date, its use is still controversial, because most studies have a short follow-up. In unstable grade 3 or 4 lunotriquetral ligament tears, we consider, as a first approach, arthroscopic debridement combined with pinning of the lunotriquetral joint. After reduction of LT dissociation with the “joy stick maneuver,” two or three K-wires are introduced through a dorsoulnar approach with a meticulous control of dorsal sensory branches of the ulnar nerve branches (Fig. 9.5). Fibrocartilage lesion is debrided in the radiocarpal space and the volar and dorsal vascularized aspect of the ligament is refreshed. Reduction is controlled in the midcarpal articulation

and other lesions are treated at the same time (Fig.  9.6a–c). Osterman and Seidman [21] reported pinning of the lunotriquetral joint and debridement and reported that 16 of 20 patients had complete pain relief. In case of chronic ulnar side pain due to lunotriquetral ligament tears without instability, secondary treatment may involve midcarpal corticosteroid injection and anti-inflammatory local physiotherapy. Arthroscopic treatment of lunotriquetral ligament tears is a reasonable option for injuries that have failed conservative treatment [14] or for Geissler grade 2–4 lesions, but immediate management appears to be more rewarding [15, 22]. In case of failure of these therapeutic options, the secondary treatment of lunotriquetral ligament tears

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1. Reduction of VISI deformity of lunatum 2. Reduction of triquetrum malaligment 3. Pinning of LT jiont under MC scoping control

Fig. 9.5  The “joy stick” maneuver for reduction of LT joint dissociation

includes direct lunotriquetral ligament repair, LTIO reconstruction, or lunotriquetral arthrodesis. Shin et al. [26] performed a retrospective review comparing these three procedures. In his series, the probability for remaining free from complications at 5 years was 69% for reconstruction, 14% for repair, and less than 1% for arthrodesis. Nine of 22 patients undergoing a lunotriquetral fusion went on to nonunion and 5 of 22 patients developed ulnocarpal impaction. The authors concluded that both objective and subjective results were better in the direct repair and the reconstruction groups than in the fusion group. VISI deformity will not respond to any type of lunotriquetral isolated procedure. In this setting, procedures such as a midcarpal fusion or proximal row carpectomy may be indicated.

Therefore, prompt diagnosis in the acute setting may achieve primary ligament healing and possibly avoid later unrewarding reconstructive procedures [17, 18].

Extrinsic Ligaments Lesions Volar Extrinsic Ligament Injury Volar extrinsic ligament injuries in association with distal radius fractures are rare. A violent shearing pattern of injury may be more frequently encountered as observed during fracture dislocation of the radiocarpal joint, as described by Jupiter and Fernandez [13]. A pure fracture dislocation of the joint may appear to

9  Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures

a

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c Scaph Fracture

T

L

LTIO

b Fig. 9.6  Complex perilunar and transscaphoid lesion benefited of an all inside arthroscopic management. (a) Preoperative plain X-ray. (b) Midcarpal control of LT dissociation and scaphoid fracture. (c) Postoperative plain X-rays

have taken place; however, there is usually a small volar fragment (Fig. 9.3) that carries the origin of one or more volar extrinsic ligaments (radioscaphocapitate, long radiolunate, and short radiolunate). Direct reduction and stabilization of the small bony fragment and the associated volar ligaments reestablishes stability. Pinning across the radiocarpal joint for 6 weeks or suturing of a volar plate may still be a necessary adjunct to avoid subluxation or failure of fixation at the small fragment site. The same may be true for volar extrinsic ligament injuries without the associated fragment [34] (see Chap. 11).

Dorsal Extrinsic Ligament Injury Until recently, dorsal extrinsic ligaments have not received the attention of the volar extrinsics in the ­ biomechanic descriptions of the wrist. Nevertheless, the dorsal radiocarpal ligament (DRCL) and dorsal

intercarpal ligament may be frequently injured in association with distal radius fractures [3, 8]. Too often this injury is only recognized later as a shift into volar flexion of the proximal row, stigmatized by the lunate VISI deformity. There may be no apparent damage to the LTIO or other critical wrist ligaments [30]. When this pattern of injury is recognized, 4–6 weeks of radiocarpal pin stabilization may eliminate VISI pattern deformity. The dorsal extrinsic ligaments are allowed to adhere back to their anatomic site of attachment on the dorsum of the proximal carpal row, primarily the lunate distal pole and triquetrum. On the other hand, in most series, the DRCL is underestimated during the standard arthroscopic exam because it is difficult to visualize through the standard dorsal portals. The DRCL is best viewed through the volar radial portal (Fig. 9.7) due to the straight line of sight [27, 28]. David Slutsky proposed a surgical procedure for DRCL repair [29]. A volar radial portal is established at the proximal wrist crease. The flexor carpi radialis is retracted, and the

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radiocarpal space is identified with a 22-gauge needle. A blunt trochar and cannula are inserted, followed by the arthroscope. A hook probe is placed in the 3–4 portal. The DRCL is visualized ulnar to the 3–4 portal (Fig. 9.8a), Fig. 9.7  Dorsal radio carpal ligament (DRCL) lesion visualized from volar portal

a

b

Fig. 9.8  Slutsky procedure for DRCL repair. (a) exploration through radiocarpal volar portal. (b) Introduction of a PDS suture through a needle introduced in 3–4 portal and exteriorized with a 4–5 portal loop-retriever. (c) The suture is tightened. (d) After the suture is tightened, complementary shrinkage can be performed with radiofrequency device

underneath the lunate. A 2-0 absorbable suture is passed through a curved spinal needle that is introduced through the 3–4 portal. The end of the suture is retrieved with a grasper in the 4–5 portal (Fig. 9.8b). After both ends of

9  Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures Fig. 9.8  (continued)

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c

d

the suture are withdrawn, dorsal traction can be seen to pull the torn edge of the DRCL up against the dorsal capsule. One suture is usually sufficient. A curved hemostat is used to pull either end of the suture underneath the extensor tendons, and the knot is tied either at the 3–4 or 4–5 portal after the wrist traction has been released (Fig. 9.8c). The repair is augmented with thermal shrinkage (Fig.  9.8d). Following the repair, the patient is placed in a below-elbow cast with the wrist in neutral rotation for 4 weeks, followed by wrist mobilization. Geissler presented a similar procedure for repairing dorsal TFCC 1C lesions with good results [10].

Conclusion Wrist arthroscopy in distal radius fractures has unique advantageous features, mainly the most accurate assessment of the articular surface reduction and the stabilization [16, 35] of the different fragments and the

evaluation of associated soft-tissue injuries (i.e., LTIO and extrinsic ligaments), which are valuable especially in the treatment of complex intraarticular distal radius fractures [3, 7, 18]. Furthermore, it adds minimal risks than those normally expected of the surgical treatment of a distal radius fracture. There is now enough evidence in the literature to support the effectiveness and safety of arthroscopically-assisted repair of LTIO and extrinsic radiocarpal ligaments contemporary with radius fracture management. At this point, however, because of the lack of prospective, randomized studies comparing arthroscopy with other treatment options for distal radius fractures, one cannot be unequivocal in favor of one method vs. another, and, as always, the surgeon should aim to match the treatment option appropriately with each individual patient’s objective findings and expectations, especially for young athletes, and the surgeon’s own personal experience and expertise in wrist surgery and arthroscopy [11, 24].

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References   1. Cognet JM, Bonnomet F, Ehlinger M, Dujardin C, Kempf JF, Simon P. Contrôle arthroscopique dans le traitement des fractures articulaires du radius distal: à propos de 16 cas. Rev Chir Orthop Reparatrice Appar Mot. 2003;89: 515–23   2. Darlis NA, Weiser RW, Sotereanos DG. Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage. J Hand Surg Am. 2005;30:908–14   3. Fontès D, Lenoble E, de Somer B, Benoit J. Lesions of the ligaments associated with distal fractures of the radius. 58 intraoperative arthrographies. Ann Chir Main Memb Super. 1992;11:119–25   4. Fontès D. Therapeutic interest of wrist arthroscopy [a series of 280 cases]. In: 6th Congress of IFSSH. Bologna: Monduzzi; 1995. p. 723–8   5. Fontès D. Wrist arthroscopy – current indications and results. Chir Main. 2004;23(6):270–83   6. Fontès D. Arthroscopic management of chronic and acute lesions of TFCC of the wrist. Chir Main. 2006;25:178–86   7. Fontès D. Arthroscopie du poignet dans le traitement des fractures récentes et anciennes du radius distal. In: Monographies de la SOFCOT: fractures du radius distal de l’adulte sous la direction de Y Allieu. Exp. Scientifiques publications, 75007 Paris (France); 1998. p. 195-207   8. Geissler WB, Freeland AE, Savoi FH, et al. Intracarpal softtissue lesions associated with an intraarticular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78: 357–64   9. Geissler WB, Freeland AE. Arthroscopically assisted reduction of intraarticular distal radial fractures. Clin Orthop. 1996;327:125–34 10. Geissler WB, Short WH. Repair of peripheral radial TFCC tears. In: Geissler WB, editor. Wrist arthroscopy. New York: Springer; 005 11. Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005;21(3):407–16. 12. Hanker GJ. Radius fractures in the athlete. Clin Sports Med. 2001;20:189–201 13. Jupiter JB, Fernandez DL. Comparative classification of fractures of the distal end of the radius. J Hand Surg Am. 1997;22(4):563–7 14. Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg. 2008;33A(9):1669–79 15. Lindau T, Arner M, Hagberg L. Intra-articular lesions in distal fractures of the radius in young adults: a descriptive arthroscopic study in 50 patients. J Hand Surg Br. 1997;22: 638–43 16. Lindau T. Treatment of injuries to the ulnar side of the wrist occurring with distal radial fractures. Hand Clin. 2005;21: 417–25 17. Luchetti R, Atzei A. Trattamento arthroscopico delle lesioni del legamento luno-piramidale. Riv Chir Mano. 2006;43(3): 380–2

D. Fontès 18. Luchetti R, Papini Zorli I, Atzei A. Ruolo dell’artroscopica nel trattamento delle fratture di radoi. Riv Chir Mano. 2006; 43(3):309–13 19. Mathoulin C, Sbihi A, Panciera P. Intérêt de l’arthroscopie du poignet dans le traitement des fractures articulaires du quart inférieur du radius: à propos de 27 cas. Chir Main. 2001;20(5):342–50 20. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius (an arthroscopically-assisted approach). J Bone Joint Surg. 2000;82B: 79–86 21. Osterman AL, Seidman GD. The role of arthroscopy in the treatment of lunotriquetral ligament injuries. Hand Clin. 1995;11:41–50 22. Richards RS, Bennett JD, Roth JH, Milne K. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg. 1997;22A: 772–6 23. Ruch DS, Poehling GG. Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist. J Hand Surg. 1996;21A:412–7 24. Ruch DS, Vallee J, Poehling GG, Paterson Smith B, Kuzma GR. Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fracture. J Arthrosc Relat Surg. 2004;3:225–30 25. Shih JT, Lee HM. Monopolar radiofrequency electrothermal shrinkage of the scapholunate ligament. Arthroscopy. 2006; 22:553–7 26. Shin AY, Weinstein LP, Berger RA, Bishop AT. Treatment of isolated injuries of the lunotriquetral ligament (a comparison of arthrodesis, ligament reconstruction and ligament repair). J Bone Joint Surg. 2001;83B:1023–8 27. Slutsky DJ. Volar portals in wrist arthroscopy. J Am Soc Surg Hand. 2002;2:225–32 28. Slutsky DJ. Incidence of dorsal radiocarpal ligament tears in the presence of other intercarpal derangements. Arthroscopy. 2008;24(5):526–33 29. Slutsky DJ. Arthroscopic dorsal radiocarpal ligament repair. Arthroscopy. 2005;21(12):1486 30. Viegas SF, Patterson RM, Peterson PD. Ulnar sided perilunate instability: an anatomic and biomechanic study. J Hand Surg Am. 1990;15:268–78 31. Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg. 1996;78A:348–56 32. Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg. 1997;22A:344–9 33. Westkaemper JG, Mitsionis G, Giannakopoulos PN, Sotereanos DG. Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries. Arthroscopy. 1998; 14:479–83 34. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem Surg. 2006;10: 139–44 35. Wiesler ER, et al. Arthroscopic management of distal radius fractures. J Hand Surg. 2006;31A:1516–26

Management of Concomitant Scaphoid Fractures

10

Christophe Mathoulin

Introduction The treatment of scaphoid fractures has evolved from a conservative long standing cast immobilization to a more operative approach over the last three decades. As a result of the important physical and economic morbidity in these fractures and the high rate of nonunion in unstable fractures, open reduction and internal fixation has become a recommended and well-accepted treatment for displaced and unstable scaphoid fractures [1, 7, 12]. In this context, Herbert and Fischer, in their classic paper in 1984, advocated the use of a new double-threaded bone screw to fix the scaphoid [7]. Due to the importance of preserving the surrounding ligaments of the carpal bones, different operative techniques and modifications have been proposed [4]. These have evolved to avoid destabilization of the reduction and to protect the fragile blood supply of the scaphoid bone. In particular, the minimally invasive and percutaneous techniques with cannulated or noncannulated screws were published with good results [2, 5, 8, 9]. Using a combined arthroscopic examination procedure for the wrist while treating a scaphoid fracture was the next innovative step. Whipple first presented a method of percutaneous screw fixation using a modified Herbert screw and control of the fracture reduction using image intensification and arthroscopic evaluation [18, 19]. In addition, the assessment of potential associated ligamentous and bony injuries is a crucial advantage of this technique.

C. Mathoulin Institut de la Main, Clinique Jouvenet, 6 Square Jouvenet, 75016 Paris, France e-mail: [email protected]

We describe our arthroscopic technique point-by-point, illustrated in detail with an emphasis on the important surgical principles. These include verification of precise fracture reduction, avoiding intraarticular screw exposure, maintaining the fixation under compression, and allowing an early return to the activities of daily living.

Indications The aim of this technique is stable fracture fixation allowing early mobilization without compromising bony union. Neutralization of the fracture forces is important, while compressing the fracture. The disabling long cast immobilization in this mostly young and active patient population along with the risk of nonunion or malunion favors surgical reduction and internal fixation of the scaphoid fractures. The minimally invasive technique and hence limited operative trauma allows early functional rehabilitation. Arthroscopy helps to reduce the fragments, control the quality of the reduction and to assess the screw position, especially with regard to the radiocarpal joint. Ideally, the patient has obtained fully informed consent, i.e., they are cognizant of treatment aims and understand the risks and benefits. They should also be motivated to achieve an early return to work or sporting activities. The delay between trauma and surgery should be as short as possible and certainly not more than 1 month. Emergency surgery should be delayed if the conditions are suboptimal. In these situations, the wrist should be immobilized until the conditions are more ideal. We only perform an anterograde introduction of the screw in proximal pole fractures (Herbert type B3). More commonly, a retrograde percutaneous fixation is done.

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Absolute contraindications are noncooperative patients and comminuted fractures. Advanced age, cutaneous lesions, suboptimal operative conditions (e.g., inadequate surgical equipment), and severe associated injuries (e.g., severe scapholunate dissociation) are relative contraindications.

Logistics It is crucial in cases of scaphoid fractures associated with distal radial fractures, to ideally plan both osteo­ syntheses. 1. If the scaphoid fracture is undisplaced, we initially fix the scaphoid in order to avoid any secondary displacement of the scaphoid fracture during maneuvers to reduce the distal radius fracture. Once the scaphoid has been correctly fixed, we then treat the radius fracture. 2. If the scaphoid fracture is displaced, we then reduce and treat the distal radius fracture, and once the radius is correctly reduced and stabilized, we treat the scaphoid as described below. Only in the case of proximal pole fracture do we use a dorsal approach, with initial fixation of the scaphoid with an anterograde screw, then treatment and fixation of radius. We avoid the dorsal approach as much as possible simply because we do not prefer to go through the cartilage. With the retrograde approach, the cartilage is left completely intact, thereby avoiding any chondral changes in future.

C. Mathoulin

The first step is to introduce (after positioning the wrist on the table in slight extension) a retrograde (from distal to proximal) 1-mm K-wire through a small (2 mm) incision to the distal tubercle of the scaphoid in a retrograde fashion (Figs. 10.1–10.6). We always try not to breach the scaphotrapezial joint. The wrist is then put under traction, allowing arthroscopic control to verify the reduction of the scaphoid (Figs. 10.7 and 10.8). The Finochietto interdigital traction device is placed outside the arm table while still allowing positioning of the image intensifier. First, the fracture is visualized under arthroscopy using standard portals 3–4, 4–5, midcarpal ulnar (MCU), midcarpal radial (MCR). The arthroscope is then introduced in the radial midcarpal portal (MCP) through which the fracture can be assessed very easily (Figs. 10.9 and 10.10). If necessary a debridement of the articulation can be done with the shaver while cleaning the medial

Fig. 10.1  Extended position of the wrist using a pad with 2-mm incision to the scaphoid tubercle

Technique Under ambulatory conditions, the operation is performed with locoregional anesthesia, mostly under an axillary plexus block. The patient is placed in the supine position on a special arm table with a tourniquet on the arm applied as proximal as possible. During the critical parts of the operation, the forearm can be extended using a pad underneath the wrist (Fig. 10.1). Of course, if a concomitant distal radial fracture is present, an open reduction and internal fixation of this fracture is done first, before fixing the scaphoid.

Fig. 10.2  K-wire introduction under fluoroscopic control

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Fig. 10.3  Clinical operative view of the percutaneous K-wiring retrogradely

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Fig. 10.6  Classical position of the K-wire directed 45° dorsally and 45° ulnar deviation

Fig.  10.4  Earlier open reduction and internal fixation of the concomitant distal radial fracture

Fig. 10.7  Arthroscopic radiocarpal control with the K-wire in situ

Fig. 10.5  Fluoroscopic control of the K-wire positioned in the proximal pole

(ulnar) surface of the scaphoid. If the fracture is displaced, reduction of the fragments is possible with a small retractor introduced through the STT midcarpal portal. Therefore, under arthroscopic control, the fracture fixation K-wire is slightly pulled back from the fracture line (within the distal scaphoid), the fracture is then reduced, and the pin is advanced into the proximal fragment (Figs. 10.11–10.15). Once a satisfactory

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Fig. 10.8  Arthroscopic midcarpal view

Fig.  10.10  MCR portal visualization of the displaced frac­ ture after initial K-wire fixation demonstrating unsatisfactory reduction

Fig. 10.9  Fracture fixation and localization of the K-wire

Fig. 10.11  Retraction of the K-wire under arthroscopic control

reduction is achieved, the hand is removed from the traction device and the wrist is positioned on the pad on the arm table. Under fluoroscopic control, the hole for the screw is then tapped (Fig.  10.16). Drilling is different between proximal and distal poles. A 3 mm diameter tap is used for the proximal pole (Fig. 10.17). However a 3.5 mm diameter tap is used for the distal scaphoid pole (Fig. 10.18). The diameter of the tap is of course, dependent on the type of the screw used.

The screw is then inserted over the guide wire under fluoroscopic control (Figs.  10.19–10.21). The radiocarpal compartment is then visualized arthroscopically through the 3–4 radiocarpal portal (Fig. 10.22). This allows to verify the absence of any intraarticular exposure of the advancing screw head of the dorsal scaphoid cartilage (Fig. 10.23). Then the entire radiocarpal compartment is inspected to assess potential associated lesions. Midcarpal exploration allows the

10  Management of Concomitant Scaphoid Fractures

Fig. 10.12  Reduction maneuver with teaser and manipulation of the thumb

Fig. 10.13  Palpation of the fracture side and reduction maneuver with a teaser or probe

inspection of the fracture line at the ulnar articular surface of the scaphoid, along with assessment of the reduction quality (Figs.  10.24 and 10.25). In case of insufficient compression, the screw can be redrilled while visualizing the compressive effect. The STT articulation remains untouched. It is important to bury the screw head under the distal articular scaphoid surface (Fig.  10.26). The incisions are not closed. Postoperatively, the wrist is left unprotected. A simple volar splint can be applied after the first dressing to ease postoperative pain.

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Fig. 10.14  Postreduction, accurate fracture fixation pinning via the arthroscope

Fig.  10.15  Final result after replacement of the K-wire with closure of the fracture side, seen through a MCR portal view

Fig. 10.16  Fluoroscopic control while tapping the fracture

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Fig. 10.20  Need to bury the head of the screw deep enough Fig.  10.17  Tapping 3  mm till proximal pole of the fractured scaphoid over the K-wire

Fig. 10.21  Fluoroscopic check for the correctly-positioned screw

Fig. 10.18  Tapping 3.5 mm of the distal pole of the fractured scaphoid over the K-wire

Fig.  10.22  Control by radiocarpal arthroscopic (3–4 portal) view of the proximal pole to avoid proximal intraarticular penetration of the screw Fig. 10.19  Introducing the cannulated Herbert double-threaded screw

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Fig. 10.25  Final midcarpal view of the fracture after compression

Fig.  10.23  Control by radiocarpal arthroscopic (3–4 portal) view of the proximal pole to avoid proximal intraarticular penetration of the screw

Fig. 10.26  Take care of the positioning of the screw head under the distal scaphoid surface, not to harm the scaphotrapezial joint

The important aspects of the operative technique are:

Fig. 10.24  Midcarpal control of the reduced fracture site

• Arthroscopic assessment of the midcarpal joint to verify anatomic reduction. • Partial pull back of the K-wire from the proximal portion of the scaphoid back into the distal scaphoid (i.e., not crossing the fracture line) can be done in case of an inadequate reduction. Readvancement of the K-wire is then performed under arthroscopic control upon anatomic reduction of the displaced scaphoid. • Drilling and precise mechanical tapping are separately performed for both distal and proximal poles, depending on the type of the screw used. • Systematic arthroscopic radiocarpal examination is done at the end of the surgery to verify the nonexposure of the screw, i.e., nil articular surface involve­ment.

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The risks of the procedure are: • Seemingly satisfactory screw position under fluoroscopy, although in reality intraarticular screw positioning has occurred with an overlapping screw tip. Arthroscopic radiocarpal control at the end of the operation avoids this potential mistake. • Scaphoid fixation of a nonreduced or insufficiently reduced fracture. In addition, perioperative complications can often be diagnosed and managed arthroscopically. Some examples include: • Excess length of the screw tip with intraarticular exposure of the proximal pole of the scaphoid is possible. Radiocarpal arthroscopic control can reveal this error, although intraoperative imaging can also do so. • Fracture of the guide wire can occur. Arthroscopicguided removal can then be carried out.

Discussion The incidence of combined injuries of scaphoid and distal radius varies from 0.7 to 6.5% of all distal radius fractures. High-energy loading on an outstretched, radially deviated, dorsiflexed wrist leads to this kind of injury and often the associated scaphoid fracture is displaced and angulated requiring surgical intervention [11]. Therefore, this technique is not only applicable in isolated scaphoid fractures but can be extended to treating a concomitant scaphoid and distal radius fracture. However, this combined technique can be more technically demanding. Numerous recent studies have shown the capability of percutaneous fixation of scaphoid fractures using cannulated screws [5, 8, 9, 21]. The various cannulated screw types underline the interest in this method and compete with the classical conservative method of forearm immobilization for 3 months. Several studies confirm the increased rate of fracture union with this method [5, 8, 9, 14]. The time to union in nondisplaced fractures seems to be shorter with percutaneous screw fixation. Shin et al. reported in their randomized study (percutaneous screw fixations vs. conservative treatment) a union time of 4–5 weeks after percutaneous screw fixation [14].

C. Mathoulin

Wrist arthroscopy combined with percutaneous screw fixation assists in avoiding certain complications, which are relatively frequent in internal fixation of the scaphoid. Filan and Herbert found fourteen intraarticular (Herbert) screw penetrations in their series of 431 patients [3]. Arthroscopic radiocarpal control after screw fixation can detect and avoid screw tip exposure of the proximal pole. Arthroscopic midcarpal examination also allows the assessment of the accuracy of fracture reduction after screw fixation. We agree with Whipple that direct visual examination of the reduction quality is much more efficient than fluoroscopic evaluation [20]. Direct visualization of fracture compression is an added source of security to the surgeon. Fracture compression can be followed closely and clearly via the radial midcarpal portal. The possibility to diagnose and treat associated injuries with arthroscopic exploration of the wrist has been described by many authors [13, 20]. Shin et al. have found eleven intracarpal lesions during arthroscopic exploration in a series of 15 displaced scaphoid fractures, which were treated with arthroscopic reduction and percutaneous fixation [14]. Most of them were minor lesions, but the authors also found two complex scapholunate lesions, which were treatable with reduction and pinning. Due to the need for reduction, displaced scaphoid fractures usually required classic open reduction [1, 15]. However, the realization that the reduction could be maintained by external maneuvers justified the use of percutaneous screw fixation [6]. If one could not maintain the reduction, conversion to the open procedure was indicated. While introducing the screw from distal to proximal, we always try to avoid entering and injuring the scaphotrapezial joint. Interestingly, a transtrapezial modification of the volar percutaneous technique was recently proposed with no degenerative changes of the scaphotrapezial joint in a group of 41 patients with a mean follow up of 36 months [10]. Nevertheless, we have not found any problems introducing the screw and therefore always try not to involve the scaphotrapezial joint. In essence, with the volar approach (retrograde technique) we reduce the scaphoid with arthroscopic assistance, while with the dorsal approach (anterograde technique) screw insertion is done under fluoroscopy, and only at the end, do we place the scope into the joint to ensure accurate reduction [17]. We recently reviewed our own series of 53 scaphoid fractures in 52 patients (one bilateral case) treated by

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Table  10.1  Classification of scaphoid fractures according to Schernberg Displacement Type II Type III Type IV None

6

24

5

<2 mm

 7

8

>2 mm

 1

2

arthroscopic-assisted percutaneous screw fixation between 2001 and 2008 with a mean follow-up of 24.7 months (range 6–50 months). The male to female ratio was 5.6:1. The mean age was 34.8 years. There were 16 left hands and 37 right hands with 52/53 involving the dominant side. Fractures were classified according to Schernberg [16] (Table 10.1). Mean delay of time to treatment was 8.43 days. An arthroscopic reduction was necessary in 19 cases. Mean duration of surgery was 23.9 min (range 10–45 min). Concomitant injuries that were identified include one scapholunate ligament tear, one distal radial fracture, and three TFCC lesions that all were treated in the same operation. In five cases, we had to change the initial screw because of intraarticular screw exposure that was revealed arthroscopically. Radiologic consolidation was seen after 1.56 months (Figs. 10.27–10.30). Return to activities ranged between 1 and 45 days (mean 8.5 days). In four cases, a second operation with screw removal was performed secondary to STT joint pain.

Fig. 10.27  Case presentation of a displaced scaphoid fracture preoperatively

Conclusion It is clear that wrist arthroscopy is a rapidly evolving tool in the surgical armementarium for treating wrist and carpal pathology. We are convinced that this technique has its place in the specific indication of an isolated or combined scaphoid injury. It not only assists to avoid screw exposure in the radiocarpal joint, but also in fracture reduction maneuvers if necessary. We mostly opt for retrograde screw placement in order to avoid harming the proximal scaphoid surface. On the other hand, the possibility of developing secondary osteoarthritis of the STT joint has to be followed up after this approach. Therefore, removing the screw after 1 year or using absorbable screws may also be an appropriate alternative.

Fig. 10.28  Postoperative X-ray with radiological consolidation (absorbable screw)

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References

Fig. 10.29  Another displaced scaphoid fracture preoperatively

Fig. 10.30  Nonabsorbable screw fixation with union

Acknowledgments  The author acknowledges Arne Decramer’s assistance in reviewing the patients and writing this article.

  1. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Rel Res. 1980;149:90–7   2. De Vos J, Vandenberghe D. Acute percutaneous scaphoid fixation using a non-cannulated Herbert screw. Chir Main. 2003;22:78–83   3. Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Am. 1996;78:519–29   4. Gelberman RH, Menon J. Vascularity of the scaphoid bone. J Hand Surg Am. 1980;5:508–13   5. Haddad FC, Goddard NJ. Acute percutaneous scaphoid fixation: a pilot study. J Bone Joint Surg Br. 1998;80:95–9   6. Herbert TJ. Internal fixation of the scaphoid – history. Le Scaphoïde. Sauramps; Montpellier; 2004. p. 125–9   7. Herbert TJ, Fischer WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984; 66-B:114–23   8. Inoue G, Sionoya K. Herbert screw fixation by limited access for acute fracture of the scaphoid. J Bone Joint Surg Br. 1997;79:418–21   9. Ledoux P, Chahidi N, Moermans JP, et  al. Percutaneous Herbert screw osteosynthesis of the scaphoid bone. Acta Orthop Belg. 1995;61:43–7 10. Meermans G, Verstreken F. Percutaneous transtrapezial fixation of acute scaphoid fractures. J Hand Surg Br. 2008;33(6): 791–6 11. Merrell GA, Slade JF III. Simultaneous fractures of the scaphoid and distal radius. In: Slutsky DJ, Osterman AL, editors. Fractures and injuries of the distal radius and carpus. Philadelphia: Saunders Elsevier; 2009 12. Retig AC, Kollias SC. Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med. 1996;24: 182–6 13. Shih JT, Lee HM, Hou YT, et  al. Result of arthroscopic reduction and percutaneous fixation for acute displaced scaphoid fractures. Arthroscopy. 2005;21:620–6 14. Shin A, Bond A, McBride M, et  al. Acute screw fixation versus cast immobilisation for stable scaphoid fractures: a prospective randomized study. Presented at the 55th American Society of surgery for the hand, Seattle; 5–7 Oct 2000 15. Schernberg F. Les fractures récentes du scaphoïde. Chir Main. 2005;24:117–31 16. Schernberg F, Elzein F, Gerard Y. Etude anatomo-clinique des fractures du scaphoïde carpien. Problème des cals vicieux. Rev Chir Orthop. 1984;70(II suppl):55–63 17. Slade JF III, Taksali S, Safanda J. Combined fractures of the scaphoid and distal radius; a revised treatment rationale using percutaneous and arthroscopic techniques. Hand Clin. 2005;21(3):427–41 18. Whipple T (ed) Arthroscopic surgery. In: The wrist. Philadelphia: Lippincott; 1992 19. Whipple TL. Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am. 1995;26:749–54 20. Whipple TL. The role of arthroscopy in the treatment of intra-articular wrist fractures. Hand Clin. 1995;11:13–8 21. Wozasek GE, Moser KD. Percutaneous screw fixation of fractures of the scaphoid. J Bone Joint Surg Am. 1991;73: 138–42

11

Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations Mark Henry

Introduction By virtue of its complex anatomy, the human wrist is subject to a wide variety of injury patterns resulting from similar mechanisms of injury. The most common mechanism of injury occurs when force is transmitted through the wrist, ascending from a palmar contact as the patient resists a fall or other contact. The second major mechanism of injury occurs when the wrist itself is directly trapped between two hard objects and subjected to a crushing force. Other mechanisms are also possible but less frequent. The force transmitted through the tissues of the wrist becomes dissipated as energy is consumed to disrupt various structures, both bony and ligamentous. The force typically travels along identifiable pathways. Recognizing one injured structure that is more obvious leads the surgeon to identifying other injured structures that are less obvious. Multiple structures may be injured during the same traumatic event. Fracture dislocations of the wrist include those injuries that fracture the distal radial (DR) articular margin and carpal bones of both the proximal and distal rows. Ligament structures that may be involved in fracture dislocations of the wrist include: The intrinsic ligaments (Fig. 11.1):

The volar extrinsic ligaments (Figs. 11.1 and 11.2): • • • • • • •

Radioscaphocapitate (RSC) Long radiolunate (LRL) Short radiolunate (SRL) Ulnolunate (UL) Ulnocapitate (UC) Ulnotriquetral (UT) Also included are the extension fibers and individual additional ligaments crossing the midcarpal joint

The dorsal extrinsic ligaments (Fig. 11.2): • Dorsal radiocarpal (DRC) • Dorsal intercarpal (DIC) For the purpose of this chapter, the term fracture dislocations of the wrist is meant to encompass perilunate

• Scapholunate interosseous (SLIL) • Lunotriquetral interosseous (LTIL) • Intrinsic ligaments between the carpal bones of the distal row (i.e., capitohamate)

M. Henry, MD Hand and Wrist Center of Houston, 1200 Binz Street, 13th Floor, Houston, TX 77004, USA e-mail: [email protected]

Fig. 11.1  The intrinsic carpal ligaments: scapholunate interosseous (SLIL), lunotriquetral interosseous (LTIL), and the intrinsic ligaments of the distal carpal row

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_11, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 11.2  The radiocarpal extrinsic ligaments: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL), ulnolunate (UL), ulnocapitate (UC), ulnotriquetral (UT), dorsal radiocarpal (DRC)

dislocations, perilunate fracture dislocations, radiocarpal dislocations, and radiocarpal fracture dislocations. Predictable patterns of injury are by far the most common, but any pattern of injury is possible. It is this possibility that makes a thorough arthroscopic assessment of the extent of injury so important.

