Arthroscopic Management of

Distal Radius Fractures

Francisco del Pial
Editor
Christophe Mathoulin
Riccardo Luchetti
Co-Editors

Arthroscopic
Management of
Distal Radius Fractures
Dr. Francisco del Pial Dr. Riccardo Luchetti
Private practice and Hospital Mutua Montaesa Rimini Hand Surgery and
Caldern de la Barca 16-entlo. RehabilitationCenter
39002 Santander Multimedica Policlinic, Milano
Spain Via Pietro da Rimini, 4
drpinal@drpinal.com 47900 Rimini
Italy
Dr. Christophe Mathoulin rluc@adhoc.net
Professor
Clinique Jouvenet Institut de la Main
6 square Jouvenet
75016 Paris
France
cmathoulin@orange.fr

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

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Springer-Verlag Berlin Heidelberg 2010

Chapter 2: all figures

David J. Slutsky 2007. All Rights Reserved.

Chapter 4: Figures 1, 6, 811, and 1619.

Francisco del Pial 2009. All Rights Reserved.

Chapter 14: 11, 13, 14, and 26.

Francisco del Pial 2009. All Rights Reserved.

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Supported by EWAS

v
 Dedication

To my kids Luca, 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 Pial

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 Pial, 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

vii
viii Dedication

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 patients 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
patients complaints are based on something physical. Arthroscopy was introduced to
help patients, to make our treatments more reliable, to have better control of our pro-
cedures. It is merely a tool, indeed, but a marvelous one which nobody should under-
score among all surgical options we have when it comes to solving wrist trauma.
Seeing is understanding. This could be another leitmotiv for these authors cam-
paign to get more hand surgeons to incorporate arthroscopy in their practices.
Certainly, mastering these newly developed techniques help understanding the
patients 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 infor-
mation, but the surgeon need not accept biased interpretations of the patients prob-
lem 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 unre-
duced 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 frag-
ment 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
x Foreword

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 indica-
tions may attract our attention. There is enormous interest in providing detailed how-
to-do descriptions that will guide our steps toward perfecting each ones 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.
Lets 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. Lets 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 profes-
sionals, 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 descrip-
tion of the indications, pearls, and pitfalls of this wonderful tool.
Because arthroscopy is here to help our patients, lets 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 ligamen-
tous 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 inac-
curate. 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 ones 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
xii Preface

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 some-
what 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. Dont 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; dont leap into too complicated cases before you are con-
fident 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 recom-
mend 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 sup-
porting me on it.

Editor in chief Francisco del Pial

President of the European Wrist Arthroscopy Society
 Contents

1 Pre-Operative Assessment in Distal Radius Fractures . . . . . . . . . . . . 1

Gregory I. Bain

2 Portals and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

David J. Slutsky

3 Management of Simple Articular Fractures . . . . . . . . . . . . . . . . . . . . 27

Ferdinando Battistella

4 Treatment of Explosion-Type Distal Radius Fractures . . . . . . . . . . . . 41

Francisco del Pial

5 Management of Distal Radius Fracture-Associated

TFCC Lesions Without DRUJ Instability . . . . . . . . . . . . . . . . . . . . . . 67
Alejandro Badia

6 Arthroscopic Management of DRUJ Instability Following

TFCC Ulnar Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Andrea Atzei

7 Radial Side Tear of the Triangular Fibrocartilage Complex . . . . . . . 89

Toshiyasu Nakamura

8 Arthroscopic Management of Scapholunate Dissociation . . . . . . . . . . 99

Tommy Lindau

9 Lunotriquetral and Extrinsic Ligaments Lesions Associated

with Distal Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Didier Fonts

10 Management of Concomitant Scaphoid Fractures . . . . . . . . . . . . . . . 117

Christophe Mathoulin

11 Perilunate Dislocations and Fracture Dislocations/

Radiocarpal Dislocations and Fracture Dislocations . . . . . . . . . . . . . . 127
Mark Henry
xiv Contents

12 The Role of Arthroscopy in Postfracture Stiffness . . . . . . . . . . . . . . . 151

Riccardo Luchetti

13 Treatment of the Associated Ulnar-Sided Problems. . . . . . . . . . . . . . 175

Pier Paolo Borelli and Riccardo Luchetti

14 Arthroscopic-Assisted Osteotomy for Intraarticular

Malunion of the Distal Radius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Francisco del Pial

15 The Role of Arthroscopic Arthrodesis and Minimal Invasive

Surgery in the Salvage of the Arthritic Wrist: Midcarpal Joint . . . . 211
Joseph F. Slade

16 Arthroscopic Radiocarpal Fusion for Post-Traumatic

Radiocarpal Arthrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Pak-cheong HO

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
 Pre-Operative Assessment in Distal
Radius Fractures 1
Gregory I. Bain

Introduction Details of the mode of injury should be sought as

The determinants of clinical outcome following distal
radial fracture are multi-factorial and may provide sev-
eral 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 char-
acteristics, articular involvement, stability features and
associated injuries to the ulna or carpus. Finally, classifi-
cation of the injury may aid treatment selection and
prognostic prediction. With vigilant pre-operative plan-
ning, 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, compli-
ance 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: greg@gregbain.com.au
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 tis-
sue 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 posi-
tion 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 dor-
sal angulation of the distal fragment.
A fall from a height of greater than two metres,
sporting injuries and motor vehicle accidents are high-
energy injuries. The soft tissue envelope may be sig-
nificantly 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 criti-
cal in the older patient who, for example, requires the
use of a walking aid to maintain independence, or suf-
fers 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 Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 1

