Plate presetting arthroscopic reduction technique for the distal radius fractures

The Flexor Carpi Radialis Portal for Arthroscopy-Assisted Reduction of the Dorsal Ulnar Fragment in Distal Radius Fractures

Background  The importance of the dorsal ulnar fragment (DUF) for stability and articular congruence of the radius is widely recognized, and standard surgical techniques often fail to ensure its reduction. Description of Technique  We describe a modification of volar wrist portals for arthroscopic management of the DUF of the distal radius. It is made in an outside-in fashion in line with the flexor carpi radialis (FCR) approach for the distal radius. Through this volar portal, we achieve wide and direct visualization of the DUF, with the advantage of protecting important anatomic structures such as the FCR tendon, the radial artery, and the median nerve; all protected with the previously made volar approach for the distal radius. In addition, easy manipulation and reduction of the DUF is obtained with instrumentation through standard dorsal portals. Patients and Methods  We performed this procedure in 23 patients with distal radius fractures (DRF) with displaced DUF. Results Early and late postoperative evaluation demonstrated intraoperative reduction maintenance and adequate range of motion, compatible with the usual findings of standard volar plating, with the benefit of anatomic reduction of the DUF. Conclusion  With our technique, volar plating associated with arthroscopy-assisted dorsal fragment specific fixation with dorsal standard and the FCR portals permits optimal surgical treatment of most DRFs.

Comminuted Dorsal Ulnar Fragment in Distal Radius Fractures Treated Using the Integrated Compression Screw With a Mini-Plate

Stabilization for displaced dorsoulnar fragments in distal radius fractures is challenging to treat with conventional volar locking plates alone. The integrated compression screw combined with a volar locking plate has been introduced as an additional tool to stabilize the dorsoulnar fragment and has been reported to work effectively. However, the compression screw is unable to stabilize a comminuted dorsal ulnar fragment; therefore, it is necessary to consider using an additional dorsal plate. We have developed a modified surgical technique to stabilize a comminuted dorsal intra-articular fragment by combining the integrated compression screw with a mini-plate as a washer or a buttress.

Revolutions in arthroscopic wrist surgeries

Recent technical and technological developments in wrist arthroscopic surgery allow for advanced treatments of difficult wrist disorders. In this review, world leaders of wrist arthroscopy describe bone graft for scaphoid nonunion, transosseous repair for triangular fibrocartilage fovea avulsion, palmaris longus reconstruction of the triangular fibrocartilage, and arthroscopic reconstruction of the scapholunate and lunotriquetral ligaments.

Combined Approach for Intra-articular Distal Radius Fracture: A Case Series and Literature Review

Background

The purpose of this study was to classify the possible indications for a combined approach to distal radius fractures (DRFs) by investigating surgical outcomes of patients treated according to our treatment algorithm.

Methods

A combined approach was performed in 32 patients. Patients who were thought to need a combined approach were classified into three types according to the combined injuries associated with loss of volar cortical buttresses in DRFs. The classifications included the following: type 1, free intra-articular fragments; type 2, distally migrated dorsal fragments located beyond the wrist joint; and type 3, centrally impacted articular fragments and displaced dorsal fragments, not reduced by indirect methods.

Results

Seven patients had type 1 fractures treated with volar plates and excision of the intra-articular fragments. Fourteen patients had type 2 fractures: 12 were treated with volar plates and excision of dorsal fragments, and 2 with relatively large unstable dorsal fragments were treated with combined volar and dorsal plates. The remaining 11 patients had type 3 fractures treated with combined volar and dorsal plates. At the latest follow-up, the radiographs revealed an average of 16.9° of radial inclination, an average of 4.2° of volar tilt, and an average of 7.5 mm of radial height. According to the Garland and Werley scores, the functional results were excellent for 3 patients, good for 25, and fair for 4.

Conclusions

The classification system indicated when an additional dorsal approach was needed in unstable DRFs, and it may establish useful guidelines for appropriate surgical decision-making.