Indications Any patient presenting with a mechanism of injury that is capable of producing sufficient force to disrupt bone

Fig. 11.3  (a) Radiocarpal fracture dislocations can sometimes be difficult to fully appreciate from a single view. (b) The lateral view is usually the best to assess the congruence between the proximal row and the distal radius. In this case, the lunate is impacted into a dorsal defect in the radius, as outlined on the lateral view despite the relatively unimpressive PA view

M. Henry

or ligament tissue must be considered to have sustained a structural injury of the wrist until proven otherwise. There are a number of ways to acquire sufficient evidence that the patient has not sustained a structural injury of the wrist. Lack of an acute structural disruption of the wrist can be ascertained by history alone, if an accurate account demonstrates that only minor forces were experienced during the incident. Otherwise, the surgeon must obtain details such as the weight of the object, the distance that the patient fell, the position of the wrist at the time of contact, and the point on the body at which contact was made. Physical examination includes the degree and location of swelling, ecchymosis (release of blood implies some degree of structural disruption), deformity, and the range of motion possible without severe pain. A patient who is able to move through a full range of motion without pain is unlikely to have a structural disruption of the wrist. Plain two dimensional radiographs should be present at this stage (Fig. 11.3). A truly nondisplaced fracture may not be evident. Most displaced fractures will be evident. Displaced but smaller fracture fragments in the carpus may be obscured by overlap. If a major destabilizing fracture dislocation injury has been identified at this stage, more aggressive physical examination is not warranted. If there is no evidence of such an injury yet, stress examination is then appropriate. The surgeon should test all the critical structures with the appropriate stress examination, judging both the pain response and physical evidence of instability. If the patient has

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Fig. 11.4  Final motion after arthroscopically-reduced complete radiocarpal pure ligamentous dislocation that presented late at 4 weeks following injury (Fig. 11.19)

excessive pain, local anesthetic injection into the wrist joint can alleviate discomfort enough to allow ligament stress examination to be performed accurately. The SLIL is tested with the scaphoid shift test of Watson. The LTIL is tested by the shear test. The extrinsic radiocarpal joints are tested with ulnar translation shift and sagittal plane shift tests of the whole hand/carpal unit vs. the forearm. If the patient has normal range of motion, normal X-rays and a normal stress examination, that is sufficient to conclude that no structural injury has occurred and no further investigation is needed. If the patient has a high energy mechanism of injury, normal X-rays, but does not pass the stress examination, then further investigation is warranted. Additional nonsurgical tools may be appropriate at this point. Computed tomography (CT) is the best test to demonstrate the presence of a fine, nondisplaced fracture line in the carpus or distal radius and can also define the exact pattern of the fracture plane. When coupled with arthrogram, this may also constitute the best nonsurgical assessment of ligamentous injury. Magnetic resonance imaging (MRI) is useful for revealing bone edema which signifies the presence or absence of bony injury, but does not identify the pattern of a fracture as effectively as a CT scan. Thus, the main indication for an MRI is to rule out the presence of any significant bone edema and also to lend support to the physical stress examination with respect to ligament injury. A negative MRI or CT scan is not sufficiently accurate in its own right to conclude that the patient does not have a structural ligament injury of the wrist; arthroscopy may still be needed in such cases. The question of whether arthroscopic management of these injuries produces superior results to open reduction and fixation has not been definitively answered with randomized prospective studies. The arguments that favor arthroscopic management include the improved visualization of anatomy and opportunity to test structural integrity. The primary argument

is that if additional soft tissue trauma is not inflicted to the pericapsular structures, the total volumetric burden of scar tissue formation will be reduced. This, in turn, should lead to an improved range of motion and functional status (Fig. 11.4).

Technique The most important point to keep in mind with fracture dislocations of the wrist is that any combination of injured structures is possible. This is where the ­arthroscope excels, because when combined with physical examination and radiographic images, no lesion should go undiscovered. This also means that the surgeon will not use the same exact approaches, arthroscopic portals, methods of fixation, or sequence of steps on every case. Although simple arthroscopy cases are approached from only a limited access perspective, complex arthroscopic wrist trauma necessitates circumferential access to the wrist at all times during the case (Fig. 11.5). In the end, the arthroscope is just what its name indicates, a means of watching what one is doing. Nearly all, if not truly all, observations concerning articular reduction and ligament integrity should be made with the arthroscope and not with arthrotomy (Fig.  11.6). At the same time, this does not mean that the arthroscope must be inside the joint throughout the entire case. Some steps in the case are performed without the arthroscope, and then the arthroscope is reintroduced to evaluate current anatomy. In the technique descriptions that follow, the term mini incision indicates a less than 1 cm incision made for the purpose of checking cutaneous nerves (superficial radial, dorsal ulnar branch) or to pass drill bits or other surgical instruments but without any attempt to visualize deeper than the level of the nerves. The term small incision indicates an incision between 1 and 2 cm in length whose purpose is to directly ­visualize a

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Fig. 11.7  Instruments adapted for specialized purpose of small bone manipulation (top to bottom): pointed Kleinert elevator, dental pick, micro double ended curette, gauze packer

Fig. 11.5  Arthroscopic set up necessary to have circumferential access to the wrist for portals and fixation from all sides. Overhead traction boom eliminates any obstructive device on the hand table

Each disrupted anatomic structure may be considered as one element. A given injury pattern may be comprised of any number of elements. The following descriptions of surgical technique will cover strategies for individual elements. The surgeon merely has to take each of these and combine them for a successful surgical plan. Combining elements is most successful when following these rules: Stabilize from proximal to distal, beginning with the platform of the distal radius. • Perform all bony fixations prior to ligament repairs • Retest ligament stability after completing bony fixations • Use all three methods of final evaluation when finished −− Complete arthroscopic survey −− Image intensifier evaluation −− Physical examination for alignment and congruent articulation

Fig.  11.6  Viewing past the scaphoid (S) to test the intact radioscaphocapitate (RSC) and long radiolunate (LRL) origins from distal radial (DR) margin

deep target for the sake of accurately placing hardware (such as a headless compression screw). Specialized instruments for small bone work facilitate the often tricky maneuvers required to achieve the reduction of small bone fragments or individual carpal bones. These include a micro-curette, Kleinert periosteal elevator, dental pick, and gauze packer (Fig. 11.7). Each one has specific uses for which it is best suited.

Marginal Fragments from the Distal Radius Radiocarpal fracture dislocations occur via disruption of the extrinsic carpal ligaments (most importantly the RSC, LRL, SRL, and UC). Although these disruptions can occur through the midsubstance, they frequently occur by way of fracture at the ligament origin from the remaining radius (Fig. 11.8). These fragments can be thin shells barely visible on X-ray or substantial fragments that can be securely fixed with headless

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Fig. 11.10  Arthroscopically reduced volar rim (VR) fracture associated with volar radiocarpal fracture dislocation involving lunate fossa (LF)

Fig.  11.8  The most common pattern of radiocarpal fracture dislocation occurs with the pathway of disruption passing through the radial styloid (RSC stays attached to styloid) then tearing the remainder of the volar extrinsic (and dorsal extrinsic) ligaments including the LRL and SRL

compression screws (Fig.  11.9). The most common fragment comes off volar and radial and carries with it the RSC ± the LRL origin (Fig.  11.10). The pattern may also be more complex with destabilizing marginal

Fig. 11.9  (a) When the RSC ligament has been detached via a moderately sized fragment of the radius and the remaining ligaments torn midsubstance, adequate stability can be provided to the radiocarpal joint for a congruent reduction by (b) rigid fixation of the ligament origin alone without transarticular pinning of the radiocarpal joint

fractures displaced in multiple planes (Fig. 11.11). The approach is a mini incision to protect the superficial radial nerve (SRN). The reduction is arthroscopic since these are intraarticular fractures (Fig.  11.12). Viewing from the 4,5 portal, the fracture site is prepared with the micro-curette to remove the clot from the fracture interface followed by the suction shaver that clears the clot from the joint space entirely. The surgical working portals for the curette and shaver include the 3,4 portal, the 1,2 portal, and the flexor carpi radialis (FCR) volar portal (Fig.  11.13). The smaller fragment is compressed against the remaining radius using the pointed end of the Kleinert elevator

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Fig. 11.11  (a) Some bony disruptions of the ligament margins are more complex. (b) To prevent subluxation, rigid stabilization is needed in all planes of disruption (arrow) if a transarticular pin is to be avoided

Fig. 11.12  Reduced fracture (arrow) that separated the radial styloid fragment (RS) from the scaphoid fossa (SF) and extended into the tear of long radiolunate ligament (LRL) Fig. 11.14  Reduction and stabilization of the RSC origin fragment of the radial styloid includes direct pressure by the Kleinert elevator to close the fracture line under arthroscopic observation and guidewire placement in the subchondral position, to be followed by a headless compression screw

Fig. 11.13  Arthroscopically reduced dorsal rim (DR) fracture from the scaphoid fossa (SF) associated with dorsal radiocarpal fracture dislocation

while the guidewire for a headless cannulated compression screw is placed from radial to ulnar (Fig. 11.14). Prior to preparatory drilling for the screw, a second wire placed out of the plane of the first wire can assist in preventing fragment sliding or spinning on the guidewire. Fixation is completed by drilling, depth gauging, and screw placement. A single headless compression screw is not always possible depending on the fragment size and exact location. For very small fragments, the only hardware

11  Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations

Fig. 11.15  (a) Some disruptions are a very complex combination of bone fragments in multiple planes and (b) midsubstance ligament failure. (c) As long as the lunate facet remains stable relative to the proximal radius, the remaining injury can be (d)

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reconstructed back to the reference point of the lunate facet. (e) Ensuring a congruent radiocarpal reduction can necessitate (in the most severe cases) a combination of rigid bony fixation and transarticular pinning of the radiocarpal joint

possible may be a K-wire or very thin threaded pin, in which case the fixation should not be considered rigid, and transarticular pinning is required (Fig.  11.15). Other situations allow the fragments to be trapped against the radial margin by small contoured plates taken from modular hand fixation sets. The surgeon must judge each of these fixations at the time when it is accomplished to assign rigid fixation status (no transarticular pinning needed) or the status of well reduced but not stable (transarticular pinning required).

Extrinsic Ligament Midsubstance Disruption (or Marginal Fragment of Inconsequential Size) The goal in these cases is to create the proper healing en­vi­ronment for the volar extrinsic ligaments (Fig.  11.16). Classic texts have called for wide open approaches and direct suturing of the torn ligament

Fig.  11.16  In a pure radiocarpal dislocation, intrasubstance tearing or marginal avulsion without a substantial bony fragment occurs for all of the extrinsic ligaments

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started after 6 weeks, the final range achieved can be excellent as long as the surgeon does not create added scar tissue with unnecessary open surgical dissection (Fig.  11.4). The broad surface of contact for healing and the robust posttraumatic fibroplasia make the extrinsic ligament injury site a very different biologic environment than the intrinsic injury site (Fig. 11.20).

Carpal Fractures in a Perilunate Fracture Dislocation Pattern Fig. 11.17  Free margins of RSC ligament and LRL ligament avulsed from distal radius (DR) articular margin

Fig.  11.18  Free edge of ruptured volar extrinsic ulnolunate (UL) and ulnotriquetral (UT) ligaments

ends. This is not necessary. The degree of trauma that disrupts the stout volar extrinsic ligaments generates a tremendous fibroplasia response at the site of injury. All that is required to achieve sound ligament healing is to have the radiocarpal joint congruently reduced and to be sure that neither ligament edge (proximal or distal) is interposed in the joint (Fig. 11.17). Viewing from the 4,5 portal, any loose ligament tissue interposed in the joint is swept volarly with a simple motion of the arthroscopic trocar inserted through the 1,2 portal (Fig. 11.18). The joint is pinned from radius to carpus with a 1.6 mm K-wire for 4 weeks (Fig. 11.19). This is half the length of the time required for pinning of intrinsic ligament injuries (SLIL, LTIL). Once motion is

The term “greater arc injury” is supposed to mean that the pathway of disruption through the wrist has passed through bone tissue, causing fractures of the carpal bones (Fig. 11.21). This is distinguished from “lesser arc injury” where the only carpal disruptions are ligamentous. A “greater arc injury” is an advantage for the patient since bone to bone healing will restore a sound carpal unit more reliably than healing of the short fibers of the intrinsic ligaments. The most commonly fractured carpal bone in a perilunate fracture dislocation is, of course, the scaphoid, but triquetral fractures are also frequently encountered (Fig. 11.22). The evaluation and approach to the scaphoid are arthroscopic. If widely displaced, the reduction may be aided by a short incision for accuracy sake. Even when every aspect of the scaphoid’s articular cartilage fracture interface is well-visualized arthroscopically, the fracture can still be imperfectly reduced along its radial and volar borders. The surgeon has the choice of placing the headless compression screw retrograde (distal entry via the STT joint) or antegrade (entry through the proximal pole). It is not possible to place a retrograde screw down the most central axis of the scaphoid, the most perpendicular to the fracture line of a waist fracture; antegrade placement is better (Fig. 11.23). Tools that facilitate maintaining tight compression across the reduction without having to make a full open approach to the scaphoid are the dental pick inserted through the STT portal (used to pull proximally on the distal fragment and resist its pronation) and the Kleinert elevator’s sharp end on the proximal pole (used to resist push back during drill and screw advancement (Fig. 11.24). Even though headless screws exert compression by virtue of the tapering differential pitch of their threads, if the fracture site is not already maximally compressed when initiating the sequence of

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Fig. 11.19  (a) Most radiocarpal dislocations are dorsal, but any pattern can occur such as this volar radiocarpal dislocation. (b) Note the very small flake of bone from the volar radial rim (arrow)

traveling volarly with the displaced carpus. (c) Stability is achieved through radiocarpal pinning for 4 weeks and fixation of the associated ulnar fracture (cross reference Fig. 11.4)

Fig.  11.20  A late presenting radiocarpal dislocation demonstrates the reactive scar formation(center) in the interval spanning the articular surface (left) to the edge of the volar extrinsic ligament (right), prior to debridement and joint reduction

Fig.  11.21  The most common pattern of perilunate fracture dislocation occurs with the pathway of disruption passing through the scaphoid waist (SLIL remains intact) then tearing the LTIL followed by sagittal plane subluxation or dislocation

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Fig. 11.22  After the basic transscaphoid perilunate dislocation, the next most common “greater arc injury” pattern is a transscaphoid, transtriquetral perilunate dislocation

Fig. 11.23  Only an antegrade screw placed from proximal to distal can achieve the ideal central pathway in the scaphoid and come as close as possible perpendicular to the fracture plane in the waist (as opposed to a retrograde screw)

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Fig. 11.24  Percutaneous techniques to control scaphoid reduction and compression while placing the guidewire and headless compression screw antegrade include lifting the distal pole of the scaphoid and compressing in a proximal direction with the dental pick as well as applying a distally directed compression force to the proximal pole fragment with the Kleinert elevator

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Fig. 11.25  In a purely ligamentous perilunate dislocation, both the SLIL and the LTIL experience intrasubstance rupture or marginal avulsion

steps for screw placement, final compression will not be ideal. The scaphoid plays such a critical role in the stability of a perilunate fracture dislocation that a compression screw should be used. Fractures of other carpal bones are more forgiving, and 1.14  mm K-wire fixation is an acceptable alternative if fragments are not large enough to permit the use of a screw.

Intrinsic Ligament Ruptures in a Perilunate Dislocation Pattern The SLIL is ruptured far more commonly than the LTIL, but any combination may be seen, including concomitant complete SLIL rupture associated with scaphoid fracture (an injury pattern that was at one time considered not possible) (Fig. 11.25). Perilunate fracture dislocations are another place where the arthroscope excels. The only truly accurate way to determine if an intrinsic ligament has been ruptured is to test its functional performance under load while making a direct observation of the ligament’s interface (Fig. 11.26). This is done through the midcarpal

Fig. 11.26  A normal SLIL interval tested from the midcarpal joint, pressing on the scaphoid with the probe to attempt displacement

joint. Attempts to classify the ligament disruption only by the appearance of local tissues and side-to-side diastasis fail to evaluate the multidirectional functional role that these unique ligaments play (Fig. 11.27). A comprehensive grading system that examines four different directions of stress response for each ligament allows a more complete evaluation of ligament function or incompetence (Table  11.1). Direct reduction and pinning is needed for grade 2 and grade 3 disruptions (Fig.  11.28). Initial and final assessments are arthroscopic, but reduction and fixation is performed

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Fig.  11.27  Rotational instability in the sagittal plane of the lunate (L) to triquetral (T) interval, stress tested from the midcarpal joint

Fig. 11.28  Bleeding coming up through the SLIL cleft dorsally and the drive through capacity of the probe levering apart the scaphoid (S) from the lunate (L)

without the arthroscope in the joint. The classic description for reducing the SLIL interval uses “joysticks,” one K-wire each in the scaphoid and the lunate. These “joysticks” provide poor control and can easily create a nonanatomic reduction. Far better is to take advantage of the natural carpal articular relationships to ensure an anatomic reduction. Volar translation of the capitate by the manual force applied while holding the hand is the most effective way to flex the lunate. Direct thumb pressure on the distal pole of the

scaphoid is the most effective way to extend the scaphoid (Fig.  11.29). Preventing the proximal pole of the scaphoid from shifting dorsally out of the scaphoid fossa (as in the Watson test) is accomplished by direct pressure applied with the Kleinert elevator through the same mini incision radially that is used to place the K-wires (Fig. 11.30). The SLIL interface only needs two 1.14 mm K-wires for fixation (if there is any question regarding adequate separation of the two wires, then a third can be added). There is no need to pin

Table 11.1  Arthroscopic multidirectional stress testing classification of perilunate injuries Grade I Grade II Grade III Diastasis

Volar diastasis <2.3 mm; no dorsal diastasis

Volar and dorsal diastasis >2.3 mm

Volar and dorsal diastasis >2.3 mm

Distraction

Scaphoid/triquetrum distracts under arthroscopic traction <10% the height of the SLIL/ LTIL interface

Scaphoid/triquetrum distracts under arthroscopic traction 10–25% the height of the SLIL/LTIL interface

Scaphoid/triquetrum distracts under arthroscopic traction >25% the height of the SLIL/LTIL interface

Translation

Scaphoid/triquetrum translates with probe <10% the PA dimension of the SLIL/LTIL interface

Scaphoid/triquetrum translates with probe 10–25% the PA dimension of the SLIL/LTIL interface

Scaphoid/triquetrum translates with probe >25% the PA dimension of the SLIL/LTIL interface

Rotation

Scaphoid/triquetrum rotates with probe <10° relative to lunate distal surface

Scaphoid/triquetrum rotates with probe 10–25° relative to lunate distal surface

Scaphoid/triquetrum rotates with probe >25° relative to lunate distal surface

Arthroscopic reduction and pinning of Arthroscopic reduction and pinning Partial tear requires splint of SLIL/LTIL interface; no motion SLIL/LTIL interface; “dart-thrower’s” protected healing time but not until healed motion at surgeon’s discretion direct pinning Type A: radiocarpal view shows smooth synovial membrane encasing the torn edge of the ligament Type B: prereduction radiocarpal view shows the torn edge of the ligament hanging down into the joint, postreduction radiocarpal confirmation of ligament approximated to the edge of the carpal avulsion site required Treatment

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Fig. 11.29  Manual steps to reducing the SLIL include direct pressure on the distal pole of the scaphoid, volar translation (not flexion) of the capitate which then, in turn, flexes the lunate, slight extension and ulnar deviation of the wrist as a whole. The Kleinert elevator is placed on the proximal pole of the scaphoid to prevent its dorsal and radial translation, holding it compressed against the opposing surface of the lunate

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arc” (Fig.  11.31). If the SLIL is stable or has been pinned, then the LTIL interface requires only a single K-wire due to the added control over triquetral position afforded by the helical interface with the hamate (no such controlling interface exists at SLIL) (Fig. 11.32). Pins are cut below the skin after checking the cutaneous nerves and then removed at 8 weeks. Depending on other injured structures, the surgeon may use discretion in starting motion in the “dartthrower’s arc” prior to wire removal. A confounding variable to secure healing of an intrinsic ligament is the late presenting patient. It has never been definitively established how much time is required for the intrinsic ligament fibers to degenerate to the point where they will no longer effectively heal. Most likely, it is sometime between 4 and 12 weeks post injury. If after arthroscopic evaluation of a late presenting case, the surgeon believes that healing will be ineffective, he always has the option of adding a ligament stabilization procedure through small incisions volar and dorsal (Fig. 11.33).

Combined Injuries

Fig. 11.30  Internal relationships drawn to depict the reduction accomplished in Fig.  11.29. The Kleinert elevator solves the dilemma created when dorsal and radial shift of the scaphoid proximal pole would otherwise occur as a result of the reduction maneuvers executed on the scaphoid distal pole and via wrist positioning. The Kleinert elevator keeps the scaphoid proximal pole reduced and compressed against the lunate while the two are pinned together

across the midcarpal joint, and doing so prevents any opportunity for early motion using the “dart-thrower’s

The complexity of combined injury patterns ranges from the simple coexistence of two identifiable disrupted elements to the maximum challenge of restoring anatomy and stability to the exploded wrist (Fig. 11.34). The simplest combination occurs when the SRL ligament and the lunate remain as one unit and the RSC, LRL, and scaphoid dissociate as another unit (Fig. 11.35). One point of fixation is required for the extrinsic ligament disruption and one for the intrinsic ligament disruption using the above described techniques. Another very simple combination is a carpal fracture combined with intrinsic ligament rupture (Fig. 11.36). To avoid missing the ligament component of this injury by assuming that the carpal fracture was the only injury, the surgeon must apply the previously stated rules of fix all bony injuries first and then retest arthroscopically for ligament injuries once the fracture has been stabilized (Fig.  11.37). Slightly more complex are combined patterns where the pathway of disruption diverges to different levels within the wrist (Fig.  11.38). However, managing these injuries is not difficult as long as one follows the rules and the order of testing. No matter how

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Fig.  11.31  (a) Acute traumatic perilunate dislocation (as opposed to an isolated tear of an intrinsic ligament) will demonstrate an immediate static collapse of the scapholunate relationship as demonstrated by the increased lateral SL angle and (b) foreshortened scaphoid with ring sign on the PA view. (c) The

Fig. 11.32  (a) Grade 2 and 3 perilunate dislocations require two wires from scaphoid to lunate, but (b) only one wire from triquetrum to lunate to effectively control the reduced carpal relationships during the 8 weeks of ligament healing

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ideal pathway for pin fixation of the SLIL:enters just distal to the radial styloid margin, passes just proximal to the subchondral bone of the distal surfaces of scaphoid and lunate at their interface to reach the far ulnar corner of the lunate. (d) Once healed, the static relationship of scaphoid to lunate is restored

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Fig. 11.33  (a) In late presenting cases, slight overcorrection of the SLIL angle (b) can be combined if needed with (c) capsulorrhaphy via tendon weave (arrow) if the surgeon does not believe that the quality of the ligament has remained sufficient for healing

Fig. 11.34  (a) The rare injury of a complete scaphoid volar dislocation combines extrinsic and intrinsic ligament disruptions. (b) Scaphoid reduced and stabilized

many elements are included in the injury, fixation for each element is still performed as previously described for each individual disruption. The chance of missing

an element of ligament instability increases with more rare variations such as axial disruptions of the carpus (Fig. 11.39).

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Fig. 11.35  The combination of RSC and LRL bony dissociation and a perilunate dissociation is reduced and stabilized entirely arthroscopically apart from the mini incision used for the entry of the screw and 1.14 mm K-wires radially

Combining Arthroscopic Management of Radiocarpal and Perilunate Injuries with Open Radius Surgery For many surgeons, as the complexity of the case increases, each of them will reach a point at which he simply abandons a refined tool such as the arthroscope, citing the complexity of the case as the reason. They

Fig. 11.36  (a) Previously considered an impossibility, simultaneous scaphoid fracture and complete rupture of the SLIL is not seen infrequently. The key to fixation is to place (b) one K-wire volar to the proximal pole of the screw and the other dorsal to the screw

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perform a wide open arthrotomy instead and convince themselves that it is just “easier that way.” Again, the arthroscope is a tool for evaluation and viewing the joint while working. It is the best tool by which to judge intraarticular events, and it is needed just as much, if not more, in the very complex cases. As long as the surgeon simply treats each element of the injury on its own merits according to the previously described techniques, there is no combination of injured structures that should cause the surgeon to deviate from this plan. This remains true when an open incision has been made to place fixation at the DR metaphysis. Placement of a standard length volar fixed angle plate requires all of a 4.5 cm incision which, along with the arthroscopy portals, still adds up to a very minimally invasive surgery to accomplish a lot of fixation. The simplest combination in this category is an AO type C distal radius fracture and a basic perilunate dislocation (Fig.  11.40). More complex is the combination of a radiocarpal fracture dislocation with marginal rim fragments requiring buttressing and trapping by plates and a perilunate dislocation (Fig.  11.41). The case does actually become challenging when a comminuted AO type C distal radius fracture is combined with a radiocarpal fracture dislocation and perilunate dislocation (Fig. 11.42). Yet, the surgeon should not abandon the rules set forth: work from proximal to distal, fix bony injuries first, arthroscopically reevaluate ligament injuries and fix each element according to the

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Fig. 11.37  The pathway of structural disruption can course through more than one level proximal to distal

Fig. 11.38  The pathway of structural disruption can also diverge and rupture multiple interrelated structures as seen in this late presenting case

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Fig. 11.39  (a) Axial carpal disruptions are considered to result from volar to dorsal compressive forces and typically follow axial ulnar or axial radial patterns. (b) Any pathway of disruption through the carpus is possible, though

Fig. 11.40  The simplest of the patterns that combines carpal ligament injury with an AO type C radius fracture is just a perilunate dislocation

given techniques. The ultimate combination is to have every possible element occurring simultaneously: type C distal radius fracture, radiocarpal fracture dislocation, carpal fracture, and intrinsic ligament rupture (Fig. 11.43). The plan remains the same.

Rehabilitation After surgery, the wrist is immobilized in a splint to accommodate swelling. At the first clinic visit, there is an option of placing the patient in a cast (useful for

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Fig. 11.41  (a) The next more complex combination of radius fracture with carpal ligament injury is a radiocarpal fracture dislocation with multiple comminuted rim fragments and a perilu-

nate dislocation. (b) The rim fragments can be trapped under a buttress plate to restore radiocarpal stability. (c) Radiocarpal congruence must be verified

noncompliant patients) or in a two-sided, clam shell orthoplast splint custom fitted by the hand therapists. A compliant patient can be trusted to remove this splint for showering each day and the performance of skin hygiene. Nearly all patterns of injury discussed in this chapter require a minimum immobilization time of 4 weeks for the wrist, during which time the patient is instructed to perform full range of motion of the five digits, forearm rotation, elbow, and shoulder motion. Injuries that depend only on bony fixation for stability can initiate active range of motion at this time. Injuries that depend on healing the volar extrinsic ligaments require continued immobilization until 6 weeks (even though the transarticular pin was removed at 4 weeks). Perilunate fracture dislocations and pure dislocations that have been stably pinned within the proximal carpal row only (no K-wires crossing the midcarpal joint) can initiate the “dart-thrower’s” arc of motion from extension/radial deviation to flexion/ulnar deviation prior to pin removal at 8 weeks. Otherwise, proximal

row pins are removed at 8 weeks and wrist motion is initiated at that time. By 8 weeks from initial reduction and fixation, all elements that were previously disrupted should be securely healed. Therapy instructions beyond 8 weeks thus include not only active range of motion, but assisted and passive end range stretches as well. If the patient is not progressing according to schedule, a static progressive splint can be added. Strength can be improved at any time following articular trauma, but improving motion occurs only during a limited window of opportunity following injury. This window of opportunity typically closes sometime between 3 and 4 months after injury. This means that from the 8 week to the 16 week mark following surgery, the patient and therapist must push hard to gain wrist range of motion. As the motion window is seen to be closing, dedicated strengthening therapy can then be added. Final functional results following high level wrist trauma are not seen until greater than a year after injury.

