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

27

  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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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

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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

1  Pre-Operative Assessment in Distal Radius Fractures

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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 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

1  Pre-Operative Assessment in Distal Radius Fractures

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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

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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 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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100

T. Lindau

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

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

106

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

 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

Volar and dorsal diastasis >2.3 mm

Distraction

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

Translation

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

Rotation

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.

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

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

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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 (