DOI: 10.1007/978-3-642-05354-2_1, Springer-Verlag Berlin Heidelberg 2010
2 G. I. Bain
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 appropri-
ately regarding the choice of treatment and likely prog-
nosis. Those with low-energy fractures or other
evidence of osteoporosis should be investigated appro-
priately with bone mineral density scans and com-
menced on suitable therapy.
Counselling an individual patient on the likely
recovery period and functional outcome can be chal-
lenging. Excellent function may result despite defor-
mity and malunion in some patients, where others
experience long-term pain and disability in the pres-
ence 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 experi-
ence a good final result [9, 31, 59, 66], but complete
functional recovery is uncommon [5].
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 treat-
ment plans. Unlike trauma in some other body regions,
it is uncommon for soft tissue swelling to delay defini-
tive 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 frac-
ture 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 struc-
tures. Compartment syndrome is a rare occurrence in
distal radius fractures, but may occur in high-energy
forearm fractures [58, 63]. In regions of severe
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 combina-
tion with soft tissue coverage procedures in combina-
tion with a plastic surgeon.
Median nerve compression symptoms may arise
following distal radial fracture, or pre-existing symp-
toms may deteriorate following fracture [35, 62]. Acute
symptoms may relate to nerve compression from frac-
ture 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
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 1012 of volar tilt, 2223
of radial inclination and 1112 mm of radial length
[19, 22, 42]. Ulnar variance, the relation of the radial
articular surface to the ulnar head, is 1mm [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 restora-
tion [24, 53], as minor anatomical disturbances can
1 Pre-Operative Assessment in Distal Radius Fractures
Table1.1 Radiographic criteria for acceptable healing of a distal
radius fracture. (Courtesy of Graham [22], with permission)
Radiographic criterion Acceptable measurement
Radioulnar length Radial shortening <5mm at DRUJ
compared with contralateral wrist
Radial inclination Inclination on PA film 15
Radial tilt Sagittal tilt on lateral projection
between 15 dorsal tilt and 20
volar tilt
Articular incongruity Radiocarpal articular incongruity
of 2mm
significantly affect wrist mechanics. The distal radius
normally accepts approximately 82% of axial load,
with the remainder through the ulna via the triangular
fibrocartilage complex [50]. However, in the presence
of only 20 of dorsal tilt, 50% of the load is distributed
through the ulna, and the radiocarpal forces shift to the
dorsal scaphoid articular facet [46]. These anatomical
derangements manifest in poor functional results, with
malunions in more than 20 of dorsal angulation dis-
playing impairment of grip strength and endurance.
The wrist tolerates radial shortening poorly, with
2.5mm of shortening increasing the loading of the dis-
tal ulna from 18 to 42% of the total load [28, 50, 52]
(see Table1.1).
On the PA radiograph, radial inclination and ulnar
variance should be measured with relation to a central
reference point on the ulnar border of the radial articu-
lar surface, to allow for changes of position in the dor-
sal and volar ulnar corners in angulated fractures [42]
(Fig.1.1). The adequacy of a lateral radiograph can be
assessed by the relation of the pisiform to the scaphoid.
In a true lateral view, the pisiform overlaps the distal
pole of the scaphoid, but in relative pronation or supi-
nation this relationship is disrupted [42]. The attain-
ment of a true lateral view is essential, as this has a
significant effect on radial and carpal alignment mea-
surements [8]. Standard PA and lateral views may be
supplemented by further useful views. Allowing for
the normal 2223 radial articular inclination, a radio-
graph taken with the forearm inclined 2025 in a
radial direction will show a true lateral view of the
articular surface [39]. Medoff further recognized the
relevance of a 10 radial inclination of the ulnar two-
thirds of the articular surface, and advocates a 10 lat-
eral view to profile the lunate facet [42]. Oblique PA
radiographs in partial pronation and supination further
3
Fig.1.1 Measurement of the radial inclination and ulnar vari-
ance in relation to the central reference point on the ulnar border
of the radius. This point reduces variations with excessive dorsal
or volar tilt of the distal fragment
display the dorsal lunate fossa and radial styloid,
respectively (Figs.1.2 and 1.3).
Fracture Characteristics
Extra-articular fractures of the distal radius do not
involve the radiocarpal or radioulnar joint surfaces;
however, the importance of optimal management should
not be underestimated. There still exists a potential for
gross anatomical derangement, malunion and func-
tional deficit. The presence of the metaphyseal com-
minution and the initial displacement of the fracture
aid the selection of the treatment modality due to frac-
ture instability. If these fractures are displaced, the dis-
tal radioulnar joint is likely to be injured.
Involvement of the articular surface is an important
fracture characteristic, as incongruity of the joint surface
can adversely affect outcome [29]. Patients must be
counselled appropriately regarding the risk of degenera-
tive arthritis [18, 29]. Knirk and Jupiter studied 43 intra-
articular fractures for a mean of 6.7 years using plain
radiographs, and found radiographic evidence of arthri-
tis in 91% of those with residual articular incongruity,
but only 11% of those who healed with a congruous
articular surface [29]. Plain radiographs should be scru-
tinized for fracture lines extending into the radiocarpal
or radioulnar joints, and CT (computed tomography)
examination undertaken if the surgeon considers it
will aid in treatment. Melone proposed that the radial
4 G. I. Bain

Fig.1.2 Normal PA, pronated oblique and lateral radiographs

Fig.1.3 PA, oblique and lateral radiographs showing a comminuted intra-articular fracture. The oblique view shows displacement
of the dorsal ulnar corner fragment
1 Pre-Operative Assessment in Distal Radius Fractures 5