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Fig. 11.42  (a) The next more unstable pattern of injury combines (b) an AO type C distal radius fracture with radiocarpal fracture dislocation and a perilunate dislocation. (c) Marginal fragments that secure the radiocarpal fracture dislocation may

be small enough to accept only K-wire fixation and (d) the remaining metaphysis may be incompetent enough to prevent the purchase of a headless compression screw

Discussion

with an average follow-up of 37 months, 4 had already required salvage arthrodeses and 9 of the remaining 18 demonstrated radiographic arthritis, primarily at the midcarpal joint [9]. The use of a temporary screw at the SLIL interval was not able to improve the results over traditional K-wire fixation [23]. Delayed treatment may worsen the results such that, in a small comparison series, the early treatment group achieved an average range of motion arc of 129° compared to 95° in the delayed treatment group [15]. A similar difference in grip strength was seen with an average of 34 kg following early treatment compared to 26  kg following delayed treatment [15]. An advantage may exist for greater arc injuries where stable fixation of a scaphoid fracture allows for bone to bone healing as opposed to the quality of SLIL healing. A series of 25 patients followed for an average of 44 months demonstrated an average arc of motion of 114° with a mean time of 16

The literature concerning perilunate dislocations and fracture dislocations is rather sparse, with the majority of articles appearing in the form of case reports and reviews [1, 4–6, 12, 13, 16, 19, 20, 22, 26]. Even more limited is information on radiocarpal dislocations and fracture dislocations [2, 10, 11, 17, 24]. Nearly all authors recommend wide open approaches: volar, dorsal, or combined [3, 9, 14, 15, 23]. The mention of arthroscopy in the management of major wrist ligament injury first appeared only very recently [7, 18, 21, 25]. Certainly, fracture dislocations of the wrist are very challenging to manage under the best of circumstances. Furthermore, the outcome has generally been reported to be poor with most cases demonstrating posttraumatic arthritis changes within 5 years [8, 9]. In a series of 22 dorsal perilunate dislocations and fracture dislocations

11  Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations

Fig. 11.43  (a) The most complex combination injury includes all the components from a type C distal radius fracture to fracture dislocation of the carpus, to intrinsic ligament injury and carpal fracture all into one case. (b) With adequate fragment size, the rim fragment that restrains the radiocarpal fracture dis-

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location can be secured with the smallest size of headless compression screw (arrow). (c) Achieving a congruent reduction (d) from all perspectives is critical to permit the long-term result (e, f) of a stable wrist without early arthritis at 3 years follow-up

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weeks for the union of the scaphoid fracture [14]. A similar concept applies to radiocarpal dislocations where one series compared pure ligamentous radiocarpal dislocations to those with a large radial styloid (RS) fragment [3]. The two groups had similar arcs of motion between 104 and 108°, with a greater average grip strength of 38 kg in the bony group compared to 27 kg in the ligamentous group [3]. In the end, fracture dislocations of the wrist are fundamentally disruptions of anatomy. If treated early, they have the potential to heal. Different structural elements that are part of the overall injury pattern will heal with varying levels of final tissue integrity. The best is osseous union. Once healed and remodeled, the fractured element has the same integrity as prior to injury. Next in quality are the volar extrinsic ligaments. The ligaments are long fibrous sheets running within the capsular layer of the joint that shred when they rupture. The ensuing fibroplasia response is robust, resulting in solid ligament healing. The worst are the intrinsic ligaments (SLIL and LTIL). They are short fibrocartilaginous intraarticular ligaments with limited blood supply bathed in a synovial environment. If the reduction of the two relevant carpal bones is not anatomically exact, healing will be compromised with posttraumatic carpal collapse and eventual arthritis. Keeping this three-tiered biology of healing in mind, the surgeon must set out to restore the original anatomic relationships of the carpus. The more accurate the surgeon’s reduction and the more stable the fixation, the better the healing. Each structural element has an appropriate method for reduction and an appropriate device for stabilization. There is no need for the wide open approaches of the past to reduce articular injuries. The tool of the joint is the arthroscope. It affords a far better view with magnification and improved lighting of all intraarticular structures than that provided by arthrotomy. The challenge that has kept more surgeons from using the arthroscope in these complex injuries is the reduction. Reducing fracture dislocations of the wrist is not easy under the best of circumstances. Perhaps in all of hand surgery, difficult reductions of the carpus most require the surgeon to be able to think in three dimensions while being able to see only a portion of the anatomy at any one time. As wonderful a viewing tool as the arthroscope is, it only provides a limited field of view, just as the image intensifier provides only a two dimensional view. By combining

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these two viewing tools with an understanding of the anatomy, the surgeon should be able to “see” the full three dimensional picture of the carpus well enough to achieve anatomic reduction of any injury. Once the reduction has been achieved, it is only a matter of stabilization. The technical sections above cover the appropriate methods for each injured structural element. The techniques offered in this chapter were drawn from a series of 290 arthroscopically treated fracture dislocations of the wrist. The average age of the patients was 32 years, and 94% were male. The predominant mechanism of injury was fall from a height followed by motor vehicle collision, sports trauma, and industrial crush. For perilunate fracture dislocations, the scaphoid healed routinely by 8 weeks, at which time wrist motion therapy began. Perilunate dislocations also progressed to motion at 8 weeks following K-wire removal. Radiocarpal dislocations had the K-wire removed by 4 weeks, but were kept casted for 6 weeks total. Radiocarpal fracture dislocations that achieved stability via fracture fixation began motion by 4 weeks after the early healing of the supporting ligaments. The use of these time frames and the methods detailed in this chapter has largely avoided late collapse of the intrinsic ligaments, radiocarpal translocation, and nonunion. To date, two patients with radiocarpal fracture dislocations have gone on to radioscapholunate fusions with midcarpal preservation. Both of them were characterized by highly comminuted lunate fossas at the time of original injury. None of the pure radiocarpal dislocations have required secondary surgery. Three scapholunate ligaments failed to heal adequately and have since gone on to open ligament reconstruction of the carpus. Some additional cases have demonstrated posttraumatic joint space narrowing on X-ray in the absence of carpal collapse or shift, but not to the point of requiring secondary surgeries. The assumption is that the hyaline cartilage suffers a substantial impact injury at the time of the original trauma which then sets in motion an ongoing degenerative process. In the future, prevention of this will need to come in the form of biologic therapies for hyaline cartilage. What all the surgeons can do is reduce and stabilize the disrupted elements, protect each structure for the appropriate time frame, and avoid inflicting any additional iatrogenic damage to the wrist. Arthroscopic techniques help the surgeon to avoid additional iatrogenic damage to the wrist.

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Conclusion Fracture dislocations of the wrist are a less frequently presenting injury pattern than distal radius fractures, scaphoid fractures, or isolated SLIL disruptions. They are, however, more challenging and thus more fun to treat. The key to success is a thorough examination for any possible additional element of disruption occurring in addition to the already recognized elements. One should never assume that a common pattern prevails; any combination of injuries is possible. By working from proximal to distal, bone preceding ligament, and performing a comprehensive arthroscopic evaluation following all bone fixation, no injury should go overlooked. Each element of disruption should be treated by its corresponding technique no matter how complex the combination of multiple elements appears. By following this strategy, it is possible to achieve a stable and congruent wrist that avoids early posttraumatic arthritis in most cases.

References   1. Alt V, Sicre G. Dorsal transscaphoid-transtriquetral perilunate dislocation in pseudarthrosis of the scaphoid. Clin Orthop Relat Res. 2004;426:135–7   2. Apergis E, Dimitrakopoulos K, Chorianopoulos K, et  al. Late management of post-traumatic palmar carpal subluxation: a case report. J Bone Joint Surg Br. 1996;78:419–21   3. Dumontier C, Meyer zu Reckendorf G, Sautet A, et  al. Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases. J Bone Joint Surg Am. 2001;83:212–18   4. Enoki NR, Sheppard JE, Taljanovic MS. Transstyloid, translunate fracture-dislocation of the wrist: case report. J Hand Surg Am. 2008;33:1131–4   5. Gellman H, Schwartz SD, Botte MJ, et al. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. Clin Orthop Relat Res. 1988;237:196–203   6. Givissis P, Christodoulou A, Chaldis B, et  al. Neglected trans-scaphoid trans-styloid volar dislocation of the lunate. Late result following open reduction and K-wire fixation. J Bone Joint Surg Br. 2006;88:676–80   7. Henry MH. Arthroscopic treatment of acute scapholunate and lunotriquetral ligament injuries. Atlas Hand Clin. 2004;9:187–97

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  8. Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilunate fracture-dislocations: medium-term results. J Hand Surg Br. 2002;27:498–502   9. Hildebrand KA, Ross DC, Patterson SD, et al. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg Am. 2000;25:1069–79 10. Ilyas AM, Mudgal CS. Radiocarpal fracture-dislocations. J Am Acad Orthop Surg. 2008;16:647–55 11. Irwin LR, Paul R, Kumaren R, et al. Complex carpal dislocation. J Hand Surg Br. 1995;20:746–9 12. Kaneko K, Miyazaki H, Yamaguchi T, et al. Bilateral transscapholunate dislocation. Chir Main. 2000;19:263–8 13. Kaulesar Sukul DM, Johannes EJ. Transscapho-transcapitate fracture dislocation of the carpus. J Hand Surg Am. 1992;17:348–53 14. Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with a dorsal approach. J Hand Surg Am. 2005;30:1145–52 15. Komurcu M, Kurklu M, Ozturan KE, et al. Early and delayed treatment of dorsal transscaphoid perilunate fracture-dislocations. J Orthop Trauma. 2008;22:535–40 16. Mamon JF, Tan A, Pyati P, et al. Unusual volar dislocation of the lunate into the distal forearm: case report. J Trauma. 1991;31:1316–8 17. Mudgal CS, Psenica J, Jupiter JB. Radiocarpal fracturedislocation. J Hand Surg Br. 1999;24:92–8 18. Park MJ, Ahn JH. Arthroscopically assisted reduction and percutaneous fixation of dorsal perilunate dislocations and fracture-dislocations. Arthroscopy. 2005;21:1153 19. Roger DJ, Williamson SC, Whipple R. Ejection of the proximal scaphoid in a trans-scaphoid perilunate fracture dislocation. A case report. Clin Orthop Relat Res. 1994;302: 151–5 20. Sandoval E, Cecilia D, Garcia-Paredero E. Surgical treatment of trans-scaphoid, transcapitate, transtriquetral, perilunate fracture-dislocation with open reduction, internal fixation and lunotriquetral ligament repair. J Hand Surg Eur. 2008;33:377–9 21. Smith DW, Henry MH. Comprehensive management of associated soft tissue injuries in distal radius fractures. J Am Soc Surg Hand. 2002;2:153–64 22. Soejima O, Iida H, Naito M. Transscaphoid-transtriquetral perilunate fracture dislocation: report of a case and review of the literature. Arch Orthop Trauma Surg. 2003;123:305–7 23. Souer JS, Rutgers M, Andermahr J, et al. Perilunate fracturedislocations of the wrist: comparison of temporary screw versus K-wire fixation. J Hand Surg Am. 2007;32:318–25 24. Watanabe K, Nishikimi J. Transstyloid radiocarpal dislocation. Hand Surg. 2001;6:113–20 25. Weil WM, Slade JF, Trumble TE. Open and arthroscopic treatment of perilunate injuries. Clin Orthop Relat Res. 2006;445:120–32 26. Yaghoubian R, Goebel F, Musgrave DS, et al. Diagnosis and management of acute fracture-dislocation of the carpus. Orthop Clin North Am. 2001;32:295–305

The Role of Arthroscopy in Postfracture Stiffness

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Riccardo Luchetti

Introduction Painful limitation of wrist range of motion (ROM) as a consequence of extraarticular and intraarticular wrist fractures is commonly seen in conservative as well as surgical management (Table 12.1) [2, 21]. Wrist rehabilitation for a period of over 3 months is the treatment of choice, when the patient has wrist stiffness. Although variable improvement is always seen in post rehabilitation, the pain persists throughout and even after the treatment, thereby making the research into the causes of such a condition mandatory [13, 22]. Frequently, incorrect or incomplete reduction of the distal radius fracture is the cause of the painful wrist function. Macroscopic defects, both intraarticular and extraarticular malunion, need to be rectified by osteotomies of distal radius [10] that try to restore normal distal radius anatomy and alignment of the articular surface of the radius. Minimal distal radius defects can be treated arthroscopically. In minimal distal radial defects, two main conditions can contribute to painful wrist ROM limitation: (1) capsular contracture with intraarticular fibrotic bands causing rigidity (the most frequent condition), and (2) incorrect healing of multiple fragment (chip) fractures of the radial dorsal border leading to a dorsal radiocarpal conflict (Figs.  12.1 and 12.2) or a moderate increase in palmar inclination of the distal

R. Luchetti  Rimini Hand Surgery & Rehabilitation Center, Rimini Multimedia Policlinic, Milano, Via Pietro da Rimini 4, 47900 Rimini, Italy e-mail: [email protected]

radius articular surface (palmar tilt). The two conditions can sometimes coexist and must be treated at the same time. However, contemporary macroscopic and minimal distal radius defects should not be treated together because the postoperative rehabilitation protocol in both conditions is different. Wrist immobilization is indicated for the former; whereas immediate rehabilitation is mandatory for the latter. Ligament tears and chondral lesions are often associated with wrist fractures and these further complicate the intraoperative and postoperative treatment protocol. Finally, we must remember other causes of wrist pain and rigidity, i.e., neuroma of the posterior interosseous nerve, extensor and/or flexor tendons adherences, and algodystrophy. Traditionally, wrist manipulation under anesthesia is commonly used when the rehabilitation regime has failed to produce increased wrist range of motion. However, this procedure can be detrimental by provoking further damage, such as ligamentous lesions, chondral or osteochondral damage (as in dorsal radiocarpal conflict) or even fractures (ulnar head fracture). Surgical arthrolysis is a gentler option that can be performed via open surgery [1] or arthroscopy [25], as often carried out in other joints [15, 27,32, 33]. Arthroscopic arthrolysis of the wrist [6, 16–19,  24, 30] allows the surgeon to treat both the radiocarpal and intercarpal joints, without running the risk of causing secondary damage to the articulations involved, and at the same time, permitting immediate postop mobil­ization. The goal of this chapter is to provide information (materials and methods), evidence (results) and limitations associated with the use of arthroscopy to improve wrist function in patients affected by painful wrist rigidity and dorsal radiocarpal abutment.

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_12, © Springer-Verlag Berlin Heidelberg 2010

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Table 12.1  Possible causes of secondary wrist rigidity (extraand/or intraarticular) Posttrauma Postsurgery Fracture

Dorsal wrist ganglia recurrences

Fracture-dislocation

Treatment of scaphoid fracture or nonunion

Dislocation

Intercarpal arthrodesis (four bones fusion, etc)

Ligament lesions

Ligament reconstruction (SL ligament, etc) Proximal row carpectomy

Prolonged immobilization Erroneous wrist immobilization

Technique Traditional radiocarpal (RC) portals are used for arthroscopic arthrolysis of the wrist. Recently, two volar RC portals (radial and ulnar) have also been added to radiocarpal and ulno-carpal joint; however, these are not frequently used [15]. DRUJ joint can also be involved and can be scoped and debrided by specific portals. Midcarpal joints are rarely involved in wrist rigidity. However, if it is affected, traditional midcarpal portals are used.

Fig. 12.1  Drawing showing malunion of the dorsal border of the distal radius after fracture (a). Note the conflict between dorsal margin of the radius and the carpal bones (b)

Wrist arthrolysis must be performed by using both traditional and more elaborate instruments (Table 12.2) (Fig. 12.3). In recent times, dry arthroscopy is utilized more often in this pathological condition [3,11]. Traditional vertical position with counter-traction at the elbow of about 3 kg is frequently used to obtain a good articular distraction and thereby open the radiocarpal joint space affected by capsular contracture. Occasionally, the articular distraction is not sufficient enough to permit the use of a 2.7  mm scope even when more traction weight is applied. Hence a 1.9 scope is recommended even if it is more delicate. An eccentric traction tower (Fig. 12.4) is an excellent alternative to the traditional vertical position. The Whipple traction tower is not useful because it remains in front of the wrist and does not permit the use of the volar portals and an easy evaluation of the wrist ROM during surgery. Although arthroscopy starts at the level of the RC joint, the MC joint should always be thoroughly evaluated. When there is a loss of prono-supination articular range of motion, arthrolysis of the DRUJ must also be performed. In the most difficult cases, it is impossible to recognize the normal arthroscopic anatomy of the wrist due to the presence of fibrosis that completely encloses the joint space (Fig. 12.5). Difficulties could be encountered while performing triangulation with the instruments.

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Fig. 12.2  X-ray of the lateral view of the wrist affected by malunion of dorsal border of the distal radius (probe) before (a) and after (b) arthroscopic resection (courtesy of Dr Piñal)

Table 12.2  Instruments for arthroscopic arthrolysis Motor powered   Full radius blade   Cutter blade/incisor   Razor cut blade   Barrel abrader Suction punch Mini-scalpel (banana blade) Laser Radiofrequency Dissector and scalpel

Synovitis, fibrosis and adhesions that obstruct the visual field, must be resected with caution, ensuring that no damage occurs to the surrounding structures as, for example, the articular surface of the distal radius and carpal bones. Obviously, the surgeon’s surgical ability is of utmost importance.

Radiocarpal Joint All the portals (1–2, 3–4, 4–5, 6R and 6U) including the volar ones are used when needed. Inflow is permitted through the scope, and outflow by 6U portal or none. When the dry arthroscopy is used, the trocar

Fig. 12.3  Mini dissector for wrist joint

inflow portal is maintained open permitting the entrance of air as the shaver is used with constant aspiration. This permits the elimination of the synovial liquid, blood and debris. Furthermore, a 5 ml syringe can be used to inject fluid in order to wash the joint debris and blood, to be removed by the suction of the shaver. Only when the radiofrequency instrument is used fluid becomes necessary. Fluid might be prepared at the beginning of arthroscopy ready to be used. When the use of the radiofrequency is over, it is possible to return

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Fig. 12.4  The Whipple and the Borelli traction tower for wrist arthroscopy. The Whipple tower is positioned in front of the wrist and it does not permit movement of the wrist. The Borelli tower [Mikai spa, Genova (Italy)] is eccentric and it permits rotation of the wrist in prono-supination. X-ray and arthroscopy by volar portals are also permitted

Fig. 12.5  Articular vision of the wrist joint at the beginning of the arthroscopy. Look at the fibrosis that impedes the articular vision

to dry arthroscopy by using the shaver to aspirate the liquid and residual tissues inside the joint. The procedure is divided into two steps to permit a better understanding of the technique (Fig. 12.6).

First Step [Fibrosis and Fibrotic Band Resection] Arthroscopic arthrolysis always starts from the radial side (part 1) of the RC joint (Fig. 12.6). The starting portal is usually the 3–4 and the 1–2 is used as a working portal; however, portals are switched frequently. Fibrotic adhesions are initially removed in the radial part of the joint with the appropriate instruments: shaver

Fig. 12.6  Drawing which shows the division of the radiocarpal joint in three parts. The proper radiocarpal joint is divided in two parts by a line passing through the scapho-lunate joint. The ulno-carpal joint is separated from the radiocarpal joint by a line passing for the medial margin of the radius. Each part corresponds to the arthroscopic working steps through arthroscopic arthrolysis. The ulno-carpal joint is always completely uninvolved in fibrosis. Fibrosis (gray color) is localized in the radiocarpal joint and in the DRUJ, under the TFCC ligament and between the ulna head and the sigmoid notch

[full radius: 2.9 mm, aggressive or incisor: 3.2 mm] and radiofrequency instruments. However, not infrequently, difficulties are encountered in the triangulation due to intense intraarticular fibrosis (Fig.  12.7). In these

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Fig. 12.7  Typical intraarticular view of rigid wrist during dry arthroscopy, at the beginning

Fig. 12.9  Drawing showing division of the radiocarpal joint in three parts in which fibrosis localized in the radial side (part 1) was removed

Fig.  12.8  Perfect visualization of the shaver during fibrosis resection. Shaver is working against the fibrotic band

circumstances, it is better to switch the scope from the 3–4 portal to the 1–2 portal and use the 3–4 portal as the working one. The 1–2 portal is identified by a needle and the joint space is reached through a vertical skin incision and blunt dissection with a mosquito forceps. Shaving can be started only after ensuring the right position, i.e., with the full radius turned towards the scope and not to the articular surface. As the intraarticular vision improves, the resection of fibrosis becomes easier (Fig.  12.8). As fibrosis is completely removed from the radial side of the RC joint, the arthroscopic procedure is shifted to the ulnar side (Fig. 12.9). The scope is introduced into the 3–4 portal and the shaver into the 6R. Visualization of the shaver is frequently limited by the presence of the fibrotic band. Traditionally the fibrotic band [14] is localized between the scapho-

Fig. 12.10  Intraarticular arthroscopic view of the fibrotic band. It determines a complete separation of the radiocarpal joint in two rooms. Shaver is working against the fibrotic band. A little hole is in the wall. Through it, it will be possible to remove the fibrotic band producing only one joint (S scaphoid)

lunate (SL) ligament and the rim between the scaphoid and lunate facet of the radius (Figs. 12.10 and 12.11). It can be partial or complete. When it is complete, it divides the radiocarpal joint into two separate rooms.

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Fibrotic band can be incised by using a small dissector introduced via the 6R portal in the direction of the scope (Fig. 12.12). Delicate precision is used by the dissector to detach the band from the articular surface (Fig. 12.13). As it passes through the fibrotic band and is visualized by the scope, the fibrotic band can be resected by a

Fig. 12.11  Drawing showing the position of the fibrotic band

Fig. 12.12  The fibrotic band is detached from the radius by dissector introduced into the joint through 6R portal

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basket (Fig. 12.14) or a full radius or aggressive shaver from the 6R portal (Fig. 12.15). To obtain a complete resection of the band, instruments must be switched from 6R to 3–4 portal and scope from 3–4 to 6R. Sometimes, radiofrequency instruments are also used in order to resect the fibrotic band. Multiple fibrotic bands can be encountered in a joint when the articular surface of the distal radius is damaged by osteochondral defect (Figs. 12.16 and 12.17), all of them starting from the defect.

Fig. 12.13  The fibrotic band is then completely removed by shaver and radiofrequency, permitting to restore the radiocarpal joint

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Fig. 12.17  Chondritis of the articular surface of the distal radius that becomes evident after the resection of the fibrosis

Fig. 12.14  Fibrotic band can be also removed with basket

Fig. 12.15  Pictures of the wrist joint after fibrotic band resection. Note the irregularity of the articular surface of the distal radius due to the previous fracture

Fig.  12.16  Arthroscopic view of the articular surface of the radiocarpal joint still covered by dense fibrotic tissue

Fig. 12.18  X-ray showing a wrist operated with a Darrach procedure. The ulnar side of the wrist was completely asymptomatic. Patient had pain in the dorsal central side of the wrist with limited flexion and extension ROM. Wrist rigidity was correlated with X-ray view of the wrist in which reduction of the articular space between the lunate and the radius was evident

The procedure of fibrotic band and fibrosis resection is frequently sufficient enough to improve passive wrist ROM. Sometimes, fibrotic bands are included in a more intense intraarticular fibrosis, and arthrolysis becomes much more difficult. Rarely, these bands can complicate the condition by progressing into an osteofibrotic band with progressive evolution in subanchilosis or anchilosis of the radiocarpal (radio-lunate) joint (Figs.  12.18 and 12.19).

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Fig. 12.20  Drawing showing image of the wrist in which the complete resection of the fibrosis in the radiocarpal joint was done

Fig.  12.19  X-ray of the same wrist 2 years after arthroscopic arthrolysis shows the spontaneous fusion of the radio-lunate joint

In this condition, it is very difficult to remove the band and may sometimes be impossible. From the clinical point of view the procedure of resection of these osteofibrotic bands is not indicated because it produces an exposure of the osteochondral defects with persistence of the wrist pain and fibrotic band recurrences. In some of these cases, the Hyaloglide® (ACP gel by Fidia Advanced Biopolymers, Abano Terme, Italy) could be of some utility [7]. When arthroscopic arthrolysis fails, salvage procedures are indicated. As the ulnar side of the radiocarpal joint is completely free from the fibrosis, the procedure continues into the ulno-carpal joint (Fig. 12.20). This part of the wrist joint is usually never affected by the fibrosis, and arthroscopy is often only diagnostic. Occasionally, peripheral TFCC tears can be found incidentally; however, the treatment of TFCC may need to be postponed because of the different arthrolysis rehabilitation protocol. Before moving to the second step of the procedure (volar and/or dorsal capsule resection), it is mandatory

to evaluate the wrist ROM obtained at the end of this first step (Fig. 12.21). Obviously, for a better evaluation of the wrist ROM, the traction must be removed.

Second Step [Volar and Dorsal Capsule Resection] According to the ROM obtained, the volar and/or dorsal radiocarpal ligaments may need to be resected from the border of the radius for further improvement. A miniscalpel, such as a banana blade for peripheral nerve surgery, or micro-scalpel for ocular surgery, are used (Fig.  12.21). Radiofrequency instruments can also be used for resecting the ligaments. The maneuver of volar capsulotomy is easier than the dorsal one, because the ligaments are opposite the scope and the instruments can be introduced easily through the volar border of the distal radius. Initially, the shaver is used to clean the volar ligaments frequently affected by scarring in the articular part in order to better evidentiate their origin from the distal radius border. The miniscalpels are carefully introduced through the dorsal portals paying attention not to feel any resistance during their introduction. Once inside the joint, the surgeon resects the volar ligaments (Fig.12.22). Many times, the maneuver is not easy because of the articular

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Fig. 12.21  Wrist ROM evaluation after first part of arthroscopic arthrolysis procedure

Fig. 12.22  Section of the volar capsule of the wrist by using a mini-scalpel (asterisk)

Fig. 12.23  Drawing showing the site of section of the volar capsule and ligaments of the wrist (red arrows)

deformation due to step-offs making it impossible to reach all the areas of the capsule. It is therefore important to decrease the step-offs by the shaver (burr) prior to being able to reach the volar capsule. It is much easier to cut the radial side of the capsule from 1–2 portal with the scope in the 3–4 portal. Scapho-capitate and scapho-lunate ligaments are resected at their base and the procedure continues through the ulnar side (Fig.  12.23). The ulnar side of the volar capsule is reached from the 6R portal (scope in 3–4). Identifica­ tion of the volar ulnar limit of the distal radius permits the surgeon to stop the ligaments dissection at this level to prevent resection of the volar ulno-carpal ligament. At this point, the traction is removed, and gentle

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maneuvers of wrist extension are performed to increase the ROM and to quantify the amount of improvement. Traction is now reapplied and the procedure con­ tinues with resection of the dorsal wrist capsule (Fig.  12.24). The maneuver of dorsal capsulotomy consists of maintaining the scope in the 1–2 portal and resecting the dorsal capsule introducing the instruments through the 6R portal. The dorsal central part of the ligaments is sectioned first. By switching the scope to the 6R portal, the capsule can be further resected by introducing the instrument into the 1–2 portal. The intraarticular position of 3–4 portal is localized and from this point the resection of the capsule starts by using mini-scalpel, shaver, or radiofrequency with hook terminal tip (Fig. 12.25). The radial part of the

Fig. 12.24  Drawing showing the site of section of the dorsal capsule and ligament (red arrows)

Fig. 12.25  Dorsal wrist capsule sectioned by the hook tip of radiofrequency device. Attention must be paid not to damage the tissues (nerves, vessels and tendons) behind the ligament and capsule

R. Luchetti

capsule is very easily resected from the 1–2 portal and the scope in 6R portal. The ulnar part of the dorsal capsule consists of a strong ligament, namely the radio-triquetral ligament. Here, the procedure becomes more difficult due to the hard consistency of this ligament. In such an event, a volar approach can be used (volar radial portal) [12,26,28]. Recently, Bain [4,5] described a safe procedure to resect dorsal extrinsic ligaments, preserving the tendons (Fig.  12.26). However, the same results can be achieved with the technique described earlier. It is very important to remember that the volar ulnocarpal ligaments and dorsal capsule must not be resected (Fig. 12.27). The dorsal capsule of the ulnocarpal compartment is without a proper ligament, but it is reinforced by the floor of the ECU tendon sheath. The two volar ulno-carpal ligaments are the ulnolunate and the ulno-triquetral ligaments. Moritomo [23] demonstrated that the volar ulno-carpal ligaments are well inserted into the volar branch of the TFCC ligament and both run proximally attaching to the ulnar head. He demonstrated that a TFCC detachment produces both DRUJ and ulno-carpal instability. Viegas [31] reported that section of the radio scapho-capitate and radio-lunate ligaments does not lead to significant ulnar translation of the carpus, and that either the palmar ulnar ligament or the dorsal ulnar ligament complexes alone can prevent ulnar translation. The arthroscopic capsulotomy leaves the palmar ulnar ligament and dorsal ulnar ligament complexes intact. There was no clinical or radiological evidence of carpal instability in any of the patients treated by Verhellen and Bain [30]. Resection of a portion of the dorsal rim of the distal radius is mandatory when wrist extension is limited due to dorsal radiocarpal conflict secondary to incorrect reduction of a chip fracture of the dorsal border of the distal radius (Fig. 12.1). Improvement of the wrist extension can be obtained by this arthroscopic procedure. After dorsal capsule resection, the dorsal rim of the distal radius is resected by using a burr of 2.9–3.2  mm introduced from 6R or 1–2 portal. Sometimes, a volar radial portal is used, but the ulnarmost side of the dorsal rim cannot be completely reached due to the carpal bones even if wrist distraction is increased. Therefore, the ulnar-most side of the dorsal rim of the distal radius is treated mostly from the 6R portal.

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Fig. 12.26  Drawings showing the procedure of protection of the extensor tendon by dorsal shifting during the dorsal wrist capsule resection (according to Bain [4,5])

Fig. 12.27  Schematic drawing showing the extrinsic ligaments of the radiocarpal joint. (1) radio-scapho-capitate lig; (2) long radio-lunate lig; (3) short radio-lunate lig; (4) ulno-lunate lig; (5) ulno-triquetral lig; (6) ECU tendon; (7) radio-triquetral lig, (8) dorsal radial capsule. In red color the ligaments (1–2–3–7–8) that can be sectioned during the arthroscopic volar and dorsal capsulotomy (according to Verhellen and Bain). The ulno-carpal ligaments (4–5) must be preserved

Ancillary Procedures Wrist arthrolysis permits one to discover some occult articular, DRUJ, and carpal bone problems. Some of

Fig.  12.28  Arthroscopic visualization of articular step-off of the distal radius that became evident after the arthrolysis (courtesy of Dr Piñal)

these can be treated during the same procedure and others may need to be treated later due to different rehabilitation programs. Limited articular step-offs of the radius (less than 1 mm) must be leveled, whenever possible (Fig. 12.28). A burr of 2.9–3.2  mm is used at 500 revolution per second introduced from the 6R portal maintaining the scope in the 3–4 or 1.2 portal. Bigger or larger step-offs can also be treated but this often results in fibrotic band recurrences and the wrist will never be painless.

