[Lesions of the ligaments associated with distal fractures of the radius. 58 intraoperative arthrographies]

Scapholunate Diastasis in Distal Radius Fractures: Fracture Pattern Analysis on CT Scans

Objectives  Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods  We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort ( n  = 12; 46%) had a high-energy mechanism of injury. The majority of the patients ( n  = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results  The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion  Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence  This is a Level III, diagnostic study.

[Pathology of the triangular fibrocartilaginous complex in distal radius fractures]

Distal radius fracture is actually quite rarely isolated and triangular fibrocartilaginous complex (TFCC) is often involved with the same mechanism of injury. A contemporary management of the treatment of the initial fracture is ideal and so benefits from a routine arthroscopic management. Nevertheless, in the absence of diagnosis and therefore early treatment, the symptoms may be located at the ulnar crossroads and justify specific treatment of TFCC. It is generally conducted after an accurate arthroscopic lesion classification guiding a procedure, depending on the lesion vascularization as well as its possible destabilization potential (debridement, capsular suture or foveal reattachment). Unfortunately, too often the radius fracture is insufficiently stabilized by an inadequate fixation process or inappropriate orthopedic management with a positive ulnar variance consequence and an ulnar plus syndrome. A "wafer procedure" may then sometimes be proposed if a shortening of less than 3mm is needed and that the distal radio-ulnar joint is not too disorganized.

Frequency of Scapholunate Ligament Injuries Associated with Distal Radius Shearing Fracture: Correlation of Fracture Patterns and Ligament Tear

BACKGROUND

This retrospective study assessed the prevalence and outcome of intercarpal ligament injuries in non-osteoporotic patients with AO/ASIF classification type B distal radius shearing fractures treated with or without scapholunate temporary fixation.

METHODS

Fifteen patients (mean age, 33 years) were analyzed according to their scapholunate ligament status at the time of injury and graded with a modified Geissler classification system. Each patient's postoperative pain and occupational status were assessed in the context of the Modified Mayo wrist score. Second-look arthroscopy was performed for all cases.

RESULTS

Scapholunate ligament injuries were present in 14 of 15 type B fractures. Surgical outcomes yielded an improvement in the Mayo wrist score with pinning in cases involving grade 3 or 4 scapholunate injuries. Two cases without pinning had a worse score, as well as a persistent scapholunate tear that was not healed at second-look arthroscopy after eight postoperative months. However, in grade 1 or 2 scapholunate injuries, the Mayo wrist score did not differ between those treated with and without pinning.

CONCLUSIONS

Scapholunate ligament injury is an important risk factor associated with high-energy distal radius shearing fractures. To prevent these problems, temporary scapholunate joint fixation is a recommended treatment for grade 3 or 4 scapholunate injuries.

The management of chronic distal radioulnar instability

The stabilizing constraints of the distal radioulnar joint (DRUJ) include its bony geometry and the surrounding soft tissue support. Given the shallow nature of the sigmoid notch, reconstruction of the palmar and dorsal ligamentous sleeve provides the best solution for restoring stability in cases of chronic DRUJ instability. The pertinent anatomy, indications, contraindications, soft tissue stabilizing procedures, and rehabilitation for the management of chronic DRUJ instability are highlighted in this review.

Acute dislocations of the distal radioulnar joint and distal ulna fractures

This article reviews acute dislocations of the distal radioulnar joint (DRUJ) and distal ulna fractures. Acute dislocations can occur in isolation or in association with a fracture to the distal radius, radial metadiaphysis (Galeazzi fracture), or radial head (Essex-Lopresti injury). Distal ulna fractures may occur in isolation or in combination with a distal radius fracture. Both injury patterns are associated with high energy. Outcomes are predicated on anatomic reduction and restoration of the stability of the DRUJ.

Treatment of intra-articular fractures of the distal radius

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant.

Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.

Arthroscopic management of distal radius fractures

Arthroscopy has the advantage of providing a direct and accurate assessment of the articular surfaces and detecting the presence of injuries associated with distal radius fractures. Current indications, although numerous and potentially expanding, also are controversial. This report presents a global view of the current status of arthroscopy in the management of distal radius fractures. The rationale of arthroscopic treatment, the available evidence, and finally the diagnosis and treatment are discussed.

Intra-articular distal radius fractures: the role of arthroscopy?

Arthroscopic assisted fixation of distal radius fractures offers several advantages. It allows for the evaluation of the articular reduction under a bright light and magnification. Particularly, rotation of the fracture fragments, which is difficult to judge under fluoroscopy, may be detected arthroscopically and corrected. Washing out fracture hematoma and debris potentially allows for improved range of motion, as shown by the studies of Doi and Stewart. Wrist arthroscopy also allows for detection and management of associated soft tissue injuries, which has been shown to occur with distal radius fractures. Some of the more severe interosseous ligament injuries can be diagnosed on plain or traction radiographs. Arthroscopy performed at the same time as fracture reduction, however, substantially increases the recognition of these injuries. In addition, it is wellknown that the management of acute interosseous ligament tears has a better prognosis when compared with chronic lesions.

Diagnostic arthroscopy: indications and interpretation of findings

Many authors recommend arthroscopy for diagnostic or therapeutic purposes. Arthroscopy is a sophisticated investigation, which can cause damage requiring wrist fusion. It allows visualization of findings, but these are subtle and difficult, if not impossible to interpret, since the contralateral wrist cannot be used as a standard for comparison. Furthermore, not all intracarpal ligaments are directly and reliably visible through the arthroscope: for example the scaphoid-trapezial ligament which is essential for the stabilization of the distal part of the scaphoid. Therefore, it is questionable whether we can define arthroscopy as a gold standard of diagnosis just because it permits direct vision, as if what cannot be seen does not exist! Traction, mandatory for examination, induces particular stresses that may distort intracarpal motion and so-called dynamic evaluation. Each author tends to present a specific classification, rendering comprehension even more difficult. Accordingly, teaching and learning become a real challenge. Arthroscopy may be important in particular cases, but it remains only one component of a complex clinical assessment.

The arthroscopic management of intra-articular distal radius fractures

Intra-operative arthroscopy and fluoroscopy provide improved visualisation and guide the restoration of intra-articular distal radial fractures while minimising the operative dissection required for their stabilisation. Radial styloid fractures, distal radial fractures with dorsal, palmar or combined ulnar-sided "die punch" fragments, palmar and dorsal Barton's fractures, and various three- and four-part intra-articular fractures without significant bone loss or defect are especially suited for this technique. The experienced arthroscopist may wish to apply the technique to more severely comminuted intra-articular fractures. Bone defects may be approached through a limited dorsal incision traversing the 3rd dorsal wrist compartment. Arthroscopy and fluoroscopy may be used adjunctively to assess fracture reduction and fixation. Arthoscopy further facilitates initial treatment by allowing direct joint visualisation, debridement, the removal of small free intra-articular fragments, and the recognition and early treatment of wrist ligament injuries, particularly those not appreciated by X-ray evaluation

Arthroscopically assisted reduction of intraarticular distal radial fractures

Anatomic restoration of the joint surface and extraarticular alignment is the goal in management of displaced distal radial fractures. Arthroscopy provides well lit, magnified conditions in which to reconstruct the fractured joint surface and to detect and manage intracarpal soft tissue injures associated with distal radial fractures. Percutaneous and limited open reduction techniques combined with wrist arthroscopy in the arthroscopically assisted management of displaced distal radial fractures is described.