Fig.1.4 Fragment classifica-

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

articular surface fractures into three predictable frag-

ments, including the radial styloid, palmar medial and
dorsal medial fragments [43]. In forming the lunate fossa
and distal radioulnar joint, the importance of the two
medial fragments for articular function is highlighted. If
present, anatomical reduction of these two fragments is
critical to outcome. In complex fracture fixation, their
reduction early in the procedure can form a cornerstone
from which other regions are reconstructed. Melone also
introduced a classification with five subtypes, impor-
tantly recognizing that fragment location and malrota-
tion may contribute to fracture instability and inability to
be reduced by closed means [4345]. Medoff introduced
additional concepts regarding articular fragmentation
patterns, including the common central articular frag-
ments and dorsal wall fragment [42] (Fig.1.4). A key
Fig.1.5 Axial distal radius illustration with major radiocarpal
concept regarding articular fractures is that each articular and radioulnar ligament attachment regions. A: TFCC attach-
rim fragment should have an intact radiocarpal or radi- ment to sigmoid notch. B: Radioscapholunate mesentery attach-
oulnar ligamentous attachment. These ligaments not ment. C: Extremely elastic dorsal wrist joint capsule attachment.
The articular surface is most likely to fracture between ligamen-
only reinforce their zones of attachment, but also con- tous attachments, in regions A, B and C
tribute to fracture location via avulsion mechanisms,
leading to the common fragmentation patterns described
by Melone and Medoff (Fig.1.5). These fracture pattern Current recommendations for fracture reduction
models are a useful guide in the majority of injuries. include an intra-articular step of 2 mm or more [22,
Recent work by the authors of this chapter has shown 29]; however, nil displacement is desirable in younger
that, at the rim of the distal radius, fracture lines are most and highly functioning individuals [64]. Central articu-
likely to propagate in the interval between ligamentous lar depressed fragments signify a need for open reduc-
attachments. The ligaments seemingly reinforce the tion. They are unlikely to be amenable to closed
skeleton. However, a fracture line may be present in any treatment as there are no ligamentous attachments to
location on the articular surface, particularly in high- these fragments to allow successful reduction by liga-
energy comminuted injuries where high-quality imaging mentotaxis. Despite the suitability of the volar locking
is required to properly define an individual fracture. plate in the majority of cases requiring internal fixation,
6 G. I. Bain
including those with the familiar dorsal metaphyseal
comminution, dorsal and dual approaches are still
required for anatomical reduction in some cases. The
presence of dorsal shear fragments may necessitate
dorsal plating. A potential need for dorsal plate posi-
tioning should be considered pre-operatively, and the
patient specifically counselled regarding future plate
removal and the possibility of extensor tendon irritation
or rupture. In some cases of severe fracture comminu-
tion, a distal radius fracture may be unreconstructable,
and a bridging external fixator or primary wrist arthro-
desis may be considered.
The common radial styloid fragment often includes
the terminal fibres of the brachioradialis insertion [42].
This muscle acts as a significant deforming force in
fractures of the distal radius, and particularly on the
radial styloid fragment when present [30, 56]. In oper-
ative open reductions, this tendon may need to be
released or lengthened [30, 49].
Ulnar styloid fractures are a common accompani-
ment to distal radial fractures, occurring in up to 70% of
cases [20, 36]. Nonetheless, injuries to the distal radi-
oulnar joint or triangular fibrocartilage complex can be
difficult to recognize on plain radiographs, with the
potential for chronic pain and instability [29, 37]. Basal
ulnar styloid fractures are more likely than small avul-
sion fractures near the distal tip to result in DRUJ insta-
bility [37]. Whereas some authors recommend internal
fixation of basal styloid fractures or splintage in the
position of maximal stability, there is some evidence to
suggest that these extra measures will not affect the
eventual outcome. A recent large multi-centre study has
concluded that the association of a basal ulna styloid
fracture has no bearing on the outcome following distal
radius fracture even when initially displaced more than
2mm [60]. This study has some limitations inherent in
the design, in particular that DRUJ instability was not
reproducibly assessed, and therefore the conclusions
may be open to challenge. Pain often prevents timely
clinical testing of the DRUJ pre-operatively or in those
cases treated non-operatively. However, following
internal fixation of a distal radius fracture, DRUJ sta-
bility should be routinely tested and documented.
Closed manipulation and repeat radiographic or
fluoroscopic examination may further guide treatment.
The success of reduction manoeuvers and fracture sta-
bility may be judged by these methods if doubt exists,
and progression to more invasive fixation performed if
necessary.
Associated injuries to the DRUJ, carpal bones and
ligaments, or elbow region should be defined, and an
appropriate management plan devised. High-energy
fractures in particular have an elevated risk of concurrent
injuries to both local and remote regions of the limb.
Fracture Stability
The stability of a wrist fracture refers to its capacity to
withstand displacement following manipulation into
an anatomic position. Numerous factors contribute to
this, including bone quality, initial fracture displace-
ment, comminution and the amount of energy applied
to the wrist at the time of injury. Closed manipulation
and cast application is often valuable in the acute pre-
sentation of grossly displaced fractures. In some cases,
it may be the only treatment that is required; however,
judgement should be based on the patient characteris-
tics and an assessment of fracture stability.
Numerous authors have further quantified the fac-
tors leading to fracture instability. Mackenney and co-
workers examined factors contributing to early or late
instability, dependent on the presence of fracture dis-
placement at presentation. In fractures minimally dis-
placed at presentation, they discovered significant
risks of early or late instability with age >80 years, any
form of comminution, positive ulnar variance and dor-
sal angulation of 510 [40]. Overall, similar factors
were relevant to fractures displaced at the time of pre-
sentation. Assessment should be made of the radiocar-
pal 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 intra-
articular 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
4mm of shortening have been reported as indicative of
instability [1, 47].
Medoff recognized the implication of dorsal radio-
carpal instability in the presence of a dorsal wall frag-
ment [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
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-
fragments and CT requested if necessary to exclude
radiocarpal subluxation. These fragments will require
anatomical reduction if displaced.
The extent of metaphyseal comminution is impor-
tant 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 osteo-
porotic bone not only lacks intrinsic structure but is
less likely to successfully hold Kirshner wires and
other forms of internal fixation. Conversely, high-
energy injuries in good quality bone may have a simi-
lar 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
7
mon avulsion fracture of the ulnar styloid tip, most likely of no
consequence
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 coun-
selling patients on risk of loss of reduction if closed
means are chosen. Serial plain radiographs are routinely
performed within 12 weeks following a closed manip-
ulation 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 radio-
graphs to determining articular incongruity, with poor
intra-observer and inter-observer reliability [10, 33].
8 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 etal. analyzed 18 fractures pre-operatively, and
showed that CT was better than plain radiographs at
demonstrating involvement of the DRUJ, central artic-
ular depression and fracture comminution [54]. Central
articular die punch fragments are particularly diffi-
cult 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 etal. revealed that
three-dimensional reconstructions of CT images with
subtraction of the carpal bones can further aid in frac-
ture visualization [23].
Small displaced or rotated fragments may be rele-
vant to the treatment of a particular injury. For exam-
ple, the presence of an ulno-palmar rim fragment can
signify short radiolunate ligament avulsion and resul-
tant volar carpal instability [3] (Fig.1.4). The size and
location of fracture fragments identified on axial, coro-
nal and sagittal CT images thus may influence the sur-
gical approach and the fixation method. Some surgeons
advocate mapping around fracture fragments on pre-
operative radiographs to plan a reduction. CT is more
reliable for this, but the benefits must be weighed
1 Pre-Operative Assessment in Distal Radius Fractures
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 etal. 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
9
lunate facets are associated with high rates of scapholu-
nate 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 com-
plete 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 fr 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 lim-
its its daily use.
Most useful for daily management is the use of basic
fracture description. There will rarely be confusion if
10
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 non-
orthopaedic physicians. Still in routine use are numer-
ous eponymous terms, including Colles, Smiths and
Bartons 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 pub-
lished, 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 sim-
pler low-energy injuries and is not useful in determin-
ing 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, includ-
ing 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 con-
tained 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 valu-
able in assessing fractures involving the articular sur-
face. Recognition of common articular fragmentation
patterns and instability features can aid treatment choice
to prevent poor outcomes due to malunion or degener-
ate 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.
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 Portals and Methodology
2
David J. Slutsky

Introduction also resulted in improved wrist extension (77 vs. 69)

and wrist flexion (78 vs. 59) [18]. The following
chapter will discuss the portal placement and method-
Wrist arthroscopy has steadily grown from a mostly
ology of wrist arthroscopy along with its application in
diagnostic tool to a valuable adjunctive procedure in
the treatment of distal radius fractures.
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 Relevant Anatomy
percutaneous techniques. Many studies have demon-
strated the superiority of an arthroscopic-assisted
The standard portals for wrist arthroscopy are mostly
reduction of a displaced intraarticular fracture over a
dorsal. This is in part due to the relative lack of neuro-
fluoroscopic reduction which has been shown to cor-
vascular structures on the dorsum of the wrist as well
relate with improved wrist motion and grip strength.
as the initial emphasis on assessing the volar wrist
Doi and coworkers performed a prospective study
ligaments. The dorsal portals which allow access to the
comparing 34 intraarticular distal radius fractures
radiocarpal joint are so named in relation to the ten-
treated with arthroscopic reduction, pinning (ARIF),
dons of the dorsal extensor compartments. For exam-
and external fixation vs. 48 fractures treated with open
ple, the 12 portal lies between the first extensor
plate fixation (ORIF) or with pinning external fixation.
compartment tendons which include the extensor pol-
At an average follow-up of 31 months, the ARIF group
licus brevis (EPB) and the abductor pollicus longus
had significantly better ranges of flexion-extension,
(APL), and the second extensor compartment which
radial-ulnar deviation, and grip strength (p<0.05).
contains the extensor carpi radialis brevis and longus
Radiographically, the ARIF group had better reduction
(ECRB/L). The 34 portal is named for the interval
of volar tilt, ulnar variance, and articular gap reduction
between the third dorsal extensor compartment which
[8]. Ruch etal. compared the functional and radiologic
contains the extensor pollicus longus tendon (EPL)
outcomes of arthroscopically-assisted (AA) percutane-
and the fourth extensor compartment which contains
ous pinning and external fixation vs. fluoroscopically-
the extensor digitorum communis (EDC) tendons. In a
assisted (FA) pinning and external fixation of 30
similar vein, the 45 portal is located between the EDC
patients with comminuted intraarticular distal radius
and the extensor digiti minimi (EDM). The 6R portal
fractures. Patients who underwent AA surgery had sig-
is located on the radial side of the extensor carpi ulnaris
nificantly improved supination compared with those
(ECU) tendon as compared to the 6U portal which is
who underwent FA surgery (88 vs. 73). AA reduction
located on the ulnar side (Fig.2.1ac).
The midcarpal joint is assessed through two portals,
which allow triangulation of the arthroscope and the
D. J. Slutsky, MD, FRCS(C)
The Hand & Wrist Institute, 2808, Columbia Street,
instrumentation. The midcarpal radial portal (MCR) is
Torrance, CA 90503, USA located 1 cm distal to the 34 portal and is bounded
e-mail: d-slutsky@msn.com radially by the ECRB and ulnarly by the EDC. The

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 13

DOI: 10.1007/978-3-642-05354-2_2, Springer-Verlag Berlin Heidelberg 2010
14
a b
Fig.2.1 Dorsal portal anatomy. (a) Cadaver dissection of the
dorsal aspect of a left wrist demonstrating the relative positions
of the dorsoradial portals. EDC extensor digitorum communis;
EPL extensor pollicus longus; SRN superficial radial nerve.
ulnar midcarpal portal (MCU) is similarly located
112cm distal to the 45 portal and is bounded by the
EDC and the EDM.
The relative safety of the portals has been studied by
the way of cadaver dissection. Although some artifact
is inescapable due to the displacement of neurovascular
structures postmortem, this research provides some
useful guidelines. In the clinical situation, distortion of
the topographical anatomy due to fracture/dislocation
or swelling as well as the use of intraoperative traction
may increase the potential for harm; hence, a standard-
ized method for establishing each portal is useful.
Dorsal Portals
Dorsal Radiocarpal Portals
Abrams and coworkers performed anatomical dissec-
tions on 23 unembalmed fresh cadaver extremities
andmeasured the distances between the standard dor-
sal portals and the contiguous neurovascular structures
[1]. The 12 portal was found to be the most perilous.
The radial sensory nerve exits from under the brachio-
radialis approximately 5 cm proximal to the radial
D. J. Slutsky
c
Listers tubercle=asterisk. (b) Relative positions of the dorsoul-
nar portals. EDM extensor digiti minimi; DCBUN dorsal cutane-
ous branch of the ulnar nerve. (c) Positions of the 6R and 6U
portals (Copyright by Dr. Slutsky [23])
styloid and bifurcates into a major volar and a major
dorsal branch at a mean distance of 4.2cm proximal to
the radial styloid [24]. Branches of the superficial
radial nerve (SRN) that were radial to the portal were
within a mean of 3 mm (range 16 mm), whereas,
branches that were ulnar to the portal were at a mean
of 5mm (range 212mm) (Fig.2.2). The radial artery
was found at an average of 3mm radial to the portal
(range 15mm). Up to 75% of the time, there occurs
either partial or complete overlap of the lateral ante-
brachial cutaneous nerve (LABCN) with the SRN[13].
In an anatomical study by Steinberg etal., the LABCN
was present within the anatomic snuffbox in 9 of 20
Fig. 2.2 Branches of the superficial radial nerve (SRN). SR1
minor dorsal branch; SR2 major dorsal branch; SR3 major pal-
mar branch (Copyright by Dr. Slutsky [23])
2 Portals and Methodology 15

(45%) specimens. Based on these findings, they rec-

ommended a more palmar, proximal portal in the
snuffbox that was no more than 4.5 mm dorsal to
the first extensor compartment and within 4.5mm of
the radial styloid [24].
Branches of the SRN that were radial to the 34
portal were located at a mean distance of 16 mm
(range, 522mm). In one specimen, an ulnar branch of
the SRN was found 6mm ulnar to the portal. The dis-
tance to the radial artery was a mean of 26.3mm (range
2030 mm). Sensory nerves were remote to the 45 Fig.2.3 View of the ulnar aspect of a left wrist demonstrating
the relative positions of the triquetro-hamate (TH) portal and the
portal, except in one case, where an aberrant SRN 6U portal. DCBUN dorsal cutaneous branch of the ulnar nerve;
branch was found 4mm radial to the portal. UN ulnar nerve (Copyright by Dr. Slutsky [23])
The dorsal cutaneous branch of the ulnar nerve
(DCBUN) arises from the ulnar nerve on an average of
both ulnar and distal to the MCU. Branches of the
6.4cm (SD=2.3cm) proximal to the ulnar head and
DCBUN are most at risk (Fig.2.3).
becomes subcutaneous 5cm proximal to the pisiform.
It crosses the ulnar snuffbox and gives off 39 branches
that supply the dorsoulnar aspect of the carpus, small
finger, and ulnar ring finger [4]. The mean distance of Dorsal Radioulnar Portals
the DCBUN to the 6R portal was 8.2 mm (range
014mm). Transverse branches of the DCBUN were
These portals lie between the ECU and the EDM ten-
found in 12/19 specimens and were noted to be within
dons. Transverse branches of the DCBUN were the
2mm of the portal (range 06mm). The mean distance
only sensory nerves in proximity to the dorsal radioul-
of the branches of the DCBUN that were radial to the
nar portal at a mean of 17.5 mm distally (range
6U portal was 4.5 mm (range 210 mm), while
1020mm) (Fig.2.4a).
branches that were ulnar to the portal ranged from 1.9
to 4.8mm on an average. Any transverse branches of
the DCBUN were generally proximal to the portal at
an average of 2.5mm. Volar Portals

Volar Radial Portal

Dorsal Midcarpal Portals
Branches of the SRN were found radial to the MCR
portal at a mean of 7.2mm (range 212mm; SD=2.7)
Two specimens contained SRN branches ulnar to the
portal at 2 and 4mm. Branches of the SRN were gener-
ally remote from the MCU portal except in one speci-
men (1mm). Branches of the DCBUN were found at a
mean distance of 15.1mm (range 025mm; SD=4.6).
Triquetro-Hamate (TH) Portal
This portal enters the midcarpal joint at the level of the
TH joint ulnar to the ECU tendon. The entry site is
An anatomic study was performed on five fresh frozen
cadaver arms to determine the safe landmarks for a
volar radial (VR) portal after arterial injection studies
to highlight the vascular anatomy [20]. The proximal
and distal wrist creases were marked. The volar skin
was then removed and the flexor carpi radialis tendon
(FCR) sheath was divided. The tendon was retracted
ulnarly and a trochar was inserted into the radiocarpal
joint at the level of the proximal wrist crease. The tro-
char was noted to enter the radiocarpal joint between
the radioscaphocapitate ligament (RSC) and the long
radiolunate ligament (LRL) in four specimens and
through the LRL ligament in one specimen. The
median nerve was 8mm (610mm) ulnar to the VR
portal, while the palmar cutaneous branch passed
16 D. J. Slutsky

Fig.2.4 Dorsal DRUJ portal

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

4mm (35mm) ulnar to the portal. The radial artery
was 5.8mm (46mm) radial to the portal and its super-
ficial palmar branch was located 10.6mm (616mm)
distal to the portal. The SRN lay 15.6mm (1219mm)
radial to the portal. The portal was 12.8 mm (12
14mm) distal to the border of the pronator quadratus,
which roughly corresponds to the palmar radiocarpal
arch [9]. The palmar cutaneous branch was the closest
in proximity but always lies to the ulnar side of the
FCR [5, 14]. The superficial palmar branch of the
radial artery passed through the subcutaneous tissue
over the tuberosity of the scaphoid and was out of
harms way with an incision at the proximal wrist
crease [10, 17]. When the trochar was placed through
the floor of the FCR tendon sheath at the proximal pal-
mar crease, the carpal canal was not violated. It was
thus apparent that there was a safe zone comprising the
width of the FCR tendon plus at least 3mm or more in
all directions, that was free of any neurovascular
structures.
Volar Radial Midcarpal (VRM) Portal
The volar aspect of the midcarpal joint was identified
with a 22 gauge needle through the same skin incision
and a blunt trochar was inserted. It was necessary to
angle the trochar in a distal and ulnar direction
(approximately 5) in order to access the midcarpal
joint through the same skin incision. The trochar
passed closer but still deep to the superficial palmar
branch of the radial artery, which coursed more super-
ficially over the scaphoid tuberosity at that level. The
distance between the volar radiocarpal and volar mid-
carpal entry sites averaged 11mm (712mm).
Volar Ulnar Portal
In a companion study, a volar ulnar (VU) portal was
established via a 2cm longitudinal incision made along
the ulnar edge of the finger flexor tendons at the proxi-
mal wrist crease [22]. The flexor tendons were retracted
radially and a trochar was introduced into the radiocar-
pal joint. The ulnar styloid marked the proximal point
of the VU portal, approximately 2 cm distal to the
pronator quadratus. The portal was in the same sagittal
plane as the ECU subsheath and penetrated the ulnolu-
nate ligament (ULL) adjacent to the radial insertion of
the triangular fibrocartilage. The ulnar nerve and artery
were generally more than 5mm from the trochar, pro-
vided the capsular entry point was deep to the ulnar
edge of the profundus tendons. The palmar cutaneous
branch of the ulnar nerve (nerve of Henl) was highly
variable and not present in every specimen. This incon-
stant branch provides sensory fibers to the skin in the
2 Portals and Methodology 17

distal ulnar and volar part of the forearm to a level of
3cm distal to the wrist crease. Its territory may extend
radially beyond the palmaris longus tendon [3]. This
branch tends to lie just to the ulnar side of the axis of
the fourth ray, but it was absent in 43% of specimens in
one study [15]. Martin et al. demonstrated that there
was no true internervous plane due to the presence of
multiple ulnar-based cutaneous nerves to the palm,
which puts them at risk with any ulnar incision [14].
Since there is no true safe zone, careful dissection and
wound spread technique should be observed.
Volar Distal Radioulnar (VDRU) Portal [21]
The topographical landmarks and establishment of the
portal are identical to those of the VU portal. The same
risks also apply. The capsular entry point for the VDRU
lies 5 mm to 1 cm proximal to the ulnocarpal entry
point (Fig.2.5a, b).
Field of View
The following describes the typical field of view as
seen through a 2.7mm arthroscope under ideal condi-
tions. Synovitis, fractures, ligament tears, and a tight
wrist joint may limit the field of view which necessi-
tates the use of more portals to adequately assess the
entire wrist [19].
12 portal: Structures visualized are limited to the
radial aspect of the wrist.
Radius: scaphoid and lunate fossa, dorsal rim of radius.
Carpus: proximal and radial scaphoid, proximal lunate.
Volar capsule: oblique views of the radioscaphocapi-
tate (RSC) ligament, long radiolunate ligament (LRL),
short radiolunate ligament (SRL).
Dorsal capsule: oblique views of the dorsal radiocarpal
ligament (DRCL).
TFC: poorly visualized.
34 portal: almost a complete panoramic view of the
entire volar radiocarpal joint
Radius: scaphoid and lunate fossa, volar rim of radius.
Carpus: proximal scaphoid and lunate, dorsal and mem-
branous scapholunate interosseus ligament (SLIL).
Volar capsule: RSC, radioscapholunate ligament (RSL),
LRL, ulnolunate ligament (ULL).
Dorsal capsule: oblique views of the DRCL insertion
onto the dorsal SLIL.
TFC: radial insertion, central portion, ulnar attach-
ment, palmar and dorsal radioulnar ligaments (PRUL,
DRUL), prestyloid recess pisotriquetral orifice.
45 portal: this portal gives improved views of the
ulnar aspect of the radiocarpal joint including TFCC

a b

Fig.2.5 Volar DRUJ portals.

(a) Volar aspect of a left wrist
demonstrating the relative
positions of the VU and volar
DRUJ (VDR) portals in
relation to the ulnar
nerve(asterisk) and ulnar
artery (UA). FDS flexor
digitorum sublimus; FCU
flexor carpi ulnaris. (b) Close
up view after the volar capsule
is removed showing position
of needles in relation to the
volar radioulnar ligament
(asterisk). Tr triquetrum; UH
ulnar head (Copyright by
Dr.Slutsky [23])
18
and is useful for instrumentation when combined with
the 6R.
Radius: lunate fossa, volar rim of radius.
Carpus: proximal lunate, triquetrum, dorsal and mem-
branous lunotriquetral ligament (LTIL).
Volar capsule: RSL, LRL, ULL.
Dorsal capsule: poorly seen.
TFC: radial insertion, central portion, ulnar attach
ment, PRUL, prestyloid recess pisotriquetral
orifice.
6R portal: This gives a more direct line of sight with
the dorsal LTIL and is typically used for instrumenta-
tion or outflow.
Radius: poorly seen.
Carpus: proximal lunate, triquetrum, dorsal and mem-
branous LTIL.
Volar capsule: ULL and ulnotriquetral ligament (UTL).
Dorsal capsule: poorly seen.
TFC: radial insertion, central portion, ulnar attachment,
PRUL, prestyloid recess pisotriquetral orifice.
6U portal: This is also mostly used for outflow, but it
is also useful for instrumentation for debridement
of palmar LTIL tears in combination with the VU
portal.
Radius: sigmoid notch.
Carpus: proximal triquetrum, membranous LTIL.
Volar capsule: oblique views of the ULL and ULT.
Dorsal capsule: oblique views of the DRCL
TFC: dorsal rim and radial attachment.
VR portal: This portal is mostly indicated to assess the
palmar SLIL and the DRCL. It is also of use for AA
fixation of distal radius fractures due to the direct line
of sight with the dorsal rim fragments [8].
Radius: scaphoid and lunate fossa, dorsal rim of
radius.
Carpus: proximal palmar scaphoid and lunate, palmar,
and membranous SLIL.
Volar capsule: oblique views of the RSL, LRL, ULL.
Dorsal capsule: direct in-line views of the DRCL.
TFC: oblique views of the radial insertion, central por-
tion, ulnar attachment, PRUL and DRUL.
VU portal: This portal is mostly indicated to assess
the palmar LTIL and the dorsal ulnar capsule. It is
also of use for debridement of palmar LTIL tears.
Radius: sigmoid notch region of lunate fossa.
Carpus: proximal palmar lunate and triquetrum, pal-
mar and membranous LTIL.
Volar capsule: poorly seen.
D. J. Slutsky
Dorsal capsule: direct in-line views of the dorsoulnar
capsule including the ECU subshetah.
TFC: radial insertion, central portion, ulnar attach-
ment, DRUL.
Radial Midcarpal Portal
Volar: continuation of the RSC ligament.
Radial: scaphotrapezial-trapezoidal (STT) joint and
distal scaphoid pole.
Proximal: SLIL joint, LTIL joint, distal scaphoid, dis-
tal lunate.
Distal: proximal capitate, capitohamate ligament,
oblique views of proximal hamate.
Ulnar Midcarpal Portal
Volar: continuation of the volar ulnocarpal ligament
(important in midcarpal instability).
Radial: distal articular surface of the lunate and tri-
quetrum and partial scaphoid.
Proximal: LTIL joint, SLIL joint.
Distal: proximal hamate, capitohamate ligament,
oblique views of proximal capitate.
Dorsal DRUJ Portals: Proximal and Distal
Volar: palmar radioulnar ligament
Radial: sigmoid notch, radial attachment of TFC
Ulnar: limited view of DRUL
Distal: proximal surface of articular disc (AD)
Volar DRUJ Portal
Volar: DRUL
Radial: sigmoid notch, radial attachment of TFC
Ulnar: foveal attachment of deep fibers of TFCC
Distal: proximal surface of AD
Methodology: Diagnostic Survey
The patient is positioned supine under general anes-
thesia with the arm abducted under tourniquet control.
A 2.7 mm 30 angled scope along with a camera
2 Portals and Methodology
attachment is used along with some method of over-
head traction. The structures that should be visualized
as a part of a standard exam include the radius articu-
lar surface, the proximal scaphoid and lunate, the volar
carpal ligaments, the scapholunate (SLIL) and lunotri-
quetral (LTIL) interosseous ligaments, and the trian-
gular fibrocartilaginous complex (TFCC). It is the
authors practice to establish the dorsal portals first
and then start the arthroscopic examination with the
VR portal in order to visualize the palmar SLIL and
the DRCL to minimize artifact secondary to iatrogenic
trauma to the dorsal capsular structures. The VU por-
tal is utilized to assess the palmar LTIL and DRUL,
ECU subsheath and radial TFCC attachment. The
scope is then inserted in the 34 portal followed by
various combinations of the 45 portal and 6R portal.
The 6U portal is mostly used for outflow, but it may be
used for instrumentation when debriding palmar LTIL
tears. Midcarpal arthroscopy is performed next to
assess the integrity of the intercarpal ligaments and
toinspect for chondral lesions or loose bodies in the
midcarpal joint. The special use portals such as the
dorsal and volar distal radioulnar joint (DRUJ) portals
and the 12 portal are used as needed.
34 Portal
The surgeon is initially seated facing the dorsal surface
of the wrist. The concavity overlying the lunate
between the EPL and the EDC is located just distal to
Listers tubercle, in line with the second webspace.
The radiocarpal joint is identified with a 22 gauge nee-
dle that is sloped 10 palmar to account for the volar
inclination of the radius. The joint is injected with
5 mL of saline. A shallow skin incision is made to
avoid injuring small branches of the SRN or superficial
veins. Tenotomy scissors or blunt forceps are then used
to spread the soft tissue and pierce the dorsal capsule.
This technique is repeated for each portal. The vascu-
lar tuft of the RSL is directly in line with this portal.
Superior to the RSL is the membranous portion of the
SLIL. The insertion of the dorsal capsular attachment
can often be visualized by rotating the scope dorsally
while looking ulnarwards. The radioscapholunate
(RSL) and LRL are radial to the portal and can be
probed with a hook in the 45 portal. The SRL, TFCC
and ulnolunate (ULL) and ulnotriquetral (ULT) liga-
ments are ulnar to the portal.
19
45 Portal
The interval for the 45 portal is identified with a 22
gauge needle inserted between the EDC tendons and
the EDM, in line with the ring metacarpal. Due to the
normal radial inclination of the distal radius, this portal
lies slightly proximal and about 1cm ulnar to the 34
portal. Views of the ulnar half of the lunate are obtained
by moving the scope radially, whereas the triquetrum
is seen by angling the scope in a superior and ulnar
direction. The LTIL is often difficult to differentiate
from the carpal bones without probing. The ULL and
ULT can be seen on the far end of the joint. Proximally,
the radial insertion of the TFCC blends imperceptibly
with the sigmoid notch of the radius, but it can be pal-
pated with a hook probe in either the 34 or 6R portal.
The peripheral insertion of the TFCC slopes upwards
into the ulnar capsule. The volar and DRULs can be
probed for laxity/tears, but they are not seen as distinct
structures since they blend with the TFCC. The pisotri-
quetral orifice (PTO) is just distal and anterior to the
prestyloid recess and is found within the substance of
the ULT just anterior to the proximal articular surface
of the triquetrum.
6R, 6U Portals
The 6R portal is identified on the radial side of the
ECU tendon, just distal to the ulnar head. The scope
should be angled 10 proximally to avoid hitting the
triquetrum. The TFCC is immediately below the entry
site. The LTIL is located radially and superiorly,
whereas the ulnar capsule is immediately adjacent to
the scope. The 6U portal is located ulnar to the ECU
tendon. This portal can be used to view the dorsal rim
of the TFCC or for instrumentation when debriding the
palmar LTIL.
Midcarpal Portals
The midcarpal radial (MCR) portal is found 1cm distal
to the 34 portal. The (STT) joint lies radially and can
be seen by rotating the scope dorsally. The scapholunate
(SL) articulation which is proximal to this portal can be
probed for instability or step-off. By moving the scope
in an ulnar direction, the lunotriquetral (LT) articulation
20
comes into view. Superiorly, the proximal surface of the
capitate, the interosseous ligament, and the hamate are
seen. The midcarpal ulnar (MCU) portal is located 1cm
distal to the 45 portal or 1.5cm ulnar and slightly prox-
imal to the MCR portal, in line with the ring metacarpal
axis. Normally, there is very little step-off between the
distal articular surfaces. When there is any doubt, the
traction should be released and the SL joint should
beviewed with the scope in the MCU, whereas the LT
joint should be viewed with the scope in the MCR.
Volar Portals
To establish the VR radial portal, the surgeon is seated
facing the volar aspect of the wrist. A 2cm transverse
or longitudinal incision is made in the proximal wrist
crease overlying the FCR tendon. It is not necessary to
specifically identify the adjacent neurovascular struc-
tures, provided the anatomical landmarks are adhered
to. The tendon sheath is divided and the FCR tendon is
retracted ulnarly. The radiocarpal joint space is identi-
fied with a 22 gauge needle and distended with 5mL
of saline. Tenotomy scissors or forceps are used to
pierce the volar capsule. A blunt obturator and trochar
are then introduced followed by the arthroscope. The
midcarpal joint can be accessed through the same skin
incision by angling the trochar 1 cm distally and
approximately 5 ulnarwards. A hook probe is inserted
through the 34 portal and it is used to assess the pal-
mar aspect of the SLIL and the DRCL. A useful land-
mark when viewing from the VR portal is the intersulcal
ridge between the scaphoid and lunate fossae. The
a b
Fig.2.6 Technique for VU portal. (a) Skin incision for VU por-
tal. FCR flexor carpi radialis tendon; FDS flexor digitorum sub-
limus. (b) FDS retracted, saline injection of radiocarpal joint. (c)
D. J. Slutsky
origin of the DRCL is seen immediately ulnar to this
ridge, just proximal to the lunate. The VU portal is
established via a 2 cm longitudinal incision centered
over the proximal wrist crease along the ulnar edge of
the finger flexor tendons. The tendons are retracted to
the radial side and the radiocarpal joint space is identi-
fied with a 22 gauge needle (Fig.2.6ac). Blunt teno-
tomy scissors or forceps are used to pierce the volar
capsule, followed by insertion of a cannula and blunt
trochar, then the arthroscope. The ulnar nerve is pro-
tected by use of the cannula and a more radial entry
site. The median nerve is protected by the adjacent
flexor tendons. The palmar region of the LTIL can usu-
ally be seen slightly distal and radial to the portal. A
hook probe is inserted through the 6R or 6U portal.
DRUJ Portals
The dorsal aspect of the DRUJ joint can be accessed
through a proximal and distal portal. The proximal
portal is mostly for outflow and can be identified by
inserting a 22 gauge needle horizontally at the neck of
the distal ulna. The distal portal (DDRUJ) is identified
just proximal to the 6R portal, underneath the DRUL.
This portal can be used for outflow drainage or for
instrumentation. It lies on top of the ulnar head, but
underneath the TFCC.
The topographical landmarks and establishment of
the VDRU portal are identical to those of the VU portal.
The capsular entry point lies 510mm proximally [21].
There is more room on the volar ulnar aspect of the
DRUJ for the insertion of an arthroscope with relatively
c
Insertion of cannula through capsule deep to FDS tendons
(Copyright by Dr. Slutsky [23])
2 Portals and Methodology
unimpeded views of the proximal articular disk and
thefoveal attachments. The VDRU portal is accessed
through the VU skin incision. A 1.9 mm small joint
arthroscope can be used since gaining access to the
DRUJ can be difficult, especially in a small wrist, but a
standard 2.7mm scope provides a better field of view.
It is useful to leave a needle or cannula in the ulnocarpal
joint for reference. The DRUJ is located by angling a
22gauge needle 45 proximally, and then injecting the
DRUJ with saline. Once the correct plane is identified,
the volar DRUJ capsule is pierced with tenotomy scis-
sors followed by a cannula with a blunt trochar and then
the arthroscope. Alternatively, a probe can be placed in
the DDRUJ portal and advanced through the palmar
incision to help locate the joint space. It can then be
used as a switching stick over which the cannula is
introduced. Initially, the DRUJ space appears quite
confined, but over the course of 35min, the fluid irri-
gation expands the joint space, which improves visibil-
ity. Aburr or thermal probe can be substituted for the
3mm hook probe through the DDRUJ as necessary.
Arthroscopic-Assisted Fixation:
Distal Radius
Indications
More than 2mm of articular displacement or gap are
typical indications for surgical treatment. Isolated
radial styloid fractures and simple three-part fractures
are most suited to this technique. Displaced intraartic-
ular fractures of the distal radius are often associated
with unrecognized intraarticular soft tissue injuries
a b
Fig.2.7 Soft tissue injuries
associated with distal radius
fractures. (a) Avulsed
radioscaphocapitate (RSC)
and long radiolunate
ligaments (LRL) viewed from
the 34 portal. (b) Avulsed
ulnolunate ligament
(asterisks) seen from the
45 portal (Copyright by
Dr. Slutsky [23])
21
[11] (Fig.2.7); hence, a suspicion of a significant acute
SLIL or LTIL tear or DRUJ instability due to a sus-
pected TFCC tear are additional indications. Traction
views will help to sort out the fracture anatomy. It is
my preference to perform a CT scan along with coro-
nal views to rule out an unrecognized sagittal split as
well as to assess the congruency of the sigmoid notch.
Contraindications
Large capsular tears which carry the risk of marked fluid
extravasation, active infection, neurovascular compro-
mise, and distorted anatomy are some typical contraindi-
cations. Marked metaphyseal comminution, shear
fractures and a volar rim fractures require open treat-
ment, although the arthroscope can be inserted to check
the adequacy of the joint reduction. Due to the risk of
late collapse, adjuvant internal fixation with locking
plates is advised in elderly and osteopenic patients since
fracture site settling may occur for up to 6 months [7].
Equipment and Implants
Required
In general, a 2.7mm 30 angled scope along with a cam-
era attachment is used. A fiberoptic light source, video
monitor, and printer have become the standard of care.
Digital systems allow direct writing to a CD and supe-
rior video quality as compared to analog cameras. A
3mm hook probe is needed for palpation of intracarpal
22
structures. Some method of overhead traction is useful.
This may include a traction from the overhead lights or
a shoulder holder along with 35 Kgr sand bags attached
to an arm sling. A traction tower such as the Linvatec
tower (Conmed Linvatec Corporation, Largo, FL) or
the ARC traction tower (Arc Surgical LLC, Hillsboro,
OR) greatly facilitates instrumentation. The use of a
motorized shaver or diathermy unit such as the Oratec
probe (Smith and Nephew, NY) is useful for debride-
ment. A motorized 2.9 mm burr is needed for bony
resection. A variety of Steinman pins and small eleva-
tors are useful for the elevation of bony fragments. A
K-wire driver and intraoperative fluoroscopy are integral
to the procedure. A distal radius locking plate set should
be available as per surgeon preference.
Optional
There are a variety of commercially available suture
repair kits including the TFC repair kit by Arthrex (man-
ufacturer) or Linvatec (Conmed Linvatec Corporation).
Ligament repairs can also be facilitated by the use of a
Tuohy needle which is generally found in any anesthesia
cart. Specially designed jigs have been made to facilitate
repair of radial TFC tears although Trumble etal. have
described a method with meniscal repair needles passed
through a suction cannula in the 6U portal [26].
Surgical Technique
Intraoperative fluoroscopy is used frequently through-
out the case, with the C-arm positioned horizontal to
the floor. It is preferable to wait for 35 days to allow
the initial intraarticular bleeding to stop. The author
has found it useful to perform much of the procedure
without fluid irrigation using the dry technique of del
Pial [6] which eliminates the worry of fluid extrava-
sation. If fluid irrigation is used, inflow is through a
large bore cannula in the 45 or 6U portal with the
outflow through the arthroscope cannula. The working
portals include the VR and 6R portal for fracture visu-
alization and the 34 portal for instrumentation but
all of the portals are used interchangeably. Lactated
Ringers solution is preferred over saline, and the fore-
arm is wrapped with coban to limit extravasation. The
D. J. Slutsky
fracture hematoma and debris are lavaged and any
early granulation tissue is debrided with a resector.
Mehta and colleagues described a 5 level algorithm for
reducing the fracture fragments [16]. This included the
London technique where the K-wires were advanced
through the distal ulna into the subchondral distal
radius and withdrawn from the radial aspect so that
they do not encroach on the DRUJ.
Radial Styloid Fractures
It is easiest to obtain the reduction through ligamento-
taxis while the arm is suspended in the traction tower.
A Freer elevator may also be placed in the fracture site
to facilitate this step. A 1cm incision is made over the
styloid to prevent injury to the SRN, and two 1.5mm
K-wires are inserted for manipulation of the styloid
fragment. The fracture site is best assessed by viewing
across the wrist with the scope in the 6R portal, in
order to gauge the rotation of the styloid. The K-wires
are used as joysticks to manipulate the fragment, and
then, one K-wire is driven forward to capture the
reduction. One or two cannulated screws are used to
stabilize the fracture fragment.
Three-Part Fractures
Three-part fractures are comprised of a radial styloid
fragment and a medial or lunate fragment. The radial
styloid fracture is reduced and pinned as above. It is
then used as a landmark to which the depressed lunate
fragment is reduced. An elevator or large pin is inserted
percutaneously to elevate the lunate fragment. Tena
culum forceps with large jaws are used to hold the
reduction and to prevent crushing the SRN. The reduc-
tion is captured with horizontal subchondral K-wires,
stopping short of the DRUJ. It is paramount to bone
graft the metaphyseal defect through a small dorsal
incision to prevent late collapse. The VR portal aids in
the reduction of any dorsal die punch fragments. Once
the reduction has been achieved, some type of neutral-
ization device is desirable such as a bridging external
fixator. More recently, volar locking plates and/or head-
less cannulated screws have been used. It is my prefer-
ence to use a nonbridging external fixator to allow early
wrist motion (The Fragment Specific Fixator, South
Bay Hand Surgery, LLC. Torrance, CA) (Fig.2.8an).
2 Portals and Methodology 23

b d

e f g

h i

Fig.2.8 Arthroscopic-guided pinning and nonbridging external fix-
ation. (a) Comminuted intraarticular distal radius fracture. (b) Lateral
View. (c) Anteroposterior CT view reveals the extent of the intraar-
ticular fragmentation. (d) Lateral CT highlights the small dorsal rim