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Fig. 12.29  Flexionextension ROM obtained after complete arthroscopic arthrolysis (fibrosis and capsule resections)

TFCC central tears are also treated: the flap is removed and the borders are resected. TFCC peripheral lesion or foveal detachment must be treated later because of a different rehabilitation program. Positive ulnar variance should be treated with wafer arthroscopic resection. Loose bodies, an extremely rare occurrence, should be removed if they are found inside the articulation. After the last part of radiocarpal arthroscopic surgery and before switching to midcarpal arthroscopy, it is useful to evaluate the improvement in wrist ROM. Traction is temporarily removed and passive wrist motion is evaluated for both flexion-extension and radial-ulnar arches (Fig. 12.29).

Midcarpal Joint If there is no appreciable change in passive wrist ROM after the radiocarpal arthrolysis, a midcarpal arthroscopy should be carried out. The approach for this articulation is via the two portals (RMC and UMC), but when needed, more portals can be used (STT and TH), thus making it possible to verify if there is involvement of the MC joint which could be contributing to the cause of wrist stiffness and pain. Arthroscopy of this joint is much easier to perform and synovitis is the most frequently found pathology in this zone. It is usually localized at the level of the STT and TH joints. Commonly, one tends to see an

associated capitate and hamate chondritis. This may as well be responsible for the wrist pain. Debridement of the MC joint is performed in order to improve painless joint movement. MC joint arthroscopy does not require any ligament resection. Dorsal radio-midcarpal conflict is suspected when wrist extension is clinically limited and painful with precise dorsal wrist pain localization at the level of capitate, with X-ray showing deformity of the dorsal border of the distal radius. Therefore, after the procedure is performed at the dorsal rim of the distal radius through the radiocarpal arthroscopy, it is mandatory to verify the status of midcarpal joints too. It means that midcarpal joint arthroscopy permits to verify the entity of damage of the dorsal part of the capitate due to the contact with the dorsal rim of the distal radius during wrist extension. Midcarpal arthroscopy will reveal an intense synovitis at this level. This part of capitates is shaved (synoviectomy and debridment), and with burr, it is possible to increase the depth of the neck in order to accept the dorsal rim of the distal radius during the wrist extension. The procedure is similar to that performed at the elbow for humeral-olecranon conflict.

Distal Radioulnar Joint A prerequisite that ensures a good arthroscopic arthrolysis result for the DRUJ, is the preservation of a normal articular surface (sigmoid notch and ulnar head).

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Malunion of the sigmoid notch due to fracture of the medial border of the distal radius (die punch) is an adverse condition, and it should be treated by osteotomic correction of the malunion if there are no signs of osteochondritis [10]. Salvage procedures are recommended for DRUJ rigidity with secondary arthritis of the joint. Arthroscopy of the DRUJ is difficult. It is very unusual to have good visibility in the DRUJ even in normal conditions. Stiffness of this joint is due to capsular retraction, intraarticular fibrosis and synovitis which in turn make arthroscopy more difficult. DRUJ arthroscopy is performed by using distal and proximal portals. The scope is introduced in the proximal portal and the instruments in the distal one. Normally, fibrosis does not permit any visualization. Fluid is constantly used to expand the joint and improve the vision. Once some vision is achieved and the tip of the instruments can be recognized, fibrosis is progressively removed with full radius or aggressive motor power. From the arthroscopic point of view the DRUJ includes two spaces (Fig.  12.30): that between the TFCC ligament and the ulna head, and the other between the ulna head and the radius (sigmoid notch). In a posttraumatic condition, both the spaces are involved. Fibrosis under the TFCC precludes any visualization by arthroscopy, and in the absence of a central perforation of TFCC good visualization is difficult. In these conditions, we suggest introducing a blunt dissector between the TFCC and the ulnar head, and gently dissecting the adhesions. It could also be done by

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shaving using traditional DRUJ portals or just below the 6U portal (direct foveal portal) or lateral to the 6U portal. Fibrosis can be completely removed through these portals (Fig. 12.31) and it is also possible to perform a wafer resection. The second space, lying between the ulnar head and the sigmoid notch, is affected by retraction of the volar and dorsal capsule, producing rigidity in prono-supination. Arthroscopic arthrolysis of this space starts with the scope in the distal portal and instruments in the proximal one. Also in this joint, it is difficult to perfectly visualize the tip of the instrument introduced in the DRUJ proximal portal. The dorsal and the volar capsule must be detached and/or resected (Fig. 12.32). Anterior capsulectomy would improve the supination and posterior capsulectomy the pronation. To improve the visualization and speed of this last part of the procedure, a curved dissector is introduced into the joint

Fig.  12.31  Schematic drawing showing the fibrosis removal under the TFCC

Fig.  12.30  Schematic drawing showing the localization of fibrosis in the DRUJ. This joint was artificially divided into two parts according to the arthroscopic procedure

Fig. 12.32  Drawing showing an axial view of the DRUJ. Dorsal and volar capsules are sectioned (red arrows and red line)

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from the proximal portal. By passing from dorsal to volar it is possible to detach the ligament from the ulnar margin of the distal radius (sigmoid notch) (Fig. 12.33). The volar and the dorsal parts of the TFCC ligament

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must not be detached from the bony origin (radius and ulnar fovea). If this happens DRUJ instability will follow the DRUJ rigidity. The articular surface of the ulna head and sigmoid notch must not be damaged, either. Dry arthroscopy is rarely used for DRUJ. Finally, removing the traction, gentle pronation and supination maneuvers are performed to evaluate the amount of improvement in ROM (Fig. 12.34).

Clinical Experience 1. Group 1: arthroscopic wrist arthrolysis (AWA)

Fig.  12.33  Schematic drawing showing the fibrosis removal between the ulnar head and the sigmoid notch

Fig. 12.34  Intraop maneuver to evaluate the pronationsupination obtained after arthrolysis of the DRUJ

The authors’ clinical experience started in 1988, and until now, the author has operated on 63 cases. Indications for arthroscopy have not only been distal radius fractures, but also postsurgery. Among these cases, causes have been painful rigidity after corrective osteotomy for distal radius malunion, proximal row carpectomy, midcarpal arthrodesis with scaphoid resection, and TFCC open repair. The control series study performed from 1988 to 2001 included 20 patients (14 males and 6 females, with a mean age of 39 years): one of our cases was operated bilaterally and successively required an

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additional right wrist arthroscopic arthrolysis in order to reach the same level of improvement as that of the contralateral side. All the cases had wrist rigidity secondary to surgery or immobilization after wrist fracture. Preoperative and postoperative evaluation of all the patients was done using the Mayo Wrist Score [9]. The DASH Questionnaire was also administered in the postop check-up. 2. Group 2: Hyaluronan antiadhesion barrier gel, Hyaloglide®, as adjunct to AWA technique Recently, several authors have published their clinical experience in AWA with good results in terms of wrist ROM recovery and pain relief. However, for the cases in which arthroscopy had demonstrated severe chondral damage, a high recurrence of wrist rigidity has been observed. Hyaloglide®, an antiadhesive absorbable hyaluronan-based gel, already tested for tendon and nerve surgery, has been used (introduced into the wrist joint through a portal) to prevent adhesions and fibrous band formation in patients after AWA. From 2006 to 2007, 6 of 12 patients were included in the study. The average age of the patients was 37 years, all affected by wrist rigidity in which arthroscopy showed severe distal radial cartilage damage. The same preoperative and postoperative evaluation as in the previous group was carried out.

Postop Treatment

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can be initiated 1 month after surgery under the strict supervision of a physical therapist. The patient protocol is individualized depending on the strength requirements they need in order to perform their job. It is advisable that the physical therapist does an on-site ergonomic evaluation of the patient and quantifies the forces required of the patient’s entire upper extremity in order to perform their work duties [29].

Results Intraoperative findings (100%) were fibrotic bands between the radius and the scaphoid bone, the scapholunate ligament, and the lunate bone depending on the type of previous damage. Osteochondral lesions and articular step-off were recorded on the articular surface of the radius and these were in correlation with the residual pain after surgery (worst result). The dorsal rim of the distal radius was resected to improve wrist extension in such cases. No complication were documented in either group. All group 1 cases were clinically reevaluated at a mean follow-up of 32 months (range from 2 to 140 months). One case failed because the surgical indications were not correctly evaluated and one patient was deceased. In all the 19 cases, pain was significantly diminished or completely absent and wrist ROM and grip strength were improved (Table 12.3). The average modified Mayo Clinic Wrist Score improved from 39 (preop) to 87 (postop), and the DASH Questionnaire obtained an average of 21 points (Figs. 12.35). All the patients of group 2 were reevaluated at a mean followup of one year. Preliminary analysis showed that in all the patients, pain diminished, while wrist ROM and grip strength improved. The mean score of modified

Rehabilitation is started immediately after surgery [29]. The same rehabilitation protocol was used in both the studies. Routine analgesics were used for postoperative pain control. Prono-supination and flexion-extension exercises were performed for almost 3 months, gradually improving the passive mobilizing force. Aquatic reha- Table 12.3  Clinical results of AWA (group 1) Preop (mean) bilitation is the initial treatment of choice and the patient can gradually progress to exercising in antigravity pos- Pain (VAS)   7 tures out of the water. Passive, active, and active-assisted Flexion/extension (degrees)   84 exercises are performed by the patient, under the guidRadial/ulnar deviation (degrees)   48 ance of a physiotherapist. 132 Return to work is limited up to 3 months as per the Prono/supination (degrees) work requirements of the patient. A palmar wrist splint Grip strength (kg)   27 is used for protection while performing heavy activities. Mayo Wrist Score   28 Work-hardening and endurance-strengthening exercises – using isokinetic and isotonic rehabilitation equipment DASH Questionnaire

Postop (mean)   1 107   49 156   36   79   21

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Table 12.4  Clinical results of AWA + hyaloglide (group 2) Preop (mean) Postop (mean) Pain (VAS)

  6

  4

Flexion/extension (degrees)

  92

100

Radial/ulnar deviation (degrees)

  38

  50

Prono/supination (degrees)

105

135

Grip strength (kg)

  22

  27

Mayo Wrist Score

  41

  68

DASH Questionnaire

  49

  35

Fig. 12.35  Case 1: BA, 24-year-old male, affected by intraarticular distal radius fracture of the right wrist associated with crush syndrome of the forearm. Forearm and hand fasciotomies were performed in emergency. Distal radius fracture was treated

Fig. 12.36  Case 1 (cont): X-rays showed articular wrist space reduction with a small articular step-off and intense osteoporosis

Mayo Wrist Score improved from 45 to 65. Postoperative DASH score was 26 from a preoperative score of 49 (Table 12.4) (Figs 12.40).

Discussion Arthroscopic wrist arthrolysis is a difficult and time consuming procedure. It must be performed by a surgical specialist skilled in both wrist arthroscopy and wrist

with reduction and pin fixation and prolonged immobilization by cast for 50 days. After intensive rehabilitation the wrist showed a painful stiffness (Fig. 12.35)

12  The Role of Arthroscopy in Postfracture Stiffness

Fig.  12.37  Case 1 (cont): Arthroscopic arthrolysis was performed 4 months after unsatisfied rehabilitation, obtaining intraoperative improvement of flexion-extension of the wrist. Traditional portals for radiocarpal and midcarpal joint were used

Fig. 12.39  Case 1 (cont): X-ray films showed an evident improvement of the radiocarpal joint space at follow-up, but also the persistence of a scapholunate dissociation and a dorsal radio carpal abutment due to malunion of the dorsal border of the radius. Fortunately both were clinically asymptomatic

167

Fig. 12.38  Case 1 (cont): Wrist ROM at 1 year follow-up. Pain decreased from 3 to 0 at rest and from 7 to 3 at intensive activity

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R. Luchetti

Fig. 12.40  Case 2: MB, 27-year-old female affected by painful stiff wrist after intraarticular fracture of her right wrist. For the wrist fracture, immobilization in cast was adopted and maintained for 35 days. Wrist rehabilitation was prolonged for more than 3 months. X-ray films show reduction of the space of the radiocarpal joint with sclerosis of the border both in radiocarpal and midcarpal joints

Table 12.5  Comparison between previous studies in literature Authors Cases Follow-up (months) n

Preop

Postop

Flex/Ext (mean degrees)

Flex/Ext (mean degrees)

Pederzini et al. [25]

 5

10

44/40

54/60

Verhellen and Bain [30]

 5

 6

17/10

47/50

Osterman et al. [24]

20

32

  9/15

42/58

Luchetti et al. [17,21]

19

32

46/38

54/53

Hattori et al. [14]

11

NR

29/47

42/56

NR = not reported

surgery. Occasionally, in fact, the technique requires miniopen surgery or a conversion into an open procedure to obtain the best result. It is particularly true for the DRUJ, in which resection of the volar and dorsal capsule is difficult to perform arthroscopically. However, arthroscopic arthrolysis technique is a suitable and promising surgical option for the treatment of wrist rigidity after trauma or surgery. It is a safe and miniinvasive

procedure and allows the surgeon to identify the real causes leading to intraarticular rigidity and pain. Comparison between previous experiences regarding the improvement of wrist ROM after arthroscopic wrist arthrolysis is reported in Table 12.5. Compared to Verhellen and Bain [30], our cases had a greater preop wrist ROM, but the final results of wrist motion were almost the same. Our indication for

12  The Role of Arthroscopy in Postfracture Stiffness

Fig. 12.41  Case 2 (cont): MRI image shows the same result (yellow arrows) with involvement of the scapho-lunate joint (red arrows)

selecting surgical candidates is based on the subject’s level of wrist rigidity associated with pain. Wrist rigidity aloneis not considered to be important enough to require an arthroscopic arthrolysis, but when associated with pain, this surgical technique is strongly indicated. An additional arthroscopic arthrolysis can be performed if required (one such case occurred in our study) based on the clinical results and degree of improvement in ROM. Arthroscopy can reveal associated soft tissue tears that are considered to be the cause of wrist pain. In our study, we frequently found loose bodies, arthrofibrosis, radiocarpal septum, chondritis and osteochondritis, partial tears of the intercarpal ligaments and TFCC, and/or a minimal articular step, which were not evident

169

Fig. 12.42  Case 2 (cont): Preop clinical function of the wrist shows more limitation of flexion-extension than prono-supination (Fig. 12.43)

Fig. 12.43  Case 2 (cont): Preop clinical function of the wrist shows more limitation of flexion-extension than prono-supination (Fig. 12.43)

in the X-ray and/or MRI. This confirms the validity of arthroscopy in comparison to other methods of investigation [8, 34]. Moreover, by this procedure it is often

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Fig.  12.44  Case 2 (cont): Arthroscopic view of the wrist after arthrolysis

Fig. 12.46  Case 2 (cont): At the end of surgery Hyaloglide® was introduced: the radiocarpal joint was completely filled by Hyaloglide® with clear evidence at arthroscopy (Fig. 12.46)

Fig. 12.47  Case 2 (cont): At follow-up, wrist ROM improved (Figs.  12.47 and 12.48) and pain almost disappeared passing from 7.5 to 2 at intensive work

Fig. 12.45  Case 2 (cont): At the end of surgery Hyaloglide was introduced: the radiocarpal joint was completely filled by Hyaloglide® with clear evidence at arthroscopy (Fig. 12.46) ®

possible to treat all the pathologies at the same time thereby improving both wrist pain and rigidity. Conversion to open surgery is indicated only when it is necessary to surgically treat the DRUJ and when difficulty is encountered during the arthroscopy. Other surgical approaches are adopted to treat associated soft

tissue tears or pathologies, such as CTS and partial or total wrist denervation. Based on our experience, we suggest that TFCC tears type 1B or a complete lesion of the SL ligament must not be treated simultaneously with arthrolysis since they require a prolonged amount of immobilization time and the rehabilitation protocol is contrary to that of arthrolysis. Therefore, before arthroscopy, it is important to discuss with the patient, the surgical procedure indicated, based on a thorough clinical evaluation, and to plan the optimal timing of the surgery, since it is mandatory that the

12  The Role of Arthroscopy in Postfracture Stiffness

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Fig. 12.48  Case 2 (cont): At follow-up, wrist ROM improved (Figs. 12.47 and 12.48) and pain almost disappeared passing from 7.5 to 2 at intensive work

Fig. 12.49  Case 2 (cont): X-ray films of the wrist at follow-up

wrist is mobilized and the patient initiates rehabilitation immediately after an arthroscopic arthrolysis procedure. One must remember that if there is an underlying SL ligament tear, in addition to the presence of wrist rigidity, the surgeon will not be able to obtain good results by performing an arthroscopic arthrolysis. The injury to this ligament is predominantly hidden by wrist rigidity, and only after wrist arthrolysis, wrist instability due to ligament tear is manifested. The improvement of wrist range of motion that is obtained during wrist arthrolysis can be inconsistent. In a previous study [25], we found that an intraoperative increase in wrist flexion-extension ROM was followed by a temporary decrease soon after surgery, but was recuperated by the final follow-up reevaluation. On the other hand, pronation – supination improvement

that has been obtained during surgery is almost always maintained postoperatively. Rigidity of the wrist does not always involve the radiocarpal joint (flexion-extension) by itself. DRUJ (prono-supination) rigidity is more frequently encountered and it  can be isolated or associated with the radiocarpal joint. When the rigidity of the DRUJ is isolated, ROM recovery after surgery is easier to obtain than flexion-extension ROM and this improvement has been maintained overtime.

Failures and Complications Unfortunately, the surgeon may not be able to perform a wrist arthroscopic arthrolysis due to the presence of an osteofibrotic band (radiocarpal septum) that is too

172

thick and dense and obstructs the field of view. We encountered such a situation in one of our cases that eventually resulted in a radio-lunate ankylosis (Figs. 12.18 and 12.19). These are the types of cases that should not be treated arthroscopically since they easily end up with residual wrist rigidity. In addition, a radiologic wrist exam, 3–6 months from the time of fracture, does not always demonstrate all the underlying problems, and when the surgeon sees a preserved articular space, they tend to be eager to perform a surgical arthroscopic arthrolysis. Unfortunately, the underlying difficulties become quite evident during the surgery and if one is able to perform the wrist arthrolysis, they have to first detach the tenaciously adherent bands and the osteofibrotic bridges in order to improve the surgical visual field and ultimately, articular range of motion. At the same time when this technique is being performed, it becomes quite evident that the radial surface is no longer completely covered by cartilage and there is the presence of osteochondral lesions of varying severity. Even if a proper physical therapy protocol is followed, it is quite common that fibrotic bridges can reform in a few months and provoke partial (rigidity) or complete radiocarpal ankylosis. It is also possible to find extraarticular wrist rigidity that has been caused by reflex sympathetic dystrophy. In these cases, wrist arthrolysis must be associated with the release of extra-articular soft tissue adhesions. Surgery in these cases must be planned with extreme caution since the root of the wrist rigidity is much more complex than just a localized articular dysfunction. The surgeon can run into unpleasant technical situations during surgery such as the breakdown of instruments; tweezers, scissors, mini-scalpel or motorized instruments [20]. When the patient reports that wrist pain has reappeared or has never completely disappeared after surgery, the surgeon should take note that there can still be an underlying articular pathology that has not been uncovered. Often the pain can be due to intrinsic ligaments tears (SL or LT) that had not been taken into consideration preoperatively. Moreover, the use of articular instruments and motorized instruments can cause unwanted osteoarticular lesions (chondral scuffing, ligament injuries etc.), and can manifest themselves postoperatively in the form of pain or wrist instability.

R. Luchetti

References   1. af Ekenstam FW. Capsulotomy of the distal radio-ulnar joint. Scand J Plast Surg. 1988;22:169–71   2. Altissimi M, Rinonapoli E. Le rigidità del polso e della mano. Inquadramento clinico, valutazione diagnostica e indicazioni terapeutiche. Giornale Italiano di Ortopedia e Traumatologia, Suppl, LXXX Congresso SIOT. 1995;21(3): 187–92   3. Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusa M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25:S131–44   4. Bain GI, Munt J, Bergman J. Arthroscopic dorsal capsular release in the wrist: a new technique. 2008;12:191–4   5. Bain GI, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy. 2008;24:355–67   6. Bain GI, Verhellen R, Pederzini L. Procedure artroscopiche capsulari del polso. In: Pederzini L, editors. Artroscopia di Polso. Milano: Springer;1999. p. 123–8   7. Brunelli G, Longinotti C, Bertazzo C, Pavesio A, Pressato  D. Adhesion reduction after knee surgery in a rabbit model by hyaloglide, a hyaluronan derivate gel. J Orthop Res. 2005; 23:1377–82   8. Cerofolini E, Luchetti R, Pederzini L, Soragni O, Colombini R, D’Alimonte P, et  al. Evaluation of triangular fibrocartilage complex tears in the wrist: comparison with arthrography and arthroscopy. J Comput Assist Tomogr. 1990;14: 963–7   9. Cooney WP, Bussey R. Difficulty wrist fractures. Clin Orthop Rel Res. 1987;213:136–47 10. del Piñal F, Garcia-Bernal FJ, Delgado J, Sanmartin M, Regalado J, Cerezal L. Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique. J Hand Surg. 2006;31A:1029–34 11. del Piñal F, Garcìa-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist.Surgical technique. J Hand Surg. 2007;32A:119–23 12. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intraarticular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg. 1999;81A: 1093–110 13. Hanson EC, Wood VE, Thiel AE, Maloney MD, Sauser DD. Adhesive capsulitis of the wrist. Diagnosis and treatment. Clin Orthop Rel Res. 1988;234:51–5 14. Hattori T, Tsunoda K, Watanabe K, Nakao E, Nakamura R. Arthroscopic mobilization for post-traumatic contracture of the wrist. J Jpn Soc Surg Hand. 2004;21:583–6 15. Jones GS, Savoie FH. Arthroscopic capsular release of ­flexion contractures of the elbow. Arthroscopy. 1993;9: 277–83 16. Luchetti R, Atzei A. Artrolisi artroscopica nelle rigidità posttraumatiche. In: Luchetti R, Atzei A, editors. Artroscopia di Polso. Fidenza: Mattioli 1885 Editore; 2001. p. 67–71 17. Luchetti R, Atzei A, Mustapha B. Arthroscopic wrist arthrolysis. Atlas Hand Clin. 2001;6:371–87 18. Luchetti R, Atzei A, Fairplay T. Wrist arthrolysis. In: Geissler WB, editor. Wrist Arthroscopy. New York: Springer; 2004.p. 145–54 19. Luchetti R, Atzei A, Papini-Zorli I. Arthroscopic wrist arthrolysis. Chir Main. 2006;25:S244–53 20. Luchetti R, Atzei A, Rocchi L. Incidence and causes of failures in wrist arthroscopic techniques. Chir Main. 2006;25: 48–53

12  The Role of Arthroscopy in Postfracture Stiffness 21. Luchetti R, Atzei A, Fairplay T. Arthroscopic wrist arthrolysis after wrist fracture. Arthroscopy. 2007;23: 255–60 22. Maloney MD, Sauser DD, Hanson EC, Wood VE, Thiel AE. Adhesive capsulitis of the wrist: arthrographic diagnosis. Radiology. 1988;167:187–90 23. Moritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K. Change in the length of the ulnocarpal ligaments during radiocarpal motion: possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg. 2008;33A: 1278–86 24. Osterman AL, Culp RW, Bednar JM. The arthroscopic release of wrist contractures. Scientific Paper Session A1, ASSH Annual Meeting, Boston; 2000 25. Pederzini L, Luchetti R, Montagna G, Alfarano M, Soragni O. Trattamento artroscopico delle rigidità di polso. Il Ginocchio XI-XII; 1991. p. 1–13 26. Slutsky DJ. Wrst arthroscopy through a volar radial portal. Arthroscopy. 2002;18:624–30 27. Sprauge N, O’Connor RL, Fox JM. Arthroscopic treatment of post operative knee fibroarthrosis. Clin Orthop Rel Res. 1982;166:125–8 28. Tham S, Coleman S, Gilpin D. An anterior portal for wrist arthroscopy. Anatomical study and case reports. J Hand Surg. 1999;24B:445–7

173 29. Travaglia-Fairplay T. Valutazione ergonomica dell’ambiente industriale e sua applicazione per screening di pre-assunzione e riabilitazione work-hardening. In: Bazzini G, edotir. Nuovi approcci alla riabilitazione industriale. Pavia: Fondazione Clinica del Lavoro Edizioni; 1993. p. 33–48 30. Verhellen R, Bain GI. Arthroscopic capsular release for contracture of the wrist. Arthroscopy. 2000;16:106–10 31. Viegas SF, Patterson RM, Eng M, Ward K. Extrinsic wrist ligaments in the pathomechanics of ulnar translation instability. J Hand Surg. 1995;20:312–8 32. Warner JJ, Answorth A, Marsh PH, Wong P. Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg. 1995;78A:1808–16 33. Warner JJ, Allen AA, Marks PH, Wong P. Arthroscopic release of post-operative capsular contracture of the shoulder. J Bone Joint Surg. 1996;79A:1151–8 34. Zlatkin MB, Chao PC, Osterman AL, Schnall MD, Dalinka MK, Kressel HY. Chronic wrist pain: evaluation with high resolution MR imaging. Radiology. 1989;173:723–9

Treatment of the Associated Ulnar-Sided Problems

13

Pier Paolo Borelli and Riccardo Luchetti

Introduction Ulnar impaction, ulnar styloid impaction (USI), ligamentous injury, chondral lesions, associated TFC tear (triangular fibrocartilage) with or without instability [18–20], and sigmoid fossa derangements can all be associated with a radius malunion (Fig. 13.1). Although it is true that treatment of the radius malunion itself might partially correct some of the problems, particularly those caused by axial shortening (USI), many other will remain unaddressed, and will be a source of pain and patient dissatisfaction. On the other hand, the isolated treatment of the associated injuries can be sufficient to ease the patient’s symptoms without addressing the radius, and a less involved postoperative course. Arthroscopic exploration allows the assessment of the impact that those associated injuries might have on the patient’s symptoms and the degree of improvement by the radius osteotomy itself, and also helps to evaluate if additional maneuvers (arthroscopic or open) are needed for addressing concomitant injuries. The purpose of this chapter is to describe the detection and treatment of these “minor” injuries associated with the main radius deformity that can be a source of patient dissatisfaction and a poor result.

P. P. Borelli, MD () Wrist and Hand Surgery Service 1st Division of Orthopaedic and Trauma Center Spedali Civili of Brescia, Brescia, Italy e-mail: [email protected] R. Luchetti Rimini Hand Surgery & Rehabilitation Center, Rimini Multimedica Policlinic, Milano, Via Pietro da Rimini 4, 47900 Rimini, Italy e-mail: [email protected]

Fig. 13.1  The ulnar-sided pathology in an extra-articular radius malunion (DRM) (marked in red)

Ulnar Carpal Impaction (UCI) Axial radial shortening and dorsiflexion both increase the load borne by the ulnar head [35]. Degenerative central tear of the TFC; chondromalacia of the lunate, triquetrum, and head of the ulna; and finally osteoarthritis occur in a progressively unrelenting fashion (Fig.  13.2).Typically, patients complain of subacute ulnar pain. Tenderness to palpation is observed in the ulnocarpal space dorsally, and the fovea sign may be positive [31]. The pain usually worsens with pronation, and the ulnar deviation and the ulnocarpal stress test [28] may reproduce symptoms.

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_13, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 13.2  The full spectrum of pathologic conditions in the UCI syndrome. Secondary UCI syndrome is frequently associated with DRMs

Plain radiograms may show ulnar-positive variance, while subchondral sclerosis or cysts, “kissing” lesions,

a

Fig. 13.3  Ulnar impaction syndrome in a 34-year-old man with neutral ulnar variance and insidious onset of ulnar-sided wrist pain (Palmer class IIC lesion). Coronal T1-weighted (a) and coronal fat-suppressed T2-weighted (b) MR images show central perforation of the triangular fibrocartilage (TFC) (arrow),

on the lunate, triquetrum, and ulnar head can be seen in advanced cases. Neutral-rotation PA, clenched-fist PA, and fully pronated PA radiographs of the wrist should confirm an ulnar-positive variance [28, 33] and help in planning the amount of ulnar head that needs to be resected. MR imaging findings are characteristic and may help in confirming the diagnosis in doubtful cases (Fig. 13.3). Ulnar-shortening osteotomy has, for a long time, been considered the procedure of choice for the ulnar impaction syndrome [9, 22], but the arthroscopic wafer resection [21, 24] has become a valid alternative with similar results and less morbidity [6] (Fig. 13.3). In many cases, the radius osteotomy alone will correct the impaction syndrome [12, 14], and only synovectomy and tidying up of the chondral defect will be needed by arthroscopy (Fig.  13.4). In some cases, when the shortening is minor and the radius maintains a normal alignment in the frontal and sagittal planes, it is less traumatic for the patient to proceed to an arthroscopic wafer resection of the ulnar head. Also, an arthroscopic wafer resection can be useful in those cases when, after the radius osteotomy, the ulnar head remains positive and still impacts against the carpus. The arthroscopic wafer, however, is not recommended when there is a major radial shortening (more

b

chondromalacia of the lunate bone and ulnar head with secondary subchondral changes (arrowheads). An arthroscopic “wafer” procedure was performed with excellent results. (Courtesy of Dr Cerezal, Santander, Spain)

13  Treatment of the Associated Ulnar-Sided Problems

a

c

177

b

d

e

Fig. 13.4  Clinical signs of ulno carpal impaction (UCI). No signs of DRUJ instability. (a, b) Distal radius malunion with severe dorsal angulation. (c) Coronal STIR MR image suggests TFC perforation or avulsion at the radial side (yellow arrow) with signs of LT ligament degenerative wear (red arrow), indicative of UCI syndrome. (d, e) Coronal fat-sup-

pressed T2-weighted MR images showing chondromalacia in the triquetral bone (blue arrows) and a dishomogeneous signal of the deep portion of the TFCC in association with a bone fragment of the ulnar styloid at the fovea, suggesting a partial tear of TFC at this level. TFC looks thicker. The osteotomy and synovectomy, and ulnar debridement solved the symptoms

than 3 or 4 mm of ulnar head to be resected). It has to be stressed that the contact area at the distal radioulnar joint is only about 7–9 mm [32]. Consequently, a major

resection of the ulnar head will reduce the contact area at the sigmoid to a minimum, risking early overload and osteoarthritis (Fig. 13.5). For those cases, a formal

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Fig. 13.5  An arthroscopic wafer resection has been performed for UCI. Notice that the contact area at the sigmoid notch (arrow) remains minimally altered. (Courtesy of Dr Piñal)

Fig.  13.6  (a, b) In a well aligned, in the sagittal and frontal planes, but shortened radius, an open ulna-shortening osteotomy is the best alternative to restore the anatomy of the DRUJ. (c)

Instability of the ulna remained after the shortening due to TFC avulsion from the fovea. Arthroscopic reattachment of the TFC at the fovea was carried out. (Courtesy of Dr Piñal)

open ulnar shortening will restore the anatomy at the distal radioulnar joint. However, arthroscopy still plays an important role in the decision-making process, as

the DRUJ may remain unstable after the shortening, still needing TFC reattachment (Fig.  13.6), or some other intraarticular pathology may coexist (see below).

13  Treatment of the Associated Ulnar-Sided Problems

Ulnar Styloid Impaction In USI or ulnar styloid triquetral impaction [8, 17], the ulnar styloid impacts into the triquetrum. Any axial shortening can become symptomatic in patients with a congenital long styloid (Fig. 13.7), but in the setting of the DRM is much more common this is to be due to styloid non-union. The diagnosis of USI is based on tenderness at the tip of the ulnar styloid and on a positive provocative maneuver, the Ruby’s test. This test is positive when pain is elicited by taking the dorsiflexed wrist from full pronation to full supination [34]. This is so, because when the wrist dorsiflexes in supination, the space between the triquetrum and the styloid is reduced. The patient typically complains of pain when the hand is placed on the hip (Fig.  13.8) or in the back pocket. Conversely, in the ulnar head impaction syndrome, the tenderness is localized more dorsal and radial with respect to the ulnar styloid and is increased by palpation over the ulnocarpal space, and the provocative test is performed in pronation. The radiological diagnosis of USI is based on a decreased distance between the ulnar styloid and the triquetrum, but should be suspected in any case where

Fig. 13.7  Pathologic conditions of the USI syndrome, such as chondromalacia of the proximal and dorsal aspects of the triquetrum and subcortical sclerosis on the styloid process, are illustrated

179

the styloid is longer than 6 mm, or in any nonunion of the tip of the styloid (which relatively lengthens the styloid itself). MR imaging may show focal subchondral sclerosis on the tip of the styloid, chondromalacia of the ulnar styloid process and proximal triquetral bone, and possible LT joint derangement. The treatment of a classic USI is open resection of the styloid leaving intact the 2–3 mm more proximal in order not to disturb the more proximal insertions of the distal radioulnar ligaments in the fovea [5, 34] or by arthroscopic techniques [4]. When both UCI and USI are present as a consequence of radius malunion, a radius-corrective osteotomy alone or an ulnar-shortening osteotomy will treat both disorders. Alternatively, an ulnar shortening is all that may be required when the radius is shortened but maintaining normal alignment (Fig. 13.9). Never­ theless, arthroscopy plays an important role in the decision-making process, helping in the assessment of the TFCC, the LT joint, and the triquetral bone in order to perform an eventual TFC retensioning in case of concomitant DRUJ instability or a cartilage/bone debridement. As stated, USI is also frequently seen when a radius malunion is associated with a concomitant ulnar styloid nonunion, which usually includes a part, variable in size, of the ulnar TFCC (Fig. 13.10). The ulnar styloid nonunion is usually the result of avulsion of the ulnar attachment of the TFCC (Palmer class 1B) [27], but may also be a result of an impaction trauma, involving only the distal part of the styloid process that usually misses any important DRUJ stabilizer [15]. Various authors [3, 10, 23] have stressed the importance of proper judgment of an ulnar styloid as it can act as an irritative foreign body in the ulnar carpus, associated with instability or a radiological finding with no clinical correlation. In standard radiographs, apart from the nonunion, sclerosis or even cysts of the kissing areas of the triquetrum and the ulnar styloid can be seen. MR imaging may show the status of the distal and proximal part of the TFCC, the early chondromalacia of the triquetrum with subchondral edema. However, finding an ulnar styloid nonunion can be inconsequential, and the arthroscopy will help to know its real significance and the degree of instability associated with its avulsion. The following scenarios can be found:

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a

b

c

d

e

f

Fig. 13.8  (a) Insidious onset of ulnar-sided wrist pain 4 months after a distal radius “nascent” malunion treatment. (b, c, d) Pain was severe when the patient attempted dorsiflexion and supination, but not when she dorsiflexed with the wrist pronated. (e, f) Coronal T1-weighted, coronal STIR MR images show chon-

dromalacia of the triquetral bone with ­secondary subchondral changes (red arrows), indicative of the USI syndrome, and morphological alteration both at the ulnar and radial side of TFCC (yellow arrows). The thickness of TFCC opposite to the LT joint may be predictive of the UCI syndrome

13  Treatment of the Associated Ulnar-Sided Problems

Fig.  13.9  (a, b) Combined USI and UCI syndromes were treated in this patient with a congenital long styloid (10 mm), after ruling out other causes of pain by a simpler ulnar shorten-

Fig. 13.10  Possible styloid nonunion sites are shown

(a) If only the tip of the ulnar styloid process is avulsed (Fig. 13.11) and there are no clinical signs of DRUJ instability, wrist arthroscopy can help to define the presence of USI. If marked synovitis is noted in the dorsal ulnar recess, arthroscopic synovectomy

181

ing osteotomy which restored the congruency at the sigmoid fossa and widened the styloid-triquetral space (dotted line) (c) (Case courtesy of Dr Piñal)

and  resection of the free fragment is indicated. Otherwise, the small bone fleck is left in place. (b) The ulnar styloid fragment is minimally displaced and the DRUJ is pretty stable (Fig.  13.12). Radiocarpal arthroscopy may show that the superficial part of the TFCC is intact, with the tension diminished but no loss of the trampoline effect. Again, simple debridement of the synovitis and of the frayed ligaments, together with the treatment of the radius, will suffice for improving symptoms. (c) When partial detachment of the foveal insertion occurs, there will be some ballotment and the hook test will be slightly positive (Fig.  13.13). Minor degrees of instability will correct spontaneously after the radius osteotomy, but if it remains after treatment, addressing the foveal attachments of the TFCC is mandatory. Arthroscopy has a minimal role in assessing the proximal component in DRM as the ulna is positive [30]. Two treatment options are suggested depending on the size of the ulnar styloid itself. −− If the fragment is small, excision through a mini-open subcutaneous ulnar approach is recommended. Through the same approach, the fovea may be inspected and, if needed, refreshened and finally the TFCC be reinserted with a mini anchor into the fovea.

182

Fig. 13.11  Pure USI syndrome caused by a fleck of the tip of the styloid

Fig. 13.12  The ulnar styloid fragment is minimally displaced. DRUJ is often pretty stable. In longstanding conditions, signs of USI and UCI syndromes may be associated

P. P. Borelli and R. Luchetti

Fig. 13.13  Partial tear of the deep part of TFCC (see text)

−− If the fragment is large, rigid fixation with a tension wire or preferably a cannulated screw as for the acute cases (see Fig. 6.16) is recommended. The operation is carried out through a mini-open approach, and after refreshening the bony ends, the styloid is fixed in the anatomic position. The procedure has the benefit of restoring the anatomy, correcting any existing styloid impaction. A radiocarpal arthroscopy would confirm that the distal TFCC has regained proper tension, restoring the trampoline effect. It is important to remember that important stabilizers such as ulnar collateral ligament, the ECU tendon sheath, and the distal part of the TFCC are inserted onto the ulnar styloid, and all that will also be treated. (d) When the ulnar styloid remains highly displaced, and clinical signs of DRUJ instability exists after the osteotomy of the radius (intraoperative ballotment test), then one has to suspect that total detachment of all the connections of the DRU ligaments had occurred (Fig. 13.14). This will be confirmed during arthroscopy by a positive hook test. Reattachment of the TFCC at the fovea is mandatory. Alternatively, if the styloid is large enough direct fixation will solve the problem [2, 3] (see also Chap. 6).

13  Treatment of the Associated Ulnar-Sided Problems

183

Fig.  13.14  Complete ulnar detachment. The ulnar styloid is highly displaced and the DRUJ is unstable. In longstanding conditions, signs of the UCI syndrome may be associated

Fig. 13.15  Floating styloid causing styloid impaction and distal radioulnar instability

(e)    In rare instances, the ulnar styloid is totally disconnected (floating styloid) (Fig. 13.15). Typically the ulnar styloid does not show a remarkable displacement, but there are clinical signs of DRUJ instability after the osteotomy (ballotment test positive). In these cases, during the arthroscopy the surgeon will find signs of ulnar styloid impingement in the triquetrum, and RC arthroscopy will show a positive hook test and at times a positive peripheral tear. Recognition of this entity is very important because reattachment of the ulnar styloid will not correct the DRUJ instability. Correct treatment requires styloid excision and the TFCC reinserted at the fovea (Fig. 13.16).

Radiocarpal arthroscopy helps in evaluating the “distal component” of the TFCC, represented by the centrally located triangular disk, the meniscus homologue, the distal part of palmar and dorsal radioulnar ligaments, and the ulnolunate and ulnotriquetral ligaments (Fig. 13.17). Arthroscopy of the DRUJ would be ideal to assess the proximal component of the TFCC. However, it is technically very difficult and can only be performed in cases of neutral or negative variance (a rare event in a DRM). Hence, to assess the proximal component of the TFCC, one has to rely on the hook test as discussed previously and in Chap. 6 (Fig. 13.18). Tears can be associated with or without instability, and one has to be prepared to detect impaction findings in association with the traumatic tear itself. It is hence vital to understand that many conditions may be associated one another. In order to avoid oversights, the surgeon has to do a thorough exploration of the ulnar part of the joint, rather than stopping with the first diagnosis. Three different conditions may be found when dealing with tears: a peripheral detachment with a stable DRUJ clinically (ballotment negative) (Fig. 13.19); an unstable DRUJ with complete TFC detachment (ballotment positive, peripheral tear evident, and hook test

TFC Traumatic Tears TFCC tears are the most common source of ulnar-sided wrist pain in DRMs [19]. Due to the limited diagnostic help of standard radiographs and MR imaging, TFCC tear assessment requires arthroscopic evaluation of both the proximal and distal components of the TFCC [24].

184 Fig. 13.16  (a) Floating styloid. This 25-year-old patient sustained a fracture as a teenager, having had always a sour pain in the ulnar side of the wrists. He is seen because of newly appearing pain and the novo DRUJ instability after a recent twisting injury. (a, b) Preoperative X-rays and MRI disclose an ulnar and a hypertrophic styloid nonunion. (c) The hook test is positive (the probe is lifting the TFC) while the hypertrophic styloid (arrow) can be seen detached from the TFC. Notice that the TFC mid-substance is normal, which rules out an ulnar head impaction. (d) Marked dorsal synovitis was also detected in the arthroscopy, confirming a styloid impingement. (e) The styloid has been excised through a mini-incision. (f) The TFC can be seen disconnected from the fovea. (g, h) Reattachment of the TFC at the fovea and ulnar styloid excision cured the patient’s symptoms. (i) Arthroscopic view of the sutured TFC. (Courtesy of Dr Piñal)

P. P. Borelli and R. Luchetti

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13  Treatment of the Associated Ulnar-Sided Problems

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Fig. 13.16  (continued)

Fig. 13.17  Tridimensional anatomy of the ulnar aspect of the wrist is shown: the “distal component” of TFCC, represented by the centrally located triangular disk, the peripheral distal hammock-like structure (or meniscus homologue, Nakamura et al. [26]), the distal part of palmar and dorsal radioulnar ligaments and the ulnolunate and ulnotriquetral ligaments

Fig. 13.18  Coronal aspect of the ulnar wrist. The TFCC is composed of the “distal component,” formed by the UCL and the distal hammock structure, and the “proximal component,” which originates from the ulnar fovea and the basistyloid

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positive) (Fig. 13.20); and finally, a distal component intact but a proximal detachment from the fovea (ballotment test positive, hook test positive) (Fig. 13.21). The repair of each condition has been explained in Chaps. 5–7, but in this scenario, the surgery is more complicated as it has to be associated with correction of the radius deformity (Fig.  13.22), or in the more favorable deformities with a surgical procedure at the ulna (see “Ulnar Carpal Impaction”). It should be highlighted that the potential for healing diminishes after 1 year [26], and more complex ligamentous reconstructions, either open [1, 29] or arthroscopically [2], may be needed when the healing potential of the ligaments has been irreversibly lost.

Conclusion Arthroscopy helps in the diagnosis and treatment of associated pathologies of a distal radius malunion. The surgeon should understand that rarely is a single problem the cause of the pain, and this is paramount in identifying and treating all causes of pain for a good outcome (Fig. 13.23).

Fig.  13.19  The DRUJ is clinically stable. Depending on the time elapsed since the trauma, the central part of TFCC can be frayed or perforated

Fig.  13.20  The DRUJ is clearly unstable. In case of a longstanding UCI syndrome, the superficial part of TFCC can be damaged or perforated

Fig. 13.21  The DRUJ is more or less unstable The untightened TFCC may have resulted, with time, in the UCI syndrome

13  Treatment of the Associated Ulnar-Sided Problems

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Fig. 13.22  (a) X-ray preop AP and lateral views of left wrist in a 46-year-old female. Mature extra-articular malunion of the distal radius with palmar tilt loss (red interrupted line) associated with volar subluxation of the ulna head (red arrows) and evident DRUJ diastasis (yellow arrows). (b) Intraop view of dorsal extra-articular osteotomy of the distal radius and its fixation with a dorsal H-shaped plate. The DRUJ was evaluated after distal radius fixation, thus resulting unstable. TFCC

d

foveal detachment was demonstrated by arthroscopy. (c) Intraop view of TFCC foveal repair by arthroscopic assistance. (d) The anchor was introduced into the ulnar fovea through an expanded 6U portal approach. (e) X-ray postop AP and lateral views of the wrist at 6 months follow-up. Palmar tilt correction of the distal radius was achieved, with normal position of the ulnar head due to TFCC repair by foveal reattachment (anchor). (f) Result at 1 year

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f

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Fig. 13.22  (continued)

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Fig. 13.23  X-ray preop AP (a) and lateral (b) view of the right wrist in a 28-year-old male. Mature intraarticular malunion of the distal radius (green arrows and interrupted line) associated with a fracture dislocation of the luno-triquetral joint (red arrows). In the lateral view, VISI deformity of the lunate (red lines) and distal radius step-off (interrupted line) are shown. Clinical signs of UCI are present. (c) MRI coronal view of the right wrist demonstrating the intraarticular step-off (red arrows) at the level of the lunate facet and an evident derangement of the

c

LT joint (yellow arrows). TFCC looks detached from the radial sigmoid and ulnar insertions. During the arthroscopic-guided osteotomy [12] (see also Chap. 14), TFC detachment and tear was ruled out. (d) Arthroscopic view of LT joint debridement with burr in the MCU portal, looking from the MCR portal. (e) X-ray postop PA, and lateral view of the distal radius malunion correction and of the LT joint arthrodesis at follow-up (6 months). In the lateral view, the VISI deformity was partially corrected. (f, g) Result at 1 year

13  Treatment of the Associated Ulnar-Sided Problems Fig. 13.23  (continued)

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References   1. Adams BD. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. Tech Hand Up Extrem Surg. 2000;4(3):154–60   2. Atzei A. New trend in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur. 2009;20:1–10   3. Atzei A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008;12(4):226–35   4. Bain GI, Bidwell TA. Arthroscopic excision of ulnar styloid in stylocarpal impaction. Arthroscopy. 2006;22:677.e1–e3   5. Bain GI, Pourgiezis NP. Surgical approaches to the distal radioulnar joint. Tech Hand Up Extrem Surg. 2007;11(1): 51–6   6. Bernstein MA, Nagle DJ, Martinez A, Stogin JM, Wiedrich TA. A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome. Arthroscopy. 2004;20: 392–401   7. Bickel KD. Arthroscopic treatment of ulnar impaction syndrome. J Hand Surg. 2008;33A:1420–3   8. Cerezal L, del Piñal F, Abascal F, Garcia-Valtuille R, Pereda  T, Canga A. Imaging findings in ulnar-sided wrist impaction syndromes. Radiographics 2002;22(1):105–20   9. Chun S, Palmer AK. The ulnar impaction syndrome: followup of ulnar shortening osteotomy. J Hand Surg Am. 1993; 1818:46–53 10. del Piñal F. The 1-B “Constellation”: a sub-classification of TFCC tears. EWAS session, FEESH Poznam 2009 11. del Piñal F, Garcia-Bernal FJ, Delgado J, Sammartçn M, Regaldo J, Cerezal L. Correction of malunited intra-articular distal radius fractures with an Inside-out osteotomy technique. J Hand Surg Am. 2006;31A:1029–34 12. Del Piñal F, García-Bernal FJ, Studer A, Regalado J, Ayala H, Cagigal L. Sagittal rotational malunions of the distal radius: the role of pure derotational osteotomy. J Hand Surg Eur. 2009;34:160–5 13. Feldon P, Terrono AL, Belsky MR. Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg. 1992;17A:731–7 14. Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. J Bone Joint Surg Am. 1982;64-A:1164–78 15. Garcia-Elias M. Dorsal fractures of the triquetrum-avulsion or compression fractures? J Hand Surg Am. 1987;12:266–8 16. Garcia-Elias M. Soft-tissue anatomy and relationships about the distal ulna. Hand Clin. 1998;14:165–76 17. Giachino AA, McIntyre AI, Gui KJ, Conway AF. Ulnar styloid triquetral impaction. Hand Surg. 2007;12(2):123–34 18. Lindau T. Cartilage injuries in distal radial fractures. Acta Orthop Scand. 2003;74(3):327–31

P. P. Borelli and R. Luchetti 19. Lindau T, Adlercreutz C, Aspenberg P. Peripheral TFCC tears and instability of the distal radioulnar joint after distal radial fractures. J Hand Surg. 2000;22A:464–8 20. Lindau TR, Arner M, Hagberg L. Intra-articular lesions in distal radius fractures in young adults: a descriptive, arthroscopic study in 50 patients. J Hand Surg [Br]. 1997; 22-B(5):639–43 21. Loftus JB. Arthroscopic wafer for ulnar impaction syndrome. Tech Hand Up Extrem Surg. 2000;4:182–8 22. Loh YC, Den Abbellek V, Stanley JK, et al. The results of ulnar shortening for ulnar impaction syndrome. J Hand Surg Br. 1999;24:316–20 23. Luchetti R, Borelli PP, Atzei P. Moderni orientamenti nel trattamento delle fratture. Il trattamento delle fratture di polso. In: AIOD Sezione Italiana, OTC Sezione Italiana, editors. Moderni orientamenti nel trattamento delle fratture. Italia, Milano: Springer. Stryker Italia Education Program. 2008. p. 519–88 24. Mathoulin C, Pagnotta A. Resection arthroscopique distale de l’ulna dans les conflits. Chir Main. 2006;25S:202–8 25. Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex: functional anatomy and three-dimensional changes in length of the radioulnar ligament during pronation-supination. J Hand Surg Br. 2000;25:479–86 26. Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg. 2004;8:116–23 27. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg. 1989;14A:594–606 28. Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg. 2008;33A:1669–79 29. Scheker LR, Ozer K. Ligamentous stabilization of the distal radioulnar joint. Tech Hand Up Extrem Surg. 2004;8:239–46 30. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Upper Extrem Surg. 2007; 11(1): 38–44 31. Scheker LR, Slutsky OK, Tay SC DJ, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg Am. 2007;32: 438–44 32. Tolat AR, Stanley JK, Trail IA. A cadaveric study of the anatomy and stability of the distal radioulnar joint in the coronal and transverse planes. J Hand Surg Br. 1996;21:587–94 33. Tolat AR, Stanley JK, Tomaino TIA, MM EJ. Ulnar impaction syndrome. Hand Clin. 2005;21:567–75 34. Tolat AR, Stanley JK, Tomaino TIA, MM EJ, Topper SM, Wood MB, et al. Ulnar styloid impaction syndrome. J Hand Surg Am. 1997;22:699–704 35. Tolat AR, Stanley JK, Tomaino TIA, MM EJ, Topper SM, Wood MB, et al. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg Am. 1992;17: 423–8

Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius

14

Francisco del Piñal

Introduction Classically, the management of the young patient with a step-off in the distal radius has been panarthrodesis. Several pioneer surgeons such as Saffar, Fernández, and others [1, 12, 14, 18–21, 23] opened the door to the possibility of cutting the displaced fragments again and reducing them in an anatomical position. The gold standard for the most common sagittal step-off (anteroposterior) is to carry out the osteotomy through a dorsal route partly under fluoroscopic guidance [1, 14, 19, 20]. For the volar shearing-type malunions, the joint is approached volarly, the external callus removed, and with an osteotome directed toward the joint, the fragment is slowly cut away with the hope that the osteotome follows the original fracture line [19, 20, 23]. All these procedures and others can be grouped under “outside-in osteotomy” techniques, and although good results have been reported, fears of devascularization and inaccurate reduction exist. Fernández [12] considers the technique appropriate only for single line fractures, González del Pino and others [14, 20] used it for the more complex four-part fracture configurations. The outside-in techniques have had several drawbacks in my hands: first, I have found after a CT scan that some malunions have quite odd configurations far from a simple fracture line (Fig. 14.1). For these cases, unless one creates a very large capsular window to obtain visual control of the osteotomy (with the subsequent risk of devascularization and stiffness), there is no

F. del Piñal Head of Hand and Plastic Surgery, Private practice and Hospital Mutua Montañesa, Calderón de la Barca 16-entlo, 39002-Santander, Spain e-mail: [email protected] and [email protected]

way of knowing where to direct the osteotome inside the joint. By the same token, a large window is also needed to carry out the osteotomy of any malunion where there is a fracture line in the coronal plane. Secondly, in volar shearing malunions, one has to cut the bone in a relatively blind fashion as the volar ligaments need to be kept intact. The direction of the osteotome is a matter of guesswork, and any rough maneuver can create new cartilage fracture lines (Fig.  14.2). In some cases, the configuration of the fracture may not allow a straight cut from outside-in preoperatively (Fig. 14.3). Finally, I have found that another limitation of the outside-in techniques is that the joint space is small before the osteotomy, and becomes inexistent after the fragment is reduced. As a result, one is left to control the reduction in the tight joint space by palpation with a Freer elevator, and fluoroscopy, both methods being most unreliable [11, 17] (Fig. 14.4). Bearing in mind these limitations, we sought a way for assessing the status of the articular cartilage in the area of malunion, which at the same time allowed us to accurately identify the fracture(s) line(s), and in this way we could cut exactly where the malunion was located at the cartilage level [6]. Our initial attempts with the classic arthroscopic technique were frustrated by constant vision losses due to water escaping through the large portals. We later moved on to carry out the arthroscopy without the infusion of water, which solved most of the visibility problems [7]. The “dry technique” has two further advantages: there is no risk of massive fluid extravasation causing compartment syndrome, and secondly, the open part of the operation is carried out without the tissues being infiltrated with water. Conversely, not infusing water engenders a new set of difficulties secondary to vision loss due to splashes and blood staining. I have presented in detail how to deal with these inconveniences in Chap. 4.

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_14, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 14.1  (a–c) Patient with an irregular malunion (same patient as shown in Fig. 14.28)

Fig. 14.2  Above: An “outside-in” osteotomy in the coronal plane may cause a secondary fracture line in the cartilage, as the inclination of the metaphysis does not necessarily have to coincide with the line of fracture at the cartilage level. Below: Attempts to break the fragment by prying with the osteotome may cause additional fracture lines at the now weakened, yet healed, cartilage

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Fig.  14.3  (a, b) This C31 fracture was “simplified” (see “Preoperative Planning”) and only the major volar-ulnar fragment was to be mobilized (V.U.). (c) The articular line has been highlighted with red dots. (d) Notice that the metaphyseal cortex

blocked a direct osteotomy line. A secondary iatrogenic cartilage fracture would have resulted if an “outside-in” osteotomy technique had been used in this case

Fig. 14.4  “Outside-in” osteotomy in a case of depression of the lunate fossa. (a) The step-off is clearly seen prior to the planned osteotomy that will consist of the mobilization of the lunate fossa as a dice (in dots). (b) The “osteochondral dice” has been

mobilized distally, blocking any visual control of the reduction. (c) The limitations of exposure can be seen at the end of the operation (notice the capsular dissection required in this type of osteotomy)

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Indications and Contraindications As a rule, any candidate to an outside-in osteotomy ­correction [1, 12, 14, 18, 20, 21, 23] can be eligible for  an arthroscopic-guided (“inside-out”) osteotomy. Therefore, any fracture with a step-off of 2 mm or more is an absolute indication whether symptomatic or not. Some authors [10, 24] believe that step-offs of just a millimeter can also be symptomatic, and it seems sensible in young patients with a step-off involving the scaphoid or lunate facet (i.e., intrafacet) to go ahead with the operation. On the other hand, low demand patients or relatively silent areas (such as the interfacetal sulcus) are better served by a conservative approach. Wearing of the cartilage on the opposing carpal bone is a contraindication for the procedure, as restoration of the joint congruency will not prevent osteoarthritis in the short term. For this reason, delaying the operation in the hope that some of the intraarticular malunions will not be symptomatic does not seem reasonable since osteoarthritis has been shown to occur in young individuals in the midterm follow-up [15, 24]. The situation is more urgent for intrafacet malunions as the cartilage will wear much more quickly than in the cases of interfacet malunions [12, 25]. However, there is no established time frame after which the cartilage is definitely worn down and the procedure contraindicated. For example, a patient with a huge step-off who has not moved the wrist much will wear the cartilage down less than one who has a small intrafacet step-off but has undergone intensive physiotherapy. In older malunions, it seems wise to explore the wrist arthroscopically so

Fig. 14.5  Perfect restoration of the anatomy can be achieved in young malunions (5 weeks old on the left), while gaps have to be accepted in relatively old ones (11 weeks old on the right)

F. del Piñal

as to assess the condition of the cartilage of the carpal bones prior to proceeding to the osteotomy, as another option may be selected when the cartilage is damaged. But time, in itself, should not be considered a contraindication, as we have recently operated on patients with 12- and 14-month-old malunions with early pleasing results. Another argument for early intervention is that after 6–8 weeks the operation becomes increasingly more difficult technically and the reduction obtained less accurate. This is so because the gap will be filled with matured bone (rather than scarred bone and granulating tissue), making it harder to achieve reduction and to close the gaps (Fig.  14.5). In later cases it is better to accept some “holes” rather than to try to obtain cartilage-to-cartilage contact that may distort the joint anatomy. As a matter of fact, overzealous resection of tissue in the gap may cause narrowing of the radius and secondary problems (Fig.  14.6). The preoperative CT scan will point to where a defect is to be expected and if its size is going to be tolerable (Fig. 14.7). On the other hand, when there has been massive osteochondral loss, or any circumstance where multifragmentation with scarring in a large area of the radius articular surface is likely to create a large chondral defect (Fig. 14.8), our option is to carry out a vascularized osteochondral graft [3, 5, 9] or a partial wrist fusion ([13] and Chaps. 15 and 16). In summary, the surgeon should keep an open mind when approaching a malunion, as the ultimate decision depends on the arthroscopic findings (Fig. 14.9).

14  Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius Fig. 14.6  (a, b) A large defect in the scaphoid fossa in a relatively well-aligned scaphoid should have indicated a massive osteochondral defect rather than a “simple” malunion. (c) Reduction caused an ulno-carpal translocation, and ulnar pain occurred. A much better option would have been to interpose a vascularized osteochondral graft or a partial arthrodesis

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Fig. 14.7  (a) A free osteochondral fragment of about 3 mm was found to be devoid of cartilage and removed from the joint (b). (c) Intraoperative view. The contour of the fragments is outlined with dots. For orientation purposes, only the position of the frag-

ment in the joint has been sketched but not to scale. Notice correction of the step-off radially and ulnarly (arrow). (d) Fourteen months later the mirror carpal bone does not show any worn cartilage (same patient as in Fig. 14.3)

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Fig. 14.8  Massive bone loss (left) or major distortion of the anatomy (right) contraindicates the procedure (both patients were treated with a vascularized osteochondral grafting)

Fig. 14.9  Author’s decisionmaking process when dealing with an intraarticular step-off on the radius (modified from Piñal in [3])

Preoperative Planning A good quality CT scan is paramount in order to understand the deformity. I have found it useful to obtain the initial trauma films, as this gives a good view of how the original displacement was. I should warn the reader that the operation, even in its simplest form (single fragment), is not easy, and becomes all the more difficult as

the number of fragments that need to be mobilized increases. One, therefore, has to strive to accomplish a reasonable outcome with the minimal amount of surgery, knowing that intrafacet step-offs are not permissible, but that inter-facet step-offs and gaps are somewhat tolerable, with the latter being unavoidable in old malunions. Keeping this in mind, and although each case is different, four patterns of deformity can be identified in

14  Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius

order of difficulty (Fig. 14.10). Single-fragment straightline malunion configurations, such as the radial styloid, are relatively easy to deal with, as they require a simple osteotomy. Antero-ulnar malunions, quite common in our experience, do require at least two osteotomy lines, and are considerably more intricate. In order to avoid “major road-works,” in some cases of four-part fractures,

Fig. 14.10  Management of intraarticular malunions. (a) Simple styloid malunions and preferred fixation. (b) Volar-ulnar fragment. When sizable, a screw will suffice for fixation, if small a plate is required. (c) In relatively well-aligned four-part malunions, the decision of adding an ulnar osteotomy depends on the degree of radius shortening. (d) Mobilization of all fragments is required when the malunion is more severe. Fixation with a volar-locking plate is preferred

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where only one articular fragment is markedly displaced, the operation can be simplified, acting only on this malpositioned fragment. A concomitant open ulna shortening is added, when there is more than 2  mm axial shortening of the radius. Finally, when dealing with more irregular malunions, all fragments need to be mobilized and a standard volar-locking plate applied (Fig. 14.10d).

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review of the preoperative X-rays, the original fracture films, where possible, and a good quality CT scan.

Logistics Instruments and Osteotomy Technique This operation is more cumbersome and complicated than the average wrist arthroscopy [4]. First, it has all the difficulties of a distal radius fracture (Chaps. 3 and 4) plus the hindrance that the joint is scarred, and the space is very narrow, even after a preliminary arthroscopic arthrolysis (Fig. 14.11). This intraarticular scarring and fibrosis also makes it very difficult to orientate oneself once inside the joint. As time runs very fast, and ideally one should keep this operation under a tourniquet time, it is crucial that everyone on the surgical team is prepared and familiar with their assigned role. The assistance of another experienced surgeon is priceless (Fig. 14.12), as unexpected difficulties are the norm. Finally, it is invaluable to preplan the osteotomies beforehand based upon a

Fig. 14.11  The lack of working space in the joint, even after a preliminary arthrolysis, makes any movement with the instruments extraordinarily awkward (Copyright by Dr. Piñal, 2009)

Fig. 14.13  Two shoulder periosteal elevators and two sturdier osteotomes are used for cutting the bone. Notice, in the lateral view, the different angulations of their ends, which are essential for carrying out the osteotomies (Copyright by Piñal, 2009)

The setup I use for an arthroscopic-guided osteotomy is identical to the one presented in Chap. 4. The instruments are quite different, however. As there is no specific instrument for cutting the bone in the wrist set, I have borrowed them from the shoulder set. I specifically use a shoulder periosteal elevator (of 15 and 30° angle) (Arthrex® AR-1342-30° and AR-1342-15°, Arthrex, Naples, FL), and also straight and curved osteotomes (Arthrex® AR-1770 and AR-1771) (Fig.  14.13). It is important to have instruments with different angles as the space in the joint is very limited, and never sufficient to cope with the 4 mm width of the osteotome. From a technical standpoint, straight cuts with the straight osteotome are the easiest but only possible

Fig. 14.12  An arthroscopic-guided osteotomy team (Reprinted from Piñal et al, [2])

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Fig. 14.14  (a, b) A straight line malunion permits us to introduce the osteotome and to carry out the osteotomy all along the malunion line. (c) Depending on the location and the direction volarly, ulnar or radial portals may be chosen (Copyright by Dr. Piñal, 2009)

Fig. 14.15  In coronal fracture configurations, several perforations are made with osteotomes using different portals as required, creating a “tear line” for easy breakage

when the fracture line is straight and in line with one of the portals (Fig. 14.14). For those malunions not amenable to this simple osteotomy (such as any coronal fracture line), multiple perforations are made with the osteotome creating a sort of “tear line” in the cartilage and subchondral bone for easy breakage when prying with the osteotome (Fig. 14.15). In general, the osteotomes will have to be introduced from a dorsal portal to cut a volar fragment and vice versa (Fig. 14.16a). However, in some cases the ridge of the step-off impedes a direct approach from the opposite side (Fig. 14.16b). In these cases, a tear line osteotomy from the same side offers a viable alternative (Fig.  14.16c). As a matter of fact, given the space limitations and the fact that quite commonly the malunions are irregular, one has to be prepared to use any portal, any osteotome, and combinations of linear

and tear line osteotomies in order to cope with a given malunion (Fig. 14.17).

The Operation The arm is exsanguinated and stabilized to the table with an arm strap. In young malunions (4–12 weeks old), the procedure is started by preparing the proposed site of plate fixation with the arm lying on the hand table. The approach depends on the location of the malunion: a limited volar-radial approach is used in the cases of a malunited radial styloid fragment. A formal volar-radial approach is used if a multifragmented malunion is to be treated. Finally, a limited volar-ulnar incision is used for a misplaced volar-ulnar fragment (Fig. 14.18). However,

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Fig. 14.16  (a) As a rule, malunited dorsal fragments are better approached from the palmar. (b) When the fragment is depressed, however, the ridge of the step-off may block this approach. (c) In

F. del Piñal

such instances, an angulated osteotome and a “tear line” osteotomy may solve the problem

Fig. 14.17  A depressed volar-ulnar malunion cannot be approached by a dorsal route (see Fig. 14.16). Instead, a combination of volar-radial and dorso-ulnar portals with a “tear line” osteotomy technique can succeed

one has to be prepared to combine radial and ulnar approaches as required, as that is the only way to have control of the whole volar-radius surface. Provided one stays below the tourniquet time all incisions can be closed, although probably due to postoperative swelling causing tension, it is not rare to see some scar hypertrophy that responds well to ­silicone patches (Fig. 14.19). I have several times used combined approaches and provided one does not undermine the bipedicled flap, I have found no problem of skin viability. In order to facilitate the separation of the fragments when later doing the intraarticular osteotomy, the

external callus is removed with a rongeur and the outer callus is weakened with an osteotome (Fig. 14.20). As previously discussed, no attempt should be made to go all the way to the joint or to do any rough bending or prying open on the fragment with the osteotome, as this may break the cartilage at the incorrect place (Fig. 14.2). Similarly to a fracture, if possible a plate is preplaced and held in position with a single screw through its stem. In general, the preferred fixation methods are locking plates for older malunions, and buttressing plates (or lag screws) for younger ones. The rationale is that if compression is added in older

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Fig. 14.18  A volar-radial approach will give access to most of the volar surface of the radius (shadowed orange). However, the ulnar corner can only be manipulated with accuracy when the less popular volar-ulnar approach is used (shadowed blue).In the clinical picture, access to the volar-ulnar corner of the radius is shown. Notice that in this patient a volar-radial approach is also being undertaken

Fig. 14.19  Multiple accesses are at times needed to deal with all parts of the deformity. Volar-radial and volar-ulnar approaches are needed to deal with a complex malunion. On the right, a volar-ulnar approach to deal with the radius and a dorso-ulnar approach for the ulnar osteotomy

Fig. 14.20  (a) In four-part malunions, prior to application of the volar plate and the arthroscopy itself, I recommend removing the volar callus, and weaken the anterior junction by intro-

ducing an osteotome 3–4 mm parallel to the volar cortex (b). It is also crucial to remove the most exuberant callus in relation to the malunited styloid fragment

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malunions (where it is common that cartilage is lost) the joint will be distorted, causing incongruency (Fig. 14.21). Although the ideal outcome would be a normal joint, intuitively one would expect that a gap is better tolerated than a distorted joint. The hand is then placed in traction with the fingers pointing upward. In most cases, we use 7–10  kg of traction applied to all fingers, but one has to expect joint tightness, and the counterweight can be increased. The standard dorsal 3–4 and 6R portals are developed, but they are made larger, to approximately 0.5 cm, to allow easy entrance of the instruments. A hemostat is used to widen the portal. Apart from dorsal portals, a  volar-radial (VR) portal is frequently needed. If a Henry-type incision is planned, the portal is developed as recommended by Levy and Glickel, and others [10, 16, 22]. Regardless of the width of the blade, the volar wrist ligaments can be preserved by introducing the osteotome obliquely, in the direction of the cleft of the  radio-scapho-capitate and the long radiolunate ­ligaments (Fig.  14.22). Initially, a 2.7 mm scope is introduced through the 3–4 portal and a shaver in the 6R portal. It is indispensable to remove scar and debris inside the joint

Fig. 14.21  While a gap maintains most of the joint congruent, except in the defect, attempts to close all chondral defects will distort the joint anatomy (the normal radius contour has been marked with dots)

F. del Piñal

and around the capsule prior to one being able to see anything. I prefer the “aggressive” shavers (2.9  mm gator micro bladeTM; ref: C9961. ConMed Linvatec. Largo, FL) in order to do this, as otherwise it takes too long. Air should flow freely into the joint when the suction of the synoviotome or burr is working, and water should be used to wash out the joint and avoid suction clogging (see “The dry Technique” in Chap. 4). The quality of the articular cartilage of the radius, and of the adjacent scaphoid and lunate, is assessed with the shoulder probe. The step-offs are identified. Once major cartilage destruction has been ruled out, and the fragments to be mobilized are defined, the scope is placed in a position that allows visual control of the osteotome, but away from the osteotomy line. The introduction of the blade of the osteotome inside the joint is somewhat tricky if one is to avoid extensor tendon or nerve lacerations, or damage to the cartilage itself. Thus, the blade of the osteotome should be twisted twice along its path to the joint cavity (Fig. 14.23). First, it should be inserted horizontally, in the direction of the skin incision, then twisted 90° in the subcutaneous tissue in order to be parallel when

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Fig. 14.22  Intraoperative and corresponding arthroscopic view while using a volar portal. The osteotome is introduced into the joint through the radio-scapho-capitate and long radio-lunate cleft. The arrows have been used to highlight the step-off (same case as in Fig. 14.25)

Fig. 14.23  The introduction of the osteotome inside the joint is somewhat tricky if one is to avoid extensor tendons or nerve lacerations or cartilage damage. A double 90° twist is required on its path to the joint when using a dorsal portal

passing by the extensor tendons, and finally rotated again inside the joint itself. One should realize that as the extensors are in tension due to traction, they are at risk of being cut by the sharp blade of the osteotome if inserted perpendicular to their axes. Furthermore, the space inside the joint is very limited, and there is no room to insert the osteotome vertically (4 mm width) without damaging the cartilage (See Fig. 14.11). Gentle maneuvers are necessary when hammering from dorsal to volar, as there is a risk of cutting flexor tendons, if plunging volarly, or extensor tendons when performing the reverse maneuver. The displaced fragments are fully mobilized by carefully prying them apart with the osteotome. In most cases, the fragments are disimpacted and easily elevated by hooking them

with a strong shoulder probe and pulling upward, using similar maneuvers to the ones described for fresh fractures (Chap. 4). Oftentimes, scar and new bone formation between the fragments impede perfect reduction. This early granulation tissue should be resected with the help of small curettes, and the shaver or burrs introduced through the portals, permitting one to minimize the size of the gaps. Once the reduction is acceptable (Figs. 14.24 and 14.25), the operation proceeds exactly in the same manner as for a fracture, i.e., stabilization with Kirschner wires to the plate and fixation from ulnar to radial as for the typical four-fragment fracture (“Management of Fracture” in Chap. 4). The type of fixation depends on the configuration of the malunion and on whether there is cartilage loss (see

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Fig. 14.24  “Simple” straight line malunion involving the scaphoid fossa (2 mm step-off). Result after the osteotomy (Copyright of the American Society for Surgery of the Hand. 2010. [Ref 8])

Fig. 14.25  Complex malunion (multiple fragments/multi-directional fracture lines) involving both the scaphoid and the lunate fossae, after combined-type osteotomies and reduction (same as shown in Fig. 14.22)

above). Lag screws and buttressing or supporting plates can all be viable alternatives. The portals are closed with paper tape or a single stitch, and the wrist is placed in a removable splint. In most of our cases, stability has been enough as to allow protected range of motion on the first postoperative visit (48 h). One should protect the joint for 3–4 weeks if the fixation is not so rigid. When dealing with late-presenting malunions (more than 3 months old) or for cases where a high suspicion of carpal ligament injury exists, the approach is reversed. In these cases, I recommend an initial exploratory arthroscopy to assess the quality of the articular surface cartilage and/or the integrity of the ligaments. If local conditions are met, then the hand is released from traction, and the operation proceeds as explained above. I should underscore again that time, in itself, should not be considered a contraindication for the

procedure as we have experienced recently good results with malunions up to 14 months old.

Results Eleven patients were operated for malunion of the distal radius 1–5 months after the traumatic event under arthroscopic guidance and followed for at least 1 year [8]. Original fracture patterns were one radial styloid fracture, one radiocarpal dislocation, and nine C31 fractures. Seven patients have had surgery prior to the referral, while the rest had cast treatment. In five cases, an antero-ulnar (Fig. 14.26) or radial styloid fragment was only repositioned . In the rest, more than one fragment (up to 3) was osteotomized. In one patient with a

14  Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius

a

b

c

e

g

f

h

Fig. 14.26  (a–d) This C31fracture resulted in a relatively wellaligned, albeit incongruent, radius at the lunate and sigmoid fossae. The patient had scant ROM and 10° supination when first seen 12 weeks after the injury. Despite the confusing markings in (b, d) concerning the ulnar variance depicted by her

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d

original surgeon, the axial shortening was approximately 3 mm in comparison to the healthy side. A Sauve-Kapandji has been offered elsewhere. Only the antero-ulnar fragment was osteotomized with the technique presented in Fig. 14.17. (e–h) Result at 4 years (Copyright by Dr. Piñal, 2009)

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shortened radius by more than 2 mm (in comparison to the healthy side), but only an antero-ulnar fragment malpositioned, repositioning of this fragment was combined with an ulnar-shortening osteotomy with good results (Fig. 14.27).

a

b

At a minimum follow-up of 1 year, the average improvement in ROM was 44° of flexion-extension and 59° of prono-supination. The grip strength average was 85% of the contralateral side. The results in the Gartland and Werley system were excellent for four

c

e

g

f

h

Fig. 14.27  (a, b) This four-part fracture resulted in a relatively well aligned – but shortened (by 5 mm) – radius. The anteroulnar fragment was 3 mm more depressed than the rest. (c) Only this fragment was mobilized and fixed with a volar buttress plate

d

inserted from a volar-ulnar approach. In the same operation, the ulna was shortened (by 2 mm) to restore the DRUJ congruency. (d) Healthy side. (e, h) Result at 1 year

14  Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius

patients and good for seven patients with a mean score of 2.8. The Modified Green and O’Brien system achieved a mean score of 83, with excellent (three patients), good (5  patients) and fair (three patients). Intraoperative gaps were quite common as the fragments did not fit as in an acute fracture (<2 mm). Step-

a

c

Fig. 14.28  Complex malunion (multiple-fragment multi-directional osteotomies). (a, b) Radiograms of a patient who had been treated with an external fixator elsewhere (the CT scan is shown in Fig. 14.1). (c, d) Result at 2 years. (e, h) Clinical result at 2 years

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offs, however, were reduced in most cases to zero (from a maximum of 5 mm). One patient was considered a radiological failure, because the fragment redisplaced due to poor fixation, although so far no additional surgery has been required, and the patient has no complaints. Another asked for hardware removal.

b

d

208 Fig. 14.28  (continued)

F. del Piñal

e

g

f

h

Discussion It may be argued that fragments may be more easily defined early on by simply breaking the external callus as some of our patients were treated early (around the 4th–5th week). On the basis of the experience of our group and others, however, impacted bony fragments that contain cartilage are heal soundly as early as 3–4 weeks and need to be redefined with the use of an osteotome [4, 18]. Piecemeal fragmentation can occur if the mobilization is not done carefully as shown in Fig. 14.2. Herein lies the main advantage of the procedure: the arthroscope allows us to follow the exact line of ­chondral fracture under magnification, and to restore the anatomy of the cartilaginous surface. Additionally, the risk of avascular necrosis of the mobilized fragments is minimized as there is minimal interference between the soft tissues (capsule) and the fragment(s). Furthermore, the capsular ligaments are not violated, and during the arthroscopy an arthrolysis is done. All these together with rigid fixation allow rapid healing and permit ­immediate mobilization (Fig.  14.28). Finally, the ­reduction of the cartilage can be assessed under visual control.

Conclusions The inside-out osteotomy technique allows full evaluation of the articular deformity, more precise osteotomy, and mobilization of the displaced fracture fragments. Even irregular fragments, not amenable to other techniques, can be dealt with by this procedure. Correction of step-offs was achieved in every case with an accuracy of 0  mm. Residual gaps of about 1  mm were common due to cartilage loss, interposition of newly formed bone, and presumably cartilage destruction from the original injury. Understanding of the dry technique intricacies is needed to carry out the procedure in a safe and efficient manner. Any accomplished arthroscopist should not have any undue difficulty to incorporate the dry technique.

References   1. Apergis E. Proceedings of the Ninth Congress of the International federation of Societies for Surgery of the Hand. Budapest, Hungary; 2004   2. del Piñal F. Arthroscopic assisted osteotomy for ­intra-articular malunions of the distal radius. In: Slutsky DJ, Osterman AL, editors. Fractures and injuries of the distal radius and carpus. Philadelphia: Saunders; 2009. p. 543–50

14  Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius   3. del Piñal F. Reconstruction of the distal radius facet by a free vascularized osteochondral autograft. In: Slutsky DJ, Osterman AL. editors. Fractures and injuries of the distal radius and carpus. Philadelphia: Saunders; 2009. www. expertconsultbook.com/W9.   4. del Piñal F, Garcia-Bernal FJ, Delgado J, Sanmartin M, Regalado J. Results of osteotomy, open reduction, and internal fixation for late-presenting malunited intra-articular fractures of the base of the middle phalanx. J Hand Surg. 2005;30A:1039–950   5. del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Regalado J. Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a patient. J Hand Surg. 2005;30A:1200–10   6. del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Regalado J, Cerezal L. Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique. J Hand Surg. 2006;31A:1029–234   7. del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg. 2007;32A:119–23   8. del Piñal F, Cagigal L, Garcia-Bernal FJ, Studer A. Regalado J, Thams C. Arthroscopic assisted osteotomy for management of intra-articular distal radius malunions. J Hand Surg. 2010;35A:392–7   9. del Piñal F, Innocenti M. Evolving concepts in the management of the bone gap in the upper limb. Long and small defects. J Plast Reconstr Aesthet Surg. 2007;60:776–92 10. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intraarticular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg. 1999; 81A:1093–110 11. Edwards CC II, Haraszti CJ, McGillivary GR, Gutow AP. Intra-articular distal radius fractures: arthroscopic assessment of radiographically assisted reduction. J Hand Surg. 2001;26A:1036–41 12. Fernandez DL. Reconstructive procedures for malunion and traumatic arthritis. Orthop Clin North Am. 1993;24:341–63 13. Garcia-Elias M, Lluch A, Ferreres A, Papini-Zorli I, Rahimtoola ZO. Treatment of radiocarpal degenerative

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osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy. J Hand Surg. 2005;30A:8–15 14. González del Pino J, Nagy L, González Hernandez E, Bartolome del Valle E. Osteotomías intraarticulares complejas del radio por fractura. Indicaciones y técnica quirúrgica. Rev Ortop Traumatol. 2000;44:406–17 15. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg. 1986; 68A:647–59 16. Levy HJ, Glickel SZ. Arthroscopic assisted internal fixation of volar intraarticular wrist fractures. Arthroscopy. 1993;9: 122–4 17. Lutsky K, Boyer MI, Steffen JA, Goldfarb CA. Arthroscopic assessment of intra-articular distal radius fractures after open reduction and internal fixation from a volar approach. J Hand Surg. 2008;33A:476–84 18. Marx RG, Axelrod TS. Intraarticular osteotomy of distal radius malunions. Clin Orthop. 1996;327:152–7 19. Prommersberger KJ, Ring D, Del Pino JG, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius. Surgical technique. J Bone Joint Surg. 2006;88A(Suppl 1 Pt 2): 202–11 20. Ring D, Prommersberger KJ, González del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for malunited articular fractures of the distal radius. J Bone Joint Surg. 2005;87A:1503–9 21. Saffar P. Treatment of distal radial intra-articular mal-unions. In: Saffar Ph, Cooney WPIII, editors. Fractures of the distal radius. London: Martin Dunitz; 1995. p. 249–58 22. Slutsky DJ. Clinical applications of volar portals in wrist  arthroscopy. Tech Hand Up Extrem Surg. 2004;8: 229–38 23. Thivaios GC, McKee MD. Sliding osteotomy for deformity correction following malunion of volarly displaced distal radial fractures. J Orthop Trauma. 2003;17:326–33 24. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg. 1994;19A:325–40 25. Wagner WF Jr, Tencer AF, Kiser P, Trumble TE. Effects of intra-articular distal radius depression on wrist joint contact characteristics. J Hand Surg. 1996;21A:554–660

The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist: Midcarpal Joint

15

Joseph F. Slade

Introduction

Background

Wrist arthritis results in chronic pain and limited hand function. While the etiologies for wrist arthritis are numerous, the most common causes are SLAC/SNAC wrist injuries and malunion after distal radius fractures [1, 8, 34]. These injuries result in an incongruent articular gliding surface which leads to progressive degenerative arthritis (Fig.  15.1). The process of joint degeneration results in increasing decline in wrist function and increased wrist pain. The goal of treatment is to arrest the process of cartilage degeneration, reduce pain, and preserve the remaining wrist function. Treatment strategies are twofold. The first is the removal of arthritis, and the second is restoration of a normal synchronous gliding surface. Numerous partial wrist fusions have been described, some with significant complications [1, 12, 14, 24]. If these strategies can be accomplished using minimal invasive techniques, then normal uninjured structures can be preserved allowing for faster recovery of hand function while limiting the risk of complications [26]. The tools for percutaneous surgery include arthroscopy, minifluoroscopy, arthroscopic instruments, and guide-wire introduced fixation such as headless cannulated screws. These instruments permit reduction of carpal alignment, restoration of wrist motion, joint debridement, reduction of carpus, and limited wrist fusion.

Partial wrist fusion or limited carpal fusion is considered as a motion-preserving salvage procedure for multiple painful wrist conditions. It is a good alternative particularly for those patients who would prefer a mobile functional wrist rather than solid total wrist fusion [15].

J. F. Slade Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, 06519, CT, USA e-mail: [email protected]

Fig. 15.1  This a photomicrograph of a rabbit model. The top plate is a displaced articular surface of a simulated injury in a rabbit knee model. The plate below demonstrates degeneration of the articular surface which occurs over time with fractures of the cartilage

F. del Piñal et al. (eds.), Arthroscopic Management of Distal Radius Fractures, DOI: 10.1007/978-3-642-05354-2_15, © Springer-Verlag Berlin Heidelberg 2010

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The wrist consists of multiple bony linkages from the forearm to the metacarpus via the carpal bones, and this anatomic peculiarity offers an opportunity to allow fusion of the painful segments of the wrist while preserving motion in other unaffected segments. It also helps to halt any predictable mechanical collapse of the carpal column and maintain carpal height in carpal instability conditions due to the failure of ligament constraint or the loss of bony integrity such as scaphoid nonunion and Kienböck’s disease. A variety of partial wrist fusions have been designed in the past to address the problems arising from various parts of the wrist and each with its own modification with increasing experience [5, 10, 13, 16, 17, 18]. Any of the carpal bones and intervals can be fused selectively, depending on the location of the symptoms and arthritis. The resulting motion loss and the biomechanical effects have been studied extensively in laboratory and clinical settings. The following joints can be fused: 1. Between the radius and the proximal carpal row (a)  Radiolunate (RL) fusion [24, 30] (b)  Radioscapholunate (RSL) fusion [8, 25] 2. Between the two carpal rows (a) Scaphotrapeziotrapezoid (STT) fusion [6, 36] (b)  Scaphocapitate (SC) fusion [18, 20, 23, 31] (c)  CL fusion [3, 12, 26] (d)  Triquetrohamate fusion [21] (e) Four-corner fusion (involving the medial carpal bones) [1] 3. Within the proximal carpal row (a)  Scapholunate (SL) fusion [38] (b)  Lunotriquetral (LT) fusion [9] Commonly described operations in the literature and considered as standard practice in today’s care of the arthritic wrist include open surgery requiring much soft tissue dissection, including capsular and ligament incisions around the wrist to expose the carpal intervals. This may lead to iatrogenic stiffness of the joint on top of the mechanical constraint rendered by selected carpal fusion. The expected loss of motion can be predicted theoretically from the biomechanical models, although in practice, the final range of motion retained clinically will also rely on the degree of soft tissue contracture and the amount of compensatory hypermobility of the adjacent joints. It is therefore desirable to minimize the surgical insult to soft tissue so as to maximize the motion preservation that is always the interest of both the patients and the surgeons.

J. F. Slade

Arthroscopic intervention in partial wrist fusion [11, 26] has potential advantages over these open ­procedures, mainly the minimal surgical damage to the supporting ligaments and capsular structures of the wrist while allowing an unimpeded view to most articular surfaces of the joints and important soft tissue ­elements. This ensures a more accurate staging of the arthritis and facilitates clinical decision-making on the most appropriate choice of fusion. The remaining carpal motion can be maximized and the postoperative pain can be reduced, optimizing the rehabilitation potential. Finally, there is also a cosmetic benefit with the minimal surgical scar. The goal of treatment is to arrest the process of cartilage degeneration, reduce pain, and preserve the remaining wrist function. The purpose of this chapter is to describe arthroscopic and minimal surgical techniques, which preserve wrist function, limit complications, and lead to an early recovery of hand function.

Overview of Surgical Approach • Treatment strategies are twofold. The first is removal of arthritis and the second is restoration of a normal synchronous gliding surface. The tools for percutaneous surgery include arthroscopy, minifluoroscopy, arthroscopic instruments, and guidewire introduced fixation such as headless cannulated screws. • To accomplish these steps, first, the pathology must be correctly diagnosed. This is done with advanced imaging including CT, MRI, fluoroscopy, and arthroscopy. • Next, carpal alignment must be correctly restored, capturing the remaining wrist motion. This often requires the need for percutaneous surgical release of the joint capsular. • Arthritis is removed by arthroscopic debridement with aggressive shavers and arthroscopic debriders [2]. Minimal incisions using additional arthroscopic portals are also used with miniosteotomes and small rongeurs for larger osteophytes. • Fusion surfaces are identified and debrided with arthroscopic shavers and osteotomes under fluoroscopic guidance. • Percutaneous bone is inserted as needed. • Provisional fixation with Kirschner wires K-wires.

15  The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist

• Rigid fixation is performed with headless cannulated screws. • Arthroscopic and percutaneous limited wrist arthrodesis is suitable for the following surgical techniques with caveats and pearls: ○○ CL arthrodesis −− Treatment for stage II/III SLAC/SNAC −− Headless Acutrak screws placed between the second or third web-space through the central axis of capitate into the lunate provides for the most rigid biomechanical fixation of fusion surface. Also there is no violation of radiocarpal joint to accomplish this arthrodesis [25, 31, 36] ○○ Four-corner arthrodesis −− Treatment for Stage II/III SLAC/SNAC −− Reduction of lunate to capitate reduces impingement [1] −− Scaphoid excision increases radial-ulna deviation [7] ○○ Radio-scaphoid lunate (RSL) arthrodesis −− Treatment for radiocarpal arthritis (intraarticular malunion of distal radius) with normal midcarpal joint −− Excision of distal scaphoid increases motion and decreases stress at Midcarpal joint resulting in degeneration [4, 8, 16] ○○ Radio-Lunate (R-L) arthrodesis. −− Very limited motion −− Unsatisfactory for the treatment of keinböck’s disease [22] ○○ Lunate-triquetral arthrodesis −− Requires strong compression screw and tierod blocking K-wires or mini-screw for a solid union to be achieved −− Requires bone graft [9] −− Treatment for chronic LTIO ligament tear −− Fifty-five percent failure rate for union [33] ○○ STT arthrodesis −− Treatment for Keinbock’s disease −− Requires correct reduction for successful out­ come −− Little tolerance for failure. Complication rate as high as 52% [14]

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Surgical Technique in Detail Diagnosis of Pathology Using Imaging, Fluoroscopy, and Arthroscopy • Standard radiographs can identify arthritis, but often will underestimate the extent of joint involvement. Not uncommonly, radiographs may fail to identify early arthritis and correctly identify chondromalacia. MRI is best used to identify avascular necrosis of the carpal bones including proximal scaphoid fractures or lunate AVN. MRI has been effective in the early identification of occult fractures including scaphoid fracture, local impaction zones of the lunate as seen with ulna impaction, TFCC tears, and on some occasions, SLIO or LTIO carpal ligament injuries. CT scans are best used to review the wrist bone architecture. CT scans are commonly used to identify bone fractures, displacement, and confirm fracture healing. • Radiographic imaging targets the potential pathology which can now be confirmed and graded using arthroscopy (Fig. 15.2). • Arthroscopy requires longitudinal traction through four fingers permitting maximum safe traction and wrist joint penetration with minimum chance of additional cartilage injury. Five to ten kilograms can safely be applied, to stretch the wrist capsule for the safe introduction of surgical instruments. Injection of the wrist joint does little to distend the joint like it does with other joint arthroscopic examination such as the elbow. We use a standard arthroscopic infusion pump. Outflow is established using multiple 19-gauge needles or a second arthroscopic cannula when an arthroscopic shaver is not in use. • A minifluoroscopy unit is placed perpendicular to the wrist and arthroscopic joint portals are identified. 19-gauge needles are inserted under fluoroscopic guidance to label the portal entry sites. The portal site is incised no deeper than the skin level. A small curved hemostat is used to bluntly dissect the soft tissue to the level of the joint capsule. This permits extensor tendons and dorsal nerves to be safely retracted away from the portal site, preventing iatrogenic injury. • Using imaging, with wrist under traction, the small curved hemostat is introduced into the wrist joint with the clamp closed. After entry, slight spreading of the hemostat establishes a portal site for the introduction of arthroscopic instruments.

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thumb CMC, and small joints of the hand to release joint capsule arthrofibrosis [28]. • Next, a small joint arthroscopic instrument can safely be introduced to complete capsular release and joint fibrosis excision. • With SLAC/SNAC wrist pathology, a DISI deformity is commonly present with a dorsiflexed lunate. After joint capsule release, the wrist can be hyperflexed and the lunate corrected to a neutral position. A 1.5 mm K-wires is placed through the distal radius into the lunate in corrected neutral position. This provisional fixation permits the lunate to be held in position while the surgical treatment plan is executed.

Fig.  15.2  Arthroscopy requires longitudinal traction through four fingers permitting maximum safe traction-5-10 kg. A minifluoroscopy unit is placed perpendicular to the wrist. The arthroscopic joint portals 3–4; 4–5; 6R and radial and ulna midcarpal portals are identified using imaging. 19-gauge needles are inserted under fluoroscopic guidance to label the portal entry sites. This technique prevents iatrogenic cartilage injury and correct portal placement. A small curved hemostat is used to bluntly dissect the soft tissue to the level of the joint capsule. This permits extensor tendons and dorsal nerves to be safely retracted away from the portal site

Wrist and Carpal Arthrofibrosis (Fig. 15.3a–e) • Joint arthritis is commonly associated with carpal mal-alignment and joint arthrofibrosis. Arthroscopic capsular release for the contracture of the wrist was first described by Verhellen [34]. The addition of fluoroscopy provides valuable guidance when used in tandem with arthroscopy. Wrist and carpal joint release is accomplished under fluoroscopic guidance using traction and small curved hemostat. Radiocarpal arthrofibrosis is released by implanting a small curved hemostat through the 3–4 arthroscopic portal using fluoroscopic guidance. Under maximum traction and image guidance, the curved hemostat is gently swept radially and dorsally to release capsular fibrosis. The small curved hemostat is reintroduced through the 3–4 portal and now swept ulnarly and dorsally, freeing the remaining articular scar tissue and dorsal capsule. It is mandatory that these maneuvers are performed under fluoroscopic guidance to prevent iatrogenic injury to the remaining healthy joint cartilage. These same maneuvers can be performed on the midcarpal,

Surgical Technique for Capitate-Lunate Arthrodesis in Detail [26] • The patient is placed in a supine position with the arm outstretched on a hand table with a tourniquet applied to the arm. The arm is flexed and placed in a traction tower, after the operative extremity is prepped and draped in a standard surgical fashion. A minifluoroscopic imaging unit is placed perpendicular to the wrist (Fig.  15.4a). The radiocarpal, midcarpal, and DRU joints are visualized. Standard arthroscopic portals are identified and established using a small curved hemostat and these include the 3–4; the 4–5; the 6R, and 6U. The radio and ulna midcarpal portals are also identified. Longitudinal traction is applied and a small joint-angled arthroscope with an aggressive shaver is introduced into the joint and a complete synovectomy and dorsal capsular release is performed. After a complete exam of the carpus, the pathology is recorded. All superficial chondromalacia is treated with chondroplastic shaving. • The first key step is the reduction of the lunate from its current extended position (DISI deformity) to a neutral position. This is done by flexing the wrist and manually reducing the lunate to its neutral anatomic location. Elimination of the DISI deformity (extended lunate) is confirmed on lateral fluoroscopic imaging. A 1.5 mm K-wires is now placed through the dorsal aspect of the distal radius and advanced into the reduced lunate (Fig. 15.4b). The K-wires should not be directly in the center of the lunate but rather in a more ulnar position to permit the later placement of a compression screw in the center of the lunate. This effectively secures the lunate in its zero degree (neutral) lateral position.

15  The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist Fig. 15.3  Wrist capsular release for contracture can be accomplished using arthroscopy and fluoroscopy. (a) Demonstrate wrist arthrofibrosis and capsular contracture after distal radius fracture repair with volar locking plate. The wrist is placed perpendicular to the imaging units and a 19-gauge needle placed into the 3–4 portal (b). A small curved hemostat is introduced through the 3,4 arthroscopic portal using fluoroscopic guidance under maximum traction (c). The curved hemostat is gently swept radially, ulnarly, and dorsally to release the capsular fibrosis (d). After the capsular release, the arthroscope can now be inserted into the wrist joint to complete the joint debridement. After the joint release, significant mobility is obtained (e)

a

b

c

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216 Fig. 15.3  (continued)

J. F. Slade

d

e

15  The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist

Fig. 15.4  Surgical technique for arthroscopic/percutaneous capitate-lunate arthrodesis in detail. The arm is placed in a traction tower, a minifluoroscopic imaging unit is placed perpendicular to the wrist, and the radiocarpal, midcarpal, and DRU joints are identified. A small joint arthroscope is introduced into the wrist joint and the joint is debrided (a – fluro unit). After arthroscopy, the DISI deformity must be corrected. The lunate is reduced to a neutral position by flexing the wrist. The corrected lunate position is confirmed on lateral fluoroscopic imaging. A Kirschner wire is placed through the distal radius and advanced into the reduced lunate (b). Imaging is used to identify the ulna midcarpal and the 3–4 radiocarpal portal (c). An oblique incision is made between these portals. The tendons of the fourth dorsal extensor compartment are exposed and retracted. The capitolunate (CL) joint interval is identified just deep to the retracted tendons (d). A transverse incision is made through the dorsal capsule exposing the CL joint (e). Next the CL joint is resected. The resection of the CL joint now provides for easy access to the scaphoid for resection (f). This is accomplished using a small rongeur, 1 & 2-mm osteotomes, a small curved hemostat, and a bone cutting burr. After the scaphoid excision, a radial styloidectomy is performed as needed. Care must be taken not to remove more than 5 mm of the radial styloid to preserve the attachment of radio-scaphoid capitate (RSC) ligament to the carpus. After joint debridement, a guidewire is percutaneously introduced along the long axis of the capitate, the wrist is flexed, a wire is driven proximal to distal through

217

the exposed proximal pole of the capitate and driven through the base of the metacarpal into the second and/or third web-space (g). Using fluoroscopy, the capitate is now reduced on the lunate into a neutral position. The guide-wire is then advanced from the capitate into the lunate securing the reduction. (h). A cannulated, standard Acutrak drill is used to prepare the capitate and lunate for screw placement and driven from distal to proximal (i). The screw selected will be 4 mm shorter than the length of carpal fusion. A headless cannulated compression screw is implanted in a retrograde fashion over the guide-wire between the web-space (j). Fluoroscopy confirms proper screw placement along the long axis of the capitate and lunate fusion mass. The central axis radiolunate (RL) capitate K-wires is then removed. The wounds are irrigated and closed with 5-0 nylon sutures. As an alternative to the limited incision technique described above, an arthroscopic technique can also be successful. A radiocarpal portal is used to confirm preservation of the RL joint. Midcarpal and radiocarpal arthroscopy portals are utilized for the CL, scaphoid, and radial styloid resections (k). The remainder of the procedure is identical to that described above. The hand incision and portals are closed (l). CT scanning is used to confirm solid fusion commonly seen at 4–6 weeks (m). The patients are then released to full, unrestricted duties including sports and heavy labor. This is a 55-year male 1 year after a partial scaphoid excision and capitate-lunate arthrodesis. He is pain-free and has resumed both his work and avocation without difficulties (n)

218 Fig. 15.4  (continued)

J. F. Slade

d

e

15  The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist

f

g

h

Fig. 15.4  (continued)

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220

Fig. 15.4  (continued)

J. F. Slade

15  The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist

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n

Fig. 15.4  (continued)

• A line is then drawn between the ulna midcarpal and the 3–4 portal, delineating the intended surgical incision (Fig. 15.4c). • This oblique incision (approximately two cm in length) is made, and the tendons of the fourth dorsal extensor compartment are exposed and retracted. The CL joint interval is identified just deep to the retracted tendons (Fig.  15.4d). A transverse incision is made through the dorsal capsule exposing the CL joint (Fig. 15.4e). • The next step consists of the resection of the CL joint. This increases the surgeon’s working space and permits easy access to the scaphoid and radial styloid. Joint resection provides two beds of bleeding subchondral bone in anticipation for arthrodesis. The decortication of the distal lunate articular surface and proximal capitate articulation is performed using an aggressive cutting burr or small osteotomes. The resection of the CL joint now provides for easy access to the dysfunctional scaphoid for partial or full resection (Fig. 15.4f). This is accomplished using a small rongeur (such as a sinus surgery rongeur), 1 & 2-mm osteotomes, a small curved hemostat, and a bone cutting burr. All of these instruments can be introduced through an enlarged arthroscopic portal to perform carpal excision. After the scaphoid excision, these same instruments are used for radial styloidectomy.

Care must be taken not to remove more than 5 mm of the radial styloid in order to preserve the attachment of radio-scaphoid capitate (RSC) ligament to the carpus. Failure to preserve this ligament will result in ulnar translation of the carpus. • The goal of arthritic debridement is the removal of diseased ossific overgrowths (radial styloid and scaphoid), which can be impacted during radiocarpal motion. This is critical for pain relief. • Next, a guide-wire is percutaneously introduced along the long axis of the capitate, in between the second and third web-space. The guide-wire can be introduced distal to proximal through the CMC joint into the capitate or with the wrist flexed, proximal to distal through the exposed proximal pole of the capitate (Fig.  15.4g). The guide-wire is introduced into the capitate and driven through the base of the metacarpal into the second and/or third webspace. Using fluoroscopy, the capitate is now reduced on the lunate into a neutral position. Care must be taken to ensure that both the capitate and lunate are aligned in the same plane on the P.A. & lateral images. The guide-wire is then advanced from the capitate into the lunate securing the reduction (Fig.  15.4h). A cannulated, standard Acutrak drill is used to prepare the capitate and lunate for screw placement and driven from distal to proximal

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(Fig.  15.4i). It is critical not to drill closer than 2 mm to the proximal lunate cortex. If bone graft is  needed, it is percutaneously inserted into the ­capitate-lunate joint. Occasionally, an Acutrak plus drill is used to ream the CMC base to permit driver introduction. Prior to reaming, the combined length of the lunate and capitate is measured using a second guide-wire. Once the length is determined, the guide-wire is driven through the lunate into the radius. This prevents the wire from dislodging when the cannulated drill is removed. The screw selected will be 4  mm shorter than the length of carpal fusion. Finally, a headless cannulated compression screw is implanted in a retrograde fashion over the guide-wire between the web-space (Fig. 15.4j). We prefer a standard-sized Acutrak screw. The screw is advanced from the capitate into the lunate taking care to stop 2 mm from the lunate proximal surface. To prevent possible distraction or “push-off” at the arthrodesis, a 1.5 mm K-wires can be inserted into the lunate. Fluoroscopy confirms proper screw placement along the long axis of the capitate and lunate fusion mass. The central axis RL capitate K-wires is then removed. The wounds are irrigated and closed with 5-0 nylon sutures. As an alternative to the limited incision technique described above, an arthroscopic technique can also be successful. A

Fig.  15.5  Bone is percutaneously harvested from the distal radius. An imaging unit is placed perpendicular to the wrist and a 1.25 mm K-wires is driven into the distal radius (a). A cannulated reamer is used to penetrate the bone cortex (b). After the bone cortex is penetrated, an 8-gauge, 4 in. Baxter bone biopsy

J. F. Slade

radiocarpal portal is used to confirm the preservation of the RL joint. Midcarpal and radiocarpal arthroscopy portals are utilized for the CL, scaphoid, and radial styloid resections (Fig.  15.4k). The remainder of the procedure is identical to that described above. The hand incision and portals are closed (Fig. 15.4l). • Postoperative care: postoperatively, patients are immobilized in a volar wrist splint, which is then changed to a removable canvas wrist splint after suture removal. Hand therapy is then started to recover finger motion. A strengthening program is started to axially load the fusion mass. This aids in rapid recovery of hand function and stimulates bone healing. CT scanning is used to confirm solid fusion commonly seen at 4–6 weeks (Fig.  15.4m). The patients are then released to full, unrestricted duties including sports and heavy labor (Fig. 15.4n).

Percutaneous Bone Graft The bone is percutaneously harvested from the ­distal radius along the ulna border. An imaging unit is placed perpendicular to the wrist and a 1.25 mm K-wires is driven into the distal radius (Fig. 15.5). A small stab

cannula is placed over the guide-wire. The guide-wire is removed, and multiple bone plugs are harvested using the cannula. This same cannula will later be used to percutaneously introduce bone plugs at the arthrodesis site

15  The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist

incision is made next to the K-wires. A small curved hemostat is used to bluntly dissect the soft tissue away from the K-wires down to the bone. A cannulated reamer is used to penetrate the bone cortex. After the bone cortex is penetrated, an 18-gauge, 4  in. Baxter bone biopsy cannula is placed over the guide-wire. The guide-wire is removed and multiple bone plugs are harvested using the cannula. These will later be introduced percutaneously at the arthrodesis site using the same cannula and a plunger [29].

Clinical Experience Twelve cases were treated with percutaneous CL arthrodesis. At 38-month follow-up, 12 patients had solid fusions confirmed by CT scan. There was one complication. This complication was a technical error, which was a result of underresection of the radial styloid process. This patient had mild occasional pain at the radial styloid, but declined further treatment as she had no limitation in her activities The remaining patients were pain-free. All had a functional range of motion with a 70% flexion-extension arc, 68% radial-ulnar deviation arc, and 92% supination-pronation arc. Grip strength was 90% of the opposite normal uninjured wrist. All the patients returned to their prior work and avocations, including weight training, tennis, baseball, and recreational golf.

Conclusion Arthroscopic-assisted fluoroscopic percutaneous surgery to treat wrist arthritis can restore function and reduce pain with minimal complications. We report our experience on CL arthrodesis using minimally invasive surgical techniques including arthroscopy and minifluroscopy. Adjunct procedures including capsular release and percutaneous bone-grafting are often required. These cases yielded a 100% union rate with high satisfaction. These advanced techniques require training to avoid complications, as the learning curve is steep. Acknowledgments  I thank Peter C. Yeh, MD for his assistance during the preparation of this manuscript.

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References   1. Ashmead D IV, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg. 1994;19(5):741–50   2. Atik TL, Baratz ME. The role of arthroscopy in wrist arthritis. Hand Clin. 1999;15(3):489–94   3. Calandruccio JH, Gelberman RH, Duncan SFM, Goldfarb CA, Pae R, Gramig W. Capitolunate arthrodesis with scaphoid and triquetrum excision. J Hand Surg. 2000;25A:824–32   4. Calfee RP, Leventhal EL, Wilkerson J, Moore DC, Akelman E, Crisco JJ. Simulated radioscapholunate fusion alters carpal kinematics while preserving dart-thrower’s motion. J Hand Surg. 2008;33(4):503–10   5. Douglas DP, Peimer CA, Koniuch MP. Motion of the wrist after simulated limited intercarpal arthrodesis: an experimental study. J Bone Joint Surg (Am). 1987;69:1413–8   6. Kleinman WB, Carroll C IV. Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic ­scapho-lunate instability: a 10-year perspective on pitfalls and complications. J Hand Surg [Am]. 1990;15(3):408–14   7. Kobza PE, Budoff JE, Yeh ML, Luo ZP. Management of the scaphoid during four-corner fusion-a cadaveric study. J Hand Surg [Am]. 2003;28(6):904–9   8. Garcia-Elias M, Lluch A, Ferreres A, Papini-Zorli I, Rahimtoola ZO. Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy. J Hand Surg. 2005;30(1):8–15   9. Guidera PM, Watson HK, Dwyer TA, Orlando G, Zeppieri J, Yasuda M. Lunotriquetral arthrodesis using cancellous bone graft. J Hand Surg [Am]. 2001;26(3):422–7 10. Hasting DE, Silver RL. Intercarpal arthrodesis in the management of chronic carpal instability after trauma. J Hand Surg [Am]. 1984;9:834–40 11. Ho PC. Arthroscopic partial wrist fusion. Tech Hand Up Extrem Surg. 2008;12(4):242–65 12. Kirschenbaum D, Schneider LH, Kirkpatrick WH, Adams DC, Cody RP. Scaphoid excision and capitolunate arthrodesis for radioscaphoid arthritis. J Hand Surg. 1993;18A:780–5 13. Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg. 1994;19A: 751–9 14. Kleinman WB, Carroll C IV. Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic ­scapho-lunate instability: a 10-year perspective on pitfalls and complications. J Hand Surg [Am]. 1990;15(3):408–14 15. Krimmer H, Wiemer P, Kalb K. Comparative outcome assessment of the wrist joint-mediocarpal partial arthrodesis and total arthrodesis. Handchir Mikrochir Plast Chir. 2000;32(6):369–74 16. McCombe D, Ireland DC, McNab I. Distal scaphoid excision after radioscaphoid arthrodesis. J Hand Surg [Am]. 2001;26(5):877–82 17. Minami A, Kato H, Iwasaki N. Limited wrist fusions: comparison of results 22 and 89 months after surgery. J Hand Surg [Am]. 1999;24:133–7 18. Moy OJ, Peimer CA. Scaphocapitate fusion in the treatment of Kienböck’s disease. Hand Clin. 1993;9(3):501–4 19. Peterson HA, Lipscomb PR. Intercarpal arthrodesis. Arch Surg. 1967;95:127–34

224 20. Pisano SM, Peimer CA, Wheeler DR, Sherwin F. Scaphocapitate intercarpal arthrodesis. J Hand Surg. 1991; 16A:328–33 21. Rao SB, Culver JE. Triquetrohamate arthrodesis for midcarpal instability. J Hand Surg [Am]. 1995;20(4):583–9 22. Rhee SK, Kim HM, Bahk WJ, Kim YW. A comparative study of the surgical procedures to treat advanced Kienböck’s disease. J Korean Med Sci. 1996;11(2):171–8 23. Rotman MB, Manske PR, Pruitt DL, Szerzinski J. Scaphocap­ itolunate arthrodesis. J Hand Surg. 1993;18A: 26–33 24. Saffar P. Radio-lunate arthrodesis for distal radial intraarticular malunion. J Hand Surg [Br]. 1996;21(1):14–20 25. Shin EK, Jupiter JB. Radioscapholunate arthrodesis for advanced degenerative radiocarpal osteoarthritis. Tech Hand Up Extrem Surg. 2007;11(3):180–3 26. Slade JF III, Bomback DA. Percutaneous capitolunate arthrodesis using arthroscopic or limited approach. Atlas Hand Clin. 2003;8(1):149–162 27. Slade JF, Gillon TJ. Retrospective review of 234 scaphoid fractures and nonunions treated with arthroscopy for union and complications (Special issue – surgery of the hand and upper extremity). Scand J Surg. 2008;97:280–9 28. Slade JF, Gillon TJ. Percutaneous release of the posttraumatic finger joint contracture: a new technique, chapter 11. In: Capo J, Tan V, editors. Atlas of minimally invasive hand and wrist surgery. London: Taylor and Francis; 2007. p. 83–8

J. F. Slade 29. Slade JF, Dodds SD. Minimally invasive management of scaphoid nonunions. Clin Orthop Relat Res. 2006;445: 108–19. 30. Stanley JK. Radio-lunate arthrodesis. J Hand Surg [Br]. 1989;14(3):283–7 31. Sutro CJ. Treatment of nonunion of the carpal navicular bone. Surgery. 1946;20:536–40 32. Toby EB, Butler TE, McCormack TJ, Jayaraman. A comparison of fication screws for the scaphoid during application of cyclic bending loads. J Bone Joint Surg, 1997;79: 1190–7 33. Vandesande W, De Smet L, Van Ransbeeck H. Lunotriquetral arthrodesis, a procedure with a high failure rate. Acta Orthop Belg. 2001;67(4):361–7 34. Verhellen R, Bain GI. Arthroscopic capsular release for contracture of the wrist: a new technique. Arthroscopy. 2000; 16(1):106–10 35. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg. 1984;9A:358–65 36. Watson HK, Hempton RF. Limited wrist arthrodeses. I. The triscaphoid joint. Hand Surg [Am]. 1980;5(4):320–7 37. Wheeler DL, McLoughlin SW. Biomechanical assessment of compression screws. Clin Orthop Rel Res. 1998;350: 237–45 38. Zubairy AI, Jones WA. Scapholunate fusion in chronic symptomatic scapholunate instability. J Hand Surg [Br]. 2003;28(4):311–4

Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis

16

Pak-cheong HO

Introduction Post-traumatic radiocarpal arthrosis occurs mainly after fracture with major intra-articular component, without adequate articular reduction and optimal fixation. It has been well shown that intra-articular fracture of the distal radius with more than 2 mm residual articular step particularly in young patient can lead to radiological degenerative arthritis in 91% of cases [8]. Catalano et al. found that 76% of patients with residual gap over the articular surface developed radiological arthrosis [1]. Fernandez also noted a direct correlation with subjective complaint and functional result with the articular alignment on follow-up radiographs [2]. Post-traumatic arthrosis of the radiocarpal joint can happen even in cases when articular reduction is optimal [10, 13, 16]. Radiocarpal fracture dislocation, both in dorsal and palmar direction, has been associated with radiocarpal arthritis, particularly if there is residual ulnar translocation of carpus or recurrent instability [11]. Patient with unsatisfactory reduction of extraarticular fracture has a higher incidence of accelerated degeneration of the radiocarpal joint. Experimental study showed that excessive dorsal tilt of the articular surface of more than 20° can decrease the contact area between scaphoid and lunate with the articular surface of distal radius, and this leads to excessive and eccentric loading of the dorso-radial aspect of the distal radius articular surface [15]. Pak-Cheng HO, MBBS, FRCS(Edinburgh), FHKCOS, FHKAM(Orthopaedics) Department of Orthopaedics & Traumatology, Division of Hand and Microsurgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China e-mail: [email protected]

Specific type of dorsal loading of the wrist joint can lead to localized damage to the radiolunate articulation, resulting in the so-called die-punch fracture [14]. Another common form of injury involves the volar ulnar lunate facet fragment with subluxation [4]. Under such circumstance, the scaphoid fossa is frequently spared, and severe damage to the articulation between lunate and lunate fossa can be resulted. Isolated osteochondral fracture can also occur at the radiolunate joint in the absence of radiological fracture, and cause prolonged joint pain and dysfunction. Diagnosis is difficult and is frequently revealed only after arthroscopic intervention. Recent improvement in MRI technique helps to depict this type of lesion. Post-traumatic wrist arthrosis can cause protracted wrist pain, loss of motion and impairment of limb function. The aim of surgical treatment is to abolish pain by removing the source of pain, stabilize the wrist segments to halt progressive arthritis and to preserve useful wrist motion and function. Radiocarpal fusion is indicated whenever there is irreversible damage to the radiocarpal joint articulation after distal radius fracture, while the mid-carpal joint is relatively preserved. Conventional radiocarpal fusion is performed by open approach, almost exclusively from dorsal approach. Potential disadvantages include extensive surgical dissection upon exposure which may lead to unnecessary extensor tendon adhesion and undesirable loss of finger and wrist motion due to post surgical capsular contracture. Assessment of mid-carpal joint cannot be completed without unnecessary surgical insult. Remaining motion after radioscapholunate fusion can be marked limited, based on obligate interference of mid-carpal motion due to loss of scaphoid motion. Nagy and Büchler reported that flexion averaged 18°, extension 32°, radial deviation 3° and ulnar deviation 25° [12]. Kilgus reported that the active

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range of motion in the operated joint remained constant over 10 years of follow-up, with mean 60° dorsopalmar and 30° ulnoradial [7]. Motion is expected to improve to averaged 71° flexion-extension arc after simultaneous distal scaphoidectomy which unlocks the mid-carpal joint [12]. In radiolunate fusion, loss of motion can be at least 50%. By simulated fusion in the laboratory, Myerdierks et al. found a 47% loss of flexion/extension and a 37% loss of radio-ulnar deviation [9]. In clinical situation, remaining motion of the wrist can further be jeopardized by accompanying soft tissue contracture. Arthroscopic approach in principle can help to minimize unnecessary surgical trauma to the ligamentous capsular and tendon structures and hence maximize motion preservation. Simultaneous evaluation of the mid-carpal joint condition can be performed without added trauma to ensure the correct indication. Postoperative pain is minimal and overall rehabilitation can be facilitated. There is also a cosmetic merit with the small and inconspicuous surgical scars. Arthroscopic debridement of the radiocarpal joint is technically relatively straight forward. Recent advance in percutaneous cannulated screw system simplifies the surgical technique and enhances rigidity of the bony fixation to allow earlier mobilization of the wrist.

Indications and Contra-Indications Selective radiocarpal fusion is an attractive option for young patients suffering from painful post-traumatic arthrosis of the radiocarpal joint who would like to preserve useful motion of the wrist and are reluctant to consider total wrist fusion. An average of 50% of the physiological motion of the wrist can be preserved after fusing the proximal carpal row to the radius. Absence of significant mid-carpal pathology is essential to predict successful outcome of the surgery. Arthroscopic examination of the mid-carpal joint is the most reliable method to rule out mid-carpal joint arthrosis. The presence of carpal dissociation such as scapholunate ligament injury does not preclude the consideration of radiocarpal fusion, as long as there is no associated degenerative change in the mid-carpal joint. Partial wrist fusion is absolutely contraindicated when there is active ongoing sepsis over the wrist joint. Partial wrist fusion is also not a guarantee for pain

Pak-Cheng HO

relief. The potential advantage of partial wrist fusion in preserving a useful arc of motion may be offset by risks of non-union or by continuing pain despite successful fusion [5]. Nagy and Büchler reviewed a cohort of 15 cases of radioscapholunate fusion and reported a nonunion rate of 27% [12]. Nearly half of them showed secondary degenerative changes of the mid-carpal joint, two of which were progressive. Four patients had continuing symptoms despite sound radiological union of the partial wrist fusion. Revision total wrist fusion was required in 33% of cases ultimately. Thus those patients who prefer more guaranteed outcome on pain control, do not want multiple surgical procedure and do not bother loss of wrist motion may be better candidates for total wrist fusion. Chronic smoker has higher incidence of non-union after partial wrist fusion and required more revision surgery to achieve union. An alternative for pain control treatment such as wrist denervation can be considered. Interposition arthroplasty using fascial or dermo structures have been reported in rheumatoid wrist but is seldom indicated in post-traumatic lesion. Total wrist arthroplasty can be considered in older patients with limited functional demand. Wrist pain constituted by ulnar sided pathology such as TFCC injury, DRUJ instability and luno-triquetral dissociation which may be associated with the distal radius fracture cannot be adequately dealt with by radiocarpal fusion alone and requires specific treatment such as TFCC reconstruction, Darrach procedure, SauveKapandji operation etc to control the source of pain.

Surgical Approach Set Up and Instrumentation Operation is performed under general or regional anaesthesia. C-arm fluoroscopy should be available in all cases for intra-operative assessment. List of essential instrumentation includes motorized full-radius shaver and burr system of diameters ranging from 2.0 to 2.9, 2.5 mm suction punch, radiofrequency thermal ablation system and small cannulated screw system. Patient is put in supine position while the operated arm is supported on a hand table. Arm tourniquet is applied but need not be inflated routinely. Most of the procedures can be done without the use of tourniquet.

16  Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis

Vertical traction of 4–6  kg force is applied through plastic finger trap devices to the middle three fingers for joint distraction via wrist traction tower. We employ continuous saline irrigation to maintain clear arthroscopic view by using 3 L bag of normal saline solution hung up at about 1.5  m above the patient level. Infusion pump is not necessary as excessive pressure may cause harmful extravasation of fluid. We perform routine inspection of both radiocarpal joint through 3/4 portal and mid-carpal joint through RMC portal using 2.7 or 1.9  mm video arthroscope. Adrenaline solution of 1 in 200,000 dilution is injected to the portal site skin and capsule to reduce the bleeding associated with incision (Fig.  16.1) [6]. Outflow portal is established at 6U portal just volar to the ECU tendon using 18-guage needle. In general, all portals should be marked after careful palpation with thumb tip and the wrist being distracted on the traction device before saline was injected intra-articularly. When the arthroscope is being placed inside the joint, particular attention is paid to note the status of interosseous ligament, triangular fibrocartilage complex, degree of synovitis and articular cartilage condition of the radiocarpal joint. Frequently associated localized post-traumatic synovitis may obscure the observation of cartilage condition and needs to be eliminated by using 2.0 mm shavers or radiofrequency probe inserted from 4/5 portal. It may be necessary to

Fig. 16.1  Lignocaine (1%) with adrenaline solution in 1:200,000 dilution is injected into the portal sites for haemostasis effect

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swap the portal of the arthroscope and instrument in order to obtain a better attacking angle of the instrument for more efficient synovectomy. The ulno-carpal joint should also be routinely inspected and the status of TFCC ascertained. Any central perforation of the TFCC without peripheral involvement should be debrided of any unstable flap tear at the same operation to avoid possible new source of pain after the definite index procedure. The mid-carpal joint is approached through the RMC portal. Routinely, the STT joint, scaphocapitate joint, capitolunate joint and triquetrohamate joint are inspected for cartilage lesion and synovitis. The scapho-lunate and luno-triquetral joint are assessed for stability with 2 mm probe introduced from the UMC portal. Synovial overgrowth should be debrided by using shaver or radiofrequency probe to adequately expose the underlying cartilage area for the assessment of the true extent of chondral damage and subchondral bone exposure. A prerequisite for successful radiocarpal fusion is a relatively intact articular surface at the mid-carpal and STT joints. If significant arthritis change is present, one may need to abandon the planned procedure and consider other salvage option such as total wrist fusion.

Radioscapholunate Fusion Radioscapholunate fusion is indicated for severe painful post-traumatic arthritis involving the whole radiocarpal joint while the mid-carpal joint is relatively preserved [17]. It has been shown that an accompanying distal scaphoidectomy procedure can help to improve mid-carpal motion especially on ulnar radial deviation [3]. A general surveillance of the mid-carpal joint to confirm its relative integrity is a prerequisite for successful radioscapholunate fusion. Arthroscopic distal scaphoidectomy can also be performed at the same time. With the arthroscope placed at UMC portal, a 2.9  mm burr is inserted into the RMC portal and directed towards the distal scaphoid portion articulating with the trapezoid. Burring of the scaphoid is started at this point towards the distal pole from dorsoulnar to volar-radial direction. Caution has to be taken to avoid iatrogenic damage to the articular cartilage of trapezoid, trapezium and capitate. The junction between

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capitate, scaphoid and trapezoid forms the landmark of the proximal extent of resection (Fig. 16.2). A shell of cartilage can be left intact until majority of the cancellous bone of the distal scaphoid pole is removed (Fig. 16.3). This shell of cartilage can help to separate the burr from the adjacent carpal bones during the burring process. This can be removed piece-meal at the end of the distal scaphoidectomy procedure by using a small pituitary rongeur or arthroscopic punch. The STT portal can also be employed to facilitate burring of the most distal part of the scaphoid. At the end of the procedure, there should be a void opposing the trapezium and trapezoid bone, while the waist of scaphoid is preserved and is articulating with capitate. The precise extent of distal scaphoid resection can be checked with intra-operative fluoroscopy (Fig. 16.4).

Fig. 16.2  Arthroscopic view at mid-carpal joint showing the junction between capitate, trapezoid and scaphoid, which forms the proximal limit of arthroscopic distal scaphoid resection

Fig. 16.3  Shell of cartilage left intact during burring of scaphoid to protect other uninvolved articular surface

Pak-Cheng HO

After distal scaphoidectomy is complete, the arthroscope can be directed to the radiocarpal joint. The remaining articular cartilage of the radiocarpal joint is denuded. With the arthroscope in 3/4 portal, a 2.9 mm burr is inserted into 4/5 portal and both lunate fossa and proximal surface of the lunate are debrided of articular cartilage. The degree of cartilage denudation should be well controlled so that no excessive subchondral cancellous bone is being removed. Burring is completed when subchondral cancellous bone with healthy punctate bleeding is reached (Fig. 16.5). This phenomenon can be easily observed if tourniquet is not used during this process. Usually bleeding is limited and can easily be controlled with hydrostatic pressure applied through the irrigation system. If bleeding is profuse, one may use the coagulatory role of radiofrequency apparatus. Use of tourniquet is optional depending on the degree of bleeding. During the burring process, suction can be switched on and off intermittently to remove any accumulated bone debris which may block the visual field. If suction is applied continuously during the burring process, excessive air bubbles drawn in will severely compromise the visibility of the operating site. The portals are then switched so that the burr is introduced from the 3/4 portal to have a better clearance of the articular cartilage of the proximal scaphoid and the scaphoid fossa including the radial styloid area. After completion of the burring process, the hand is taken off the wrist traction tower and placed horizontally on the operating hand table. An image intensifier is moved in. Percutaneous K-wire is inserted from the distal radius to transfix the radiolunate and radioscaphoid joint (Fig.  16.6). A small longitudinal incision is made at the distal radius about 2 cm proximal to the midpoint between the 3/4 and 4/5 portal. This is corresponding to the direct articulation between radius and lunate. The extensor tendons are bluntly dissected off from the potential wire insertion point using a fine pointed stitch scissor. With the wrist placed in neutral position both in flexion-extension plane and radio-ulnar deviation plane, two 1.1 mm K-wires are inserted using a protective sheath one after the other from the distal radius to fix the lunate. If small cannulated screw is being used, the guide pin is inserted in the same manner. One or two guide pins are used according to the size of the carpal bone. The two wires should aim at the radial and ulnar border of the lunate so as to have even purchase on the bone. The radiolunate angle should be

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Fig. 16.4  Post-op radiograph showing the extent of distal scaphoidectomy in a patient receiving arthroscopic radioscapholunate fusion (circle of dotted line)

Fig. 16.5  Burring of the lunate fossa with 2.9 mm arthroscopic burr

maintained at zero degree. This requires confirmation using both AP and lateral view of X-ray. On the lateral projection, the wire should target on the anterior horn of the lunate bone. To optimize the bone purchase, the angle of insertion of the K-wires should be quite acute at 20–30° with reference to the long axis of the forearm. Another incision is made over the radial styloid at the bare area between the first and second extensor compartment. After careful blunt dissection of the superficial branches of the radial nerve, two K-wires or guide wires are inserted in sequence to transfix the distal radius to the scaphoid. After verification of the wire

position, they can be back out from the carpal bones while attaching to the distal radius. The protruded ends of the K-wires are capped to avoid injury to the surgeon. The wrist is then put back to the wrist traction tower for the arthroscopic grafting procedure. With the arthroscope introduced at 4/5 portal, the arthroscopic cannula is inserted through 3/4 portal to reach the radial side of the scaphoid fossa using a trocar. The trocar should have a flat end and the size of the trocar selected should be in such way that it does not snug fit the cannula. There should be some free space between the inner wall of the canula and the trocar so that granules of bone substitute will not be trapped and hinder the passage of the trocar. Bone substitute is inserted to fill up the radial side of the radioscaphoid joint (Fig. 16.7). Granule or injectable form can be used. As the fusion surfaces are usually well vascularized, there is generally no need to use autogenous bone graft to avoid donor site morbidity. This process requires two assistants to execute smoothly. One assistant helps to maintain the position of the arthroscope to provide optimal vision of the fusion site. The operating surgeon controls the arthroscopic cannula and trocar while a second assistant is responsible to deliver the bone substitutes into the cannula in small volume every time (Fig. 16.8). The speed of the

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Fig. 16.6  Arthroscope being inserted into the radiocarpal joint after the two percutaneous K-wires were back out from the joint

Fig. 16.7  Cannulated drill was inserted through percutaneous pins fixing the radiolunate interval. Note the acute angle of insertion with reference to the forearm

process can be enhanced by using a cannula of wider bore such as 4.5 or 5 mm, so that each time more bone substitute can be accommodated. The granule inside the joint should be compressed with a small impactor (Fig. 16.9). If injectable bone substitute is to be used, joint irrigation should be ceased and all joint fluid evacuated with suction. A wide bore needle connecting the syringe containing the bone substitute is inserted through appropriate portal to reach the fusion

Fig. 16.8  Insertion of the granule form of bone substitute into the radiocarpal joint at the fusion site through the arthroscopic cannula

site. Injection of the bone substitute can then be performed under direct vision till the cavity is filled up completely. When the radio-scaphoid joint is half filled with bone substitute, the arthroscope is switched to 3/4 portal and the cannula is inserted at the 4/5 portal. Grafting process is continued at the radiolunate joint. If necessary, intra-operative fluoroscopy can help to confirm the completeness of the filling process (Fig. 16.10). In order to prevent spillage of graft inside

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the joint to the ulno-carpal joint area, special Foley balloon blocking technique has been developed (Fig. 16.11). A French size 6 or 8 Foley catheter with stylet is introduced through 6R portal. Advancement of the catheter into the joint can be facilitated by grasping the tip of the catheter using a small arthroscopic grasper introduced from the 4/5 portal if necessary. Once the balloon portion of the catheter is completely inside the joint as monitored through the arthroscope, it can be inflated with saline solution until the joint

compartment is largely obliterated by the balloon. The balloon remains inflated during the arthroscopic grafting process. Reducing fluid inflow is also a useful trick to avoid graft spillage. When the grafting procedure is complete, the hand is again taken off the tower and the tourniquet deflated. Under image guide, the K-wires are driven back into the carpal bones just short of the articulating surface at the mid-carpal joint. For post-traumatic arthritis in younger patient, I prefer using percutaneous compression screw to enhance fusion rate. After measuring the length of the inserted portion of the K-wires, the wire

Fig.  16.9  Arthroscopic view showing impaction of the bone substitute granules with small impactor

Fig. 16.11  Foley catheter blocking technique: size 6 Foley catheter was placed at 6R portal to obliterate the ulno-carpal joint

Fig. 16.10  Intra-op fluoroscopy confirms the filling of radiocarpal joint with bone substitute while the ulno-carpal is spared

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tracks are drilled with cannulated drill bit. Definitive fixation is performed with 3.0 mm cannulated screws with the head firmly anchored over the dorsal cortex of the distal radius. Alternatively, headless cannulated screw system can also be used (Fig. 16.12a, b). X-ray is required to confirm that the thread of the screws does not perforate the mid-carpal joint surface to impinge on the distal carpal row. In osteopenic bone, where screw purchase can be sub-optimal, the 4 K-wires can serve as the definitive fixation means (Fig. 16.13a–d). They are cut short and buried underneath the skin. The wrist should be moved gently to confirm the smooth articulation at the mid-carpal joint and stable fixation at the radiocarpal joint. The incision wounds are then opposed with steri-strips or simple stitches. Comfortable compression dressing with short arm plaster slab is applied. It is changed to removable wrist splint at 1–2 weeks of time. For K-wires fixation, active mobilization of the wrist is initially after fusion is united radiologically and clinically. The K-wires can be removed under local anaesthesia through the original skin incision. For compression screw fixation, gentle active wrist mobilization can be performed at 2 weeks post-op under supervision. More vigorous mobilization can be performed when radiological and clinical union is achieved.

a

Fig. 16.12  (a) Intra-op X-ray shows the final fixation of radioscapholunate intervals with two percutaneous headless screws. Note that the ulnar shortening was performed before the indexed procedure. (b) Solid union of radioscapholunate fusion site at 39 months post-op. Surgical scar was minimal

Radiolunate Fusion Radiolunate fusion is most commonly utilized in rheumatoid arthritis where there is painful ulnar translocation of the carpus at the radiocarpal joint. In post-traumatic situation, it is indicated when the articular cartilage destruction is confined to the radiolunate joint, such as in die-punch fracture of distal radius (Fig. 16.14). The operation is essentially similar to radioscapholunate fusion, except that the radio-scaphoid joint is spared. In addition, distal scaphoidectomy is not necessary. Thus during the burring procedure, the articular surface of the proximal scaphoid and scaphoid fossa should be well protected. Also during the graft insertion procedure, a second Foley catheter can be inserted at the 1/2 portal to obliterate the space at the radioscaphoid articulation so as to isolate the space at the RL joint (Fig. 16.15). Arthroscope is placed at the 3/4 portal while bone substitute is delivered to the radiolunate joint through a cannula at the 4/5 portal (Fig.  16.16). Fixation can be accomplished by 2 K-wires or two compression cannulated screws inserted percutaneously from the distal radius as described above (Fig.  16.17a, b). In a patient with significant ulnar positive variance, an accompanying ulnar shortening osteotomy is performed to unload the ­ulno-carpal

16  Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis

b

Fig. 16.12  (continued)

Fig. 16.13  (a) Post-distal radius fracture arthrosis of the radiocarpal joint with complete eburnation of the scaphoid and lunate fossa confirmed with arthroscopy. The mid-carpal joint was preserved. (b) Fixation of radioscapholunate fusion with 4 K-wires and bone substitutes. Position of K-wires could be verified through arthroscopy at radiocarpal joint. (c) X-ray at 7 months post-op showed good fusion. Scars on patients were minimal. (d) Solid radiocarpal fusion at 40 months post-op

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234

Fig. 16.13  (continued)

Pak-Cheng HO

16  Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis

d

235

joint as well as to avoid potential ulno-carpal impaction after the radiolunate fusion which may shorten the proximal carpal row. The post-op care and rehabilitation is the same as radioscapholunate fusion as described above. However, the period of immobilization may need to be extended due to the limited contact area between the lunate fossa and proximal lunate. Post-operatively, close radiological monitoring is essential to determine the pacing of rehabilitation. The author’s limited experience favours granule form of bone substitute rather than injectable form, though the latter is very convenient for administration through arthroscopic cannula.

Results and Complication

Fig. 16.13  (continued)

Fig. 16.14  Thirty-four-yearold man with severe painful post-distal radius fracture arthrosis at radiolunate joint

From Mar 2005 to Aug 2008, we have performed four cases of arthroscopic radioscapholunate fusion and two cases of radiolunate fusion. There were 3 male and 3 female patients of average age of 42 (range 19–53). All the patients were manual workers. The average duration of symptom before surgery was 33 months (range 12–50). The indications for surgery include: post-distal radius fracture radiocarpal joint arthrosis 4, post scaphoid non-union radiocarpal joint arthrosis 1

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Fig. 16.15  Percutaneous pinning of the radiolunate joint under X-ray and arthroscopic guidance. A Foley catheter had been placed to obliterate the space at the radio-scaphoid joint

Fig. 16.16  Filling of radiolunate joint space with injectable bone substitute. Spilling of bone substitutes to adjacent space was blocked with inflated Foley catheter

and rheumatoid arthritis 1. Multiple K-wires fixation was used in two cases, cannulated bold screw in one case and 3.0 mm cannulated AO screws in the remaining three cases. In all the cases, bone substitute was being used to augment the fusion, granule form in four

cases and injectable form in two cases. In one patient, simultaneous arthroscopic wafer procedure was performed to unload the ulno-carpal joint. In another case of radioscapholunate fusion, simultaneous arthroscopic distal scaphoidectomy was performed. Radiological

16  Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis Fig. 16.17  (a) Definitive fixation with two percutaneous AO screws at radiolunate joint. (b) Post-op X-ray appearance of the radiolunate fusion with good capitolunate alignment. Note that the bone substitutes were well contained at the radiolunate joint

237

a

b

union was obtained in five cases at a median interval of 9 weeks (range 6–50 weeks). The average follow-up period was 28.7 months (range: 8–52 months). All the patients were pain-free and could resume their original duty. The average arc of motion was 64° flexion/extension and 42° radio-ulnar deviation. Pronation and

supination was full in all the patients. Grip strength averaged 84% of the opposite unaffected side. Cosmetic appearance of the surgical scar was excellent and patient satisfaction was high (Fig. 16.18a–h). We have a case of radiolunate fusion using double percutaneous screw fixation, and injectable bone

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substitute failed to heal in 9 months despite optimal internal fixation and was revised successfully with open radiolunate fusion using iliac crest block bone graft and plating. Intra-operatively marked osteolysis was noted at the fusion site though no evidence of infection was obtained. The final outcome was excellent (Fig. 16.19a–c). Other complication included one case of delayed union of radioscapholunate fusion using injectable bone substitute and screw fixation with complete radiological union apparent at 50 weeks post-op. There was one case of skin irritation by pin with minor pin tract infection requiring early removal of pin.

Pak-Cheng HO

Conclusion Post-traumatic arthrosis of the radiocarpal joint is not uncommon following distal radius fracture. Symp­ tomatic patients can be successfully treated with radiocarpal fusion, provided the mid-carpal joint is relatively preserved. Arthroscopic fusion is a viable, technically straight forward and safe procedure. Combined with percutaneous fixation technique, arthroscopic radiocarpal fusion potentially can generate the best possible functional outcome by minimizing trauma to soft tissue and favouring motion preservation. Our preliminary experience geared towards the use of granule form of

a

Fig. 16.18  (a) Fifty-three-year-old lady developed severe radiolunate arthrosis without a history of trauma. (b) Wrist arthroscopy showed complete eburnation of lunate fossa and proximal lunate, tear of TFCC with preserved ulnar head cartilage. (c) Operative diagram depicted the extent of joint pathology. There was associated small osteochondral lesion over the scaphoid fossa. The mid-carpal joint was normal. (d) Without the tourniquet on, burring of proximal lunate revealed good subchondral punctate bleeding. (e) Intra-operative fluoroscopy showed the

position of guide pins across radiolunate joint. (f) Arthroscopic view showing the position of Foley catheter at the scaphoid fossa and granule form of bone substitute at radiolunate joint space. (g) Final definitive fixation of radiolunate joint with two percutaneous bold screws. Note that both radio-scaphoid and ulno-carpal joint were free of bone substitute due to the blockage by Foley catheter. (h) Solid bone union at 6 months post-op and clinical range of motion of the left wrist. Patient was pain free and returned to normal duty as office assistant

16  Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis

b

c

e

d

f

h

Fig. 16.18  (continued)

g

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a

b

Fig. 16.19  (a) Evidence of early osteolysis of fusion site at 14 weeks post-op in the 34-year-old man with radiolunate fusion for post-traumatic radiolunate arthrosis. (b) Definite non-union at 9 months post-op as shown by X-ray and CT scan. (c) Aseptic

non-union confirmed at revision operation with fusion converted to open iliac crest block bone grafting and plating. Final radiological union attained

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c

Fig. 16.19  (continued)

bone substitute rather than the injectable one to augment bone healing.

References   1. Catalano LW, Cole J, Gelberman RH. Displaced intraarticular fractures of the distal aspect of the radius. J Bone Joint Surg. 1997;79A:1290–302   2. Fernandez DL, Jupiter JB. Fractures of the distal radius. New York: Springer; 1997   3. Garcia-Elias M, Lluch AL. Resection of the distal scaphoid for scaphotrapeziotrapezoid arthritis. J Hand Surg. 1999; 24B(4):448–52   4. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg. 2004;86A(9):1900–8   5. Hastings H. Arthrodesis (partial and complete). Green’s operative hand surgery, 5th ed. Vol. 1. Philadelphia: Elsevier/ Churchill Livingstone; 2005   6. Ho PC, Lo WN. Arthroscopic resection of volar ganglion of the wrist: a new technique. Arthroscopy. 2003;19(2):218–21

  7. Kilgus M, Weishaupt D. Radioscapholunate fusion: long-term results. Handchir Mikrochir Plast Chir. 2003;35(5): 317–22   8. Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg. 1986;68A: 647–59   9. Meyerdierks EM, Mosher JF, Werner FW. Limited wrist arthrodesis: a laboratory study. J Hand Surg. 1987;12A: 526–9 10. Mikkelsen SS, Lindbald BE. Development of osteoarthritis after fixation of Colles’ fracture (older type 4): a retrospective study. Scand J Plast Reconstr Hand Surg. 1990;24: 259–60 11. Monheim MS, Bolger JT, Omer GE. Radiocarpal dislocation – classification and rationale for management. Clin Orthop. 1985; 192:199–209 12. Nagy L, Büchler U. Long-term results of radioscapholunate fusion following fracture of the distal radius. J Hand Surg. 1997;22B:705–10 13. Overgaard S, Solgaard S. Osteoarthritis after Colles’ fracture. Orthopaedics. 1989;12:413–6 14. Scheck M. Long term follow up of treatment of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg. 1962;44A: 337–51

242 15. Short WH, Palmer AK, Werner FW. A biomechanical study of distal radius fracture. J Hand Surg. 1986;12A:529–34 16. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intraarticular distal radius fractures. J Hand Surg. 1994;19A:325–40

Pak-Cheng HO 17. Yajima H, Kobata Y, Shigematsu K. Radiocarpal arthrodesis for osteoarthritis following fractures of the distal radius. Hand Surg. 2004;9(2):203–9

Index

A AO classification, 9 Arthritic wrist, arthrodesis background, 211–212 surgical approach overview, 212–213 surgical technique capitate-lunate, 214, 217–222 carpal arthrofibrosis, 214 diagnosis of pathology, 213–216 percutaneous bone graft, 222–223 Arthroscopic arthrodesis. See Arthritic wrist, arthrodesis Arthroscopic-assisted osteotomy cartilage fracture lines, 191, 192 discussion, 207–208 indications and contraindications free osteochondral fragment, 195 massive bone loss, 196 perfect restoration, 194 radius step-off, 196 scaphoid fossa, 195 instruments, 198–200 logistics, 198 operation intraoperative view, 203 scaphoid fossa, 204 volar-radial approach, 201 preoperative planning, 196–197 results, 204–207 Arthroscopic-assisted reduction, 13, 36–38, 41 Arthroscopic-assisted reduction and internal fixation (AARIF), 41 Arthroscopic radiocarpal fusion complication and results, 235–241 partial wrist fusion, 226 radiolunate fusion Foley catheter, 232, 236 post-distal radius fracture, 235 radioscapholunate fusion Foley catheter blocking technique, 231 intra-operative fluoroscopy, 228, 229 K-wires, 232–235 shell of cartilage, 228 set up and instrumentation, 226–227 Arthroscopic role Borelli traction tower, 154 clinical experience, 164–165 discussion, 166, 168–171



distal radioulnar joint, 162–164 evaluation, 159 extraarticular and intraarticular wrist fractures, 152 failures and complications, 171–172 flexion-extension, 162 instruments, 153 limitation, 151 midcarpal joint, 162 postop treatment, 165 radiocarpal joint ancillary procedures, 161–162 fibrosis and fibrotic band resection, 154–159 volar and dorsal capsule resection, 158–161 radiocarpal portals, 152 results, 165–168 Whipple traction tower, 152, 154 Arthroscopic wafer resection, 176, 178 Arthroscopic wrist arthrolysis (AWA), 164–166 Avulsion fracture, sigmoid notch arthroscopic repair, 93–96 open repair, 93–94, 97 B Ballottement test, 76–79 Borelli traction tower, 154 Buttressing plates, 58, 63, 200 Buttressing principle, 58–63 C Carpal arthrofibrosis, 214 Carpal interosseous ligament tears, 105 Carpal tunnel, 2, 61–63, 69, 94 Class 3-A lesion, 85 Concomitant scaphoid fractures fracture compression, 124 indications, 117–118 intraarticular screw exposure, 125 percutaneous screw fixation, 117, 124 surgical armementarium, 125 technique arthroscopic radiocarpal control, 118–119 cannulated Herbert double-threaded screw, 120, 122 compressive effect, 121 Finochietto interdigital traction device, 118 fracture fixation and localization, 119–120 K-wire retraction, 119

243

244 open reduction and internal fixation, 118–119 operative aspects, 123 perioperative complications, 124 reduction quality, 121, 123 risk factors, 124 tapping, scaphoid poles, 120, 122 volar percutaneous technique, 124 D Direct foveal (DF) portal repair, 80–81 Distal hammock-like structure, 89, 90, 185 Distal radioulnar joint (DRUJ) arthroscopic role, 162–164 hypermobility, 76 laxity, 76, 78 TFC traumatic tears, 183, 186 ulnar styloid impaction, 181–183 Distal radioulnar joint (DRUJ) instability classification system, 74–75 clinical assessment and arthroscopic findings ballottement test, 76 hook test, 77–78 intraoperative parameters, 78 “soft” end-point resistance, 76, 78 TFCC laceration, 76–77 trampoline test, 77 type 1-B injury, 77 clinical implications, 74 DRF pathomechanics, 73–74 Galeazzi fracture-subluxation, 75 hyperextension injury, 73 indications, 78–80 ligamentum subcruentum, 73 long arm cast immobilization, 73 postoperative care, 85–87 risk factors, 76 technique direct foveal portal, 80–81 styloid fixation, 85 surgical treatment and diagnostic arthroscopy, 80 suture anchor foveal repair, 81–84 ulnar styloid fracture, 74–75 Doi classification, 29 Dorsal capsule resection. See Volar and dorsal capsule resection Dorsal extrinsic ligament injury Slutsky’s procedure, 113–114 thermal shrinkage, 115 Dorsal extrinsic ligaments, 127, 131 Dorsal radiocarpal (DRC), 128 Dorsal radiocarpal ligament (DRCL), 17–20, 113–115 Dry technique arthrosponge, 44 aspiration procedure, 42 moist arthroscopy, 43 soft tissue extravasation, 42 E European Wrist Arthroscopy Society (EWAS), 105 Explosion-type distal radius fractures arthroscopic part

Index fragment displacement, 48–50 stabilizing fractures, 48 unreduced fragments, 51, 53–56 carpal tunnel, 61–63 classic part flexor carpi radialis sheath, 45 volar locking plate, 45 clinical experience, 63–64 dry technique arthrosponge, 44 aspiration procedure, 42 moist arthroscopy, 43 soft tissue extravasation, 42 osteochondral fragments, 63 figure-of-eight wire suture, 61 short radio-lunate ligament, 64 postoperative care, 53, 56 scaphoid fossa comminution buttressing principle, 58, 63 external fixator and K-wires, 61 styloid fractures, 57, 60 severe metaphyseal comminution extra-articular reduction, 57 volar radiocarpal dislocation, 55 volar-ulnar fragment, 55–59 F Fernandez classification, 10 Fibrocartilage-radius interface tear, 93 Fibrosis resection, 154–159 Fibrotic band resection, 154–159 Finochietto interdigital traction device, 118 Floating styloid, 79, 85, 183, 184 Foley catheter blocking technique, 231 Fracture dislocations arthroscopic management, 142, 144–147 carpal antegrade screw, 136 greater arc injury, 134, 136 Kleinert elevator, 137 circumferential access, 129, 130 combined injuries disruption pathway, 143, 144 scaphoid volar dislocation, 141 discussion, 146, 148 extrinsic ligament midsubstance disruption, 133–135 final evaluation, 130 indications magnetic resonance imaging, 129 physical examination, 128 intrinsic ligament ruptures, 137–141 marginal fragments Kleinert elevator, 132 lunate facet, 133 lunate fossa, 131 multiple planes, 132 radioscaphocapitate, 131, 132 scaphoid fossa, 132 volar rim, 131 rehabilitation, 144–145 small bone manipulation, 130

Index Free osteochondral fragments (FOFs), 48, 50, 53, 64 Frykman classifiation, 10 G Geissler’s classification, 104–105 Greater arch perilunate dislocation, 99–100 H Hook test, 25, 79, 83, 84, 181–184, 186 DRUJ laxity, 78 partial detachment, foveal insertion, 181, 182 TFCC foveal avulsion, 77–78 TFCC peripheral tear, 80 ulnar styloid, 183, 184 Hyaloglide®, 158, 165, 166, 170 I Intraarticular distal radial fractures classification, 28–30 Intraarticular fibrosis, 154, 155 Intraarticular malunion discussion, 207–208 fracture dislocation, 188 indications and contraindications free osteochondral fragment, 195 massive bone loss, 196 perfect restoration, 194 radius step-off, 196 scaphoid fossa, 195 macroscopic defects, 151 preoperative planning, 196–197 results, 204–207 surgical technique instruments, 198–200 logistics, 198 operation, 199–204 Intraoperative fluoroscopy, 22, 228, 229 Irrigation-suction cycle, 43 L Ligamentum subcruentum, 73 Long radiolunate (LRL), 15, 113, 128, 130, 142, 202 Lunate fossa (LF), 131 Lunotriquetral and extrinsic ligaments lesions incidence, 109–110 lnotriquetral interosseous ligament (LTIO) management arthroscopic debridement, 109 chronic ulnar side pain, 111 electrothermal shrinkage, 110 Geissler classification system, 109 joy stick maneuver, 111 lunotriquetral arthrodesis, 112 management dorsal extrinsic ligament injury, 113–115 volar extrinsic ligament injury, 112–113 Lunotriquetral interosseous (LTIL) carpal fracture, 135 indications, 129 interface, 138, 139 marginal avulsion, 137

245 M Magnetic resonance imaging (MRI) and arthroscopy, 9 CT and, 103 diagnosis of pathology, 213 fracture dislocations, 129 hypertrophic styloid nonunion, 184 intraarticular step-off, 188 Midcarpal joint, 13, 15, 16, 19, 20, 48, 123, 137, 152, 162, 168. See also Arthritic wrist, arthrodesis Moist arthroscopy, 43 Müller AO classification, 27, 29 O Open plate fixation (ORIF), 13 Open radius surgery, 142, 144–147 Osteochondral fragment, 41, 48, 63, 195 Osteotomy discussion, 207–208 free osteochondral fragment, 195 instruments, 198–200 logistics, 198 massive bone loss, 196 operation, 199–204 perfect restoration, 194 preoperative planning, 196–197 radius step-off, 196 results, 204–207 scaphoid fossa, 195 ulnar carpal impaction, 176 P Percutaneous screw fixation, 117, 124–125 Perilunate dislocations arthroscopic management, 142, 144–147 carpal fractures antegrade screw, 136 greater arc injury, 134, 136 Kleinert elevator, 137 discussion, 146, 148 lunotriquetral interosseous interface, 138, 139 marginal avulsion, 137 rehabilitation, 145 scapholunate interosseous interface, 138 pin fixation, 140 scaphoid fracture, 137 Portals, wrist arthroscopy anatomy, 13–14 arthroscopic-assisted fixation, 21 diagnostic survey 3-/,4 and 4-/,5 portals, 19 DRUJ portals, 20–21 midcarpal portals, 19–20 6R, 6U Portals, 19 volar portals, 20 dorsal and volar DRUJ, 18 dorsal portals midcarpal, 15

246 radiocarpal, 14–15 Triquetro-Hamate and radioulnar, 15 equipment and implants four-part fractures, 24–25 radial styloid fractures and surgical technique, 22 requirements, 21–22 TFC repair kit and ligament repairs, 22 three-part fractures, 22–24 ulnar styloid fractures, 25 ulnar and radial midcarpal portal, 18 volar portals radial, 15–16 ulnar, 16–17 volar distal radioulnar (VDRU), 17 volar radial midcarpal (VRM), 16 Posterior ulnar (PU) fragment, 51, 95 Postfracture stiffness, arthroscopy arthroscopic wrist arthrolysis, 164–166 discussion, 166, 168–171 distal radioulnar joint, 162–164 failures and complications, 171–172 postop treatment, 165 radiocarpal joint ancillary procedures, 161–162 fibrosis and fibrotic band resection, 154–159 volar and dorsal capsule resection, 158–161 Postop treatment, 165 Post-traumatic radiocarpal arthrosis indications and contra-indications, 226 results and complication, 235–241 surgical approach radiolunate fusion, 232, 235–237 radioscapholunate fusion, 227–235 set up and instrumentation, 226–227 Pre-operative assessment classification, 9–10 examination, 2 investigations CT imaging, 7–9 fracture characteristics, 3–6 fracture stability, 6–7 MRI and arthroscopy, 9 parameters, 2–3 X-ray, 2 patient history, 1–2 Preoperative planning intraarticular malunion, 196–197 simple articular fractures, 30 Pull-out wiring method, 94, 97 R Radial midcarpal portal, 13, 18, 118, 119, 124 Radial tear, TFCC anatomy, 89–90 classification, 90–91 diagnosis and evaluation, 91–93 DRUJ instability, 89, 91, 92, 94, 98 mechanism, 91 treatment arthroscopic partial resection, 93 avulsion fracture, dorsal sigmoid notch, 93–94

Index combination injury, 94 fibrocartilage-radius interface tear, 93 palmar sigmoid notch, avulsion fracture, 94 postoperative care, 97 total radial avulsion, 94, 98 Radiocarpal dislocations arthroscopic management, 142, 144–147 discussion, 146, 148 indications, 128 marginal avulsion, 133 marginal fragments Kleinert elevator, 132 lunate facet, 133 lunate fossa, 131 multiple planes, 132 radioscaphocapitate, 131, 132 scaphoid fossa, 132 volar rim, 131 Radiocarpal joint, arthroscopic role ancillary procedures, 161–162 fibrosis and fibrotic band resection, 154–159 volar and dorsal capsule resection, 158–161 Radiocarpal (RC) portals, 152 Radiolunate (RL) fusion Foley catheter, 232, 236 post-distal radius fracture, 235 Radioscaphocapitate (RSC) free margins, 134 reduction and stabilization, 132 Radioscapholunate (RSL) fusion Foley catheter blocking technique, 231 intra-operative fluoroscopy, 228, 229 K wires, 232–235 shell of cartilage, 228 Range of motion (ROM) evaluation, 159 flexion-extension, 162 limitation, 151 Rehabilitation fracture dislocations, 144–145 postop treatment, 165 S Scaphoid fossa (SF), 132 Scaphoid fossa comminution buttressing principle, 58, 63 external fixator and K-wires, 61 styloid fractures, 57, 60 Scaphoid fractures, classification, 125 Scapholunate dissociation anatomy and biomechanics, 100–102 arthroscopic indications, 103 Geissler grading, 104–105 management acute injuries, 105–106 late presentation, 106–107 non-osteoporotic patients, 99–100 pathology arthroscopy and radiographs, 103 clinical assessment, 102 CT and MRI imaging, 103

Index radiocarpal visualization and mid-carpal arthroscopy, 104 SL ligament injury detection, 99 Scapholunate instability, 71, 99, 102, 103 Scapholunate interosseous (SLIL) carpal fracture, 135 indications, 129 interface, 138 pin fixation, 140 scaphoid fracture, 137 Scapholunate ligament tears, 9 Scapho-trapezial ligamentous complex, 101–102 Scaphotrapeziotrapezoid (STT), 18, 19, 121, 125, 162, 212, 213, 228 Severe metaphyseal comminution, 54–55 Sharpey’s fibers, 90 Short radio-lunate ligament (SRL), 17, 64, 128, 130, 131, 139 Simple articular fractures advantages, arthroscopic technique, 27 associated injuries, 37, 38 classification AO type C3 fractures, 28, 30 Müller AO classification, 27, 29 clinical experience and personal results, 38 complications, 37 four-part fractures, 36–37 indications and contraindications, 30 surgical technique, 30–31 three-part fractures arthroscopic fine-tuning, 36, 37 depressed lunate facet fragments, 34, 36 open standard volar technique, 35–36 treatment effects and outcomes, 38 two-part fractures joystick technique, 34, 35 Kirschner wire and cannulated screw, 31–32 volar fragment, 32–33 SMC flip knot, 82, 83 Styloid fixation, 85 Suture anchor foveal repair, 81–85 Suture welding technique, 70 T TFCC. See Triangular fibrocartilage complex TFCC ulnar tears. See Distal radioulnar joint (DRUJ) instability Trampoline test, 77, 78, 80 Trans-styloid perilunate injury, 103, 107 Traumatic tears, 183, 185–187 Triangular fibrocartilage (TFC) traumatic tears distal radioulnar joint, 183, 186 triangular fibrocartilaginous complex, 185, 187 ulnar carpal impaction, 176–178

247 Triangular fibrocartilage complex (TFCC), 31, 37, 67–71, 73–87, 89–98, 100, 109, 110, 115, 125, 154, 158, 160, 169, 170, 177, 213, 226 arthroscopic role, 162–164 perforation, 227 traumatic tears, 183, 185–187 ulnar styloid impaction, 179, 181–183 Triangular fibrocartilage complex lesions contraindications debridement, central tears, 68 peripheral lesions, 68–69 unstable DRUJ, 68 indications, 67–68 management, 69–71 intraoperative sugar-tong plaster splint, 70 perforation and suture passing, 69–70 pronation/supination restriction, 71 small and large central tears, 69 suture welding technique, 70 repair zone, 67 surgical technique, 69 Triquetro-Hamate (TH) portal, 15 U Ulnar carpal impaction (UCI) arthroscopic wafer resection, 176, 178 clinical signs, 177 radius osteotomy, 176 TFC reattachment, 178 triangular fibrocartilage, 176 Ulnar styloid impaction (USI) diagnosis, 179 distal radioulnar joint, 181, 182 floating styloid, 183, 184 partial detachment, foveal insertion, 181, 182 pathologic conditions, 179 Ulnocapitate (UC), 128, 130 Ulnolunate (UL), 128, 134 Ulnotriquetral (UT), 128, 134 V Volar and dorsal capsule resection, 158–161 Volar Barton fractures, 58 Volar extrinsic ligament injury, 112–113 Volar extrinsic ligaments, 127, 131, 133–135 Volar rim (VR), 131 Volar-ulnar fragment, 50, 55, 59, 197, 199–200 W Whipple traction tower, 152, 154 Wrist arthroscopy, 13, 25. See also Portals, wrist arthroscopy