Arthroscopic-Assisted Reduction of Intra-articular Distal Radius Fracture

Wrist arthroscopy is an efficient adjunct for intra-articular distal radius fracture fixation. However, performing wrist arthroscopy during the plate fixation is troublesome with the vertical traction applied and released. To facilitate the procedure, the authors developed a surgical technique, plate presetting arthroscopic reduction technique (PART), using a palmar locking plate. Since July 2005, they have performed PART for 248 intra-articular distal radius fractures with good and excellent results. Arthroscopic-assisted reduction of intra-articular fragments is superior to fluoroscopic assisted. PART also allows detection of intra-articular migration of fracture fragments, screw protrusion, and associated soft tissue injuries.

Treatment of Intra-articular Distal Radius Fractures

This review of current literature discusses the morphology of the volar aspect of the distal radius; the surgical procedure, arthroscopic findings, and clinical results of a plate presetting and arthroscopic reduction technique for acute intra-articular fractures; and a novel simulation guidance system for malunited intra-articular fractures. Classification of intra-articular distal radius fractures is also discussed, focusing on central depression fracture fragments, associated soft tissue injuries, and results for measuring scapholunate distances at different sites. Problems of the distal radioulnar joint are reviewed, in particular, functional outcomes of the authors' prospective cohort study on unstable intra-articular fractures involving the distal radioulnar joint.

Arthroscopic assistance does not improve the functional or radiographic outcome of unstable intra-articular distal radial fractures treated with a volar locking plate

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.

Comparison of scapholunate distance measurements on plain radiography and computed tomography for the diagnosis of scapholunate instability associated with distal radius fracture

PURPOSE

To investigate radiographic criteria for scapholunate instability (SLI) in the setting of distal radius fracture (DRF) confirmed by arthroscopy.

METHODS

Eighty-eight wrists with DRF treated by open reduction and internal fixation and assessed for SLI arthroscopically were evaluated. The scapholunate distance (SLD) was measured by preoperative posteroanterior wrist radiography and computed tomography (CT). SLD on radiographs was measured as the distance between the scaphoid cortex and the lunate cortex at the center of the scapholunate joint. SLDs were measured at the volar end (A1), center (A2), and dorsal end (A3) of the scapholunate joint on the central CT axial slice; and at the proximal end (C1), center (C2), and distal end (C3) of the scapholunate joint on the central CT coronal slice. Wrists were divided into three groups by arthroscopic assessments: stable (normal, Geissler grade 1 or 2), G3 (Geissler grade 3), and G4 (Geissler grade 4). SLD measurements on radiographs and CTs (A1-C3) were compared among the three groups. Receiver-operating characteristic (ROC) curve analyses were performed to evaluate the abilities of SLD measurements on radiographs and CTs to identify SLI in wrists with DRF. Interobserver and intraobserver reliabilities of SLD measurements on radiographs and CTs were analyzed by intraclass correlation coefficients (ICCs).

RESULTS

SLDs of C3 differed significantly among the G3 and G4 groups, and among the stable and G4 groups. The area under the curve on ROC curve analysis was 0.855 for the SLD of C3, which was larger than that for SLD on radiographs. For C3, the intraobserver ICC was 0.832 and interobserver ICC was 0.73.

CONCLUSIONS

SLD at the distal end of the scapholunate joint on the central coronal CT slice was the most appropriate measurement for discrimination of Geissler grade 4 SLI in wrists with DRF.

LEVEL OF EVIDENCE

Level 2.

National healthcare initiatives and pursuit of wrist surgery innovations: a report of the 2011-2012 Sterling Bunnell Traveling Fellow

Every year since 1982, the American Society for Surgery of the Hand has sponsored a young member as its Bunnell Traveling Fellow. Named eponymously for the late physician and father of hand surgery, the Sterling Bunnell Traveling Fellowship enables young hand surgeons to foster national and international relationships that contribute to their higher learning and advance the principles of scholarship by improving treatment of hand and upper extremity disorders. This report is an account of the experiences and insights I gained while exploring national health care initiatives and wrist surgery innovations.

Less invasive surgery with wrist arthroscopy for distal radius fracture

BACKGROUND

We developed a surgical procedure that can facilitate arthroscopic intervention for volar locking plate fixation for distal radius fracture (DRF) with a less invasive technique. This study is to investigate the effectiveness of our original procedure for the treatment of DRF.

METHODS

One hundred fifty-five wrists of 153 consecutive patients underwent our original procedure: the plate presetting arthroscopic reduction technique (PART) for DRF. The fractures consisted of 37 extra-articular and 118 intra-articular fractures. The fractures were reduced, anatomical alignment was regained with the aid of an image intensifier, and the volar locking plate was preset. Wrist arthroscopy was then performed and the intra-articular condition assessed. If there were any residual dislocations of the intra-articular fragments, these were reduced arthroscopically, and soft tissue injuries were subsequently treated. The traction was then removed, and the plate was securely fixed. One hundred forty-five patients were followed up from 12 to 48 months. The final outcome was evaluated with the Mayo modified wrist score and Disability of the Arm, Shoulder and Hand questionnaire (DASH). The effectiveness of arthroscopy was also investigated.

RESULT

On arthroscopic inspection, intra-articular dislocations were found to be residual in 35.2 %, even if reduction seemed to have been achieved when viewed with the image intensifier. Scapholunate interosseous ligament injury was recognized in 28.9 %, and triangular fibrocartilage complex injury was observed in 63.2 %. The final outcome was 112 excellent, 31 good, and 2 fair. The mean DASH score was 4.1.

CONCLUSION

We developed the PART to simplify the combination of volar locking plating and arthroscopy. This technique was less invasive and effective in the treatment of DRF.

Treatment with or without internal fixation for ulnar styloid base fractures accompanied by distal radius fractures fixed with volar locking plate

The purpose of this study was to evaluate the treatment results, with and without internal fixation of ulnar styloid base fractures associated with acute distal radius fractures. A total of 48 patients were enrolled, including 20 patients treated by internal fixation (fixation group) and 28 treated without internal fixation (non-fixation group). The evaluated parameters were postoperative range of motion, grip strength, DASH score, and the presence or absence of ulnar wrist pain over time. The outcome was assessed as "excellent" in 15 patients of the fixation group and 21 patients of the non-fixation group, and "good" in five patients of the fixation group and seven patients of the non-fixation group. There were no significant differences in the clinical outcomes or any of the parameters at the final evaluation between the two groups. However, the grip strength was significantly better in the non-fixation group than in the fixation group until 12 weeks postoperatively. The overall clinical outcome was good in both groups, with no significant difference between the groups.

Distal radial fracture arthroscopic intraarticular gap and step-off measurement after open reduction and internal fixation with a volar locked plate

PURPOSE

A persistent articular gap and a step-off of ≥1 mm after a distal radial fracture (DRF) may lead to post-traumatic arthritis of the radiocarpal joint. This study aims to arthroscopically assess the reduction in the articular surface in patients requiring volar locked-plate fixation for DRF via fluoroscopy-guided open reduction and internal fixation (ORIF).

METHODS

Seventy consecutive patients with DRF were prospectively enrolled. Posteroanterior and lateral radiographs and axial, coronal, and sagittal computed tomography (CT) scans were obtained before ORIF for DRF. The widest articular gap (pregap) and step-off (prestep-off) at the radiocarpal joint surface of the distal radius were measured on all radiographs and CT images. Total predisplacement was defined as the sum of all pregaps and prestep-offs. The DRF was reduced under fluoroscopic guidance, and a volar locked-plate was applied after fluoroscopic ORIF. The residual maximum articular gap and step-off (postgap and poststep-off) were measured arthroscopically with a calibrated probe. Total incongruity was defined as the sum of postgap and poststep-off. The receiver operating characteristic curve was applied within the pregaps, prestep-offs and total incongruity in order to identify the cutoff values of pregap and prestep-off beyond which total incongruity would exceed 1 mm.

RESULTS

Of the 70 patients, 40 had a postgap of ≥1 mm, and 15 had a poststep-off of ≥1 mm. All pregap and prestep-off cutoff values were judged to be unsuitable as the screening criteria for arthroscopic reduction of DRF because of their low sensitivity and specificity. The cutoff value obtained from total predisplacement was 7.85 mm, and its sensitivity and specificity were 90 and 70 %, respectively.

CONCLUSIONS

Since the cutoff value of 7.85 mm derived from total predisplacement is a good indicator of post-ORIF residual total incongruity of ≥1 mm, it is also a good indicator of the need for arthroscopic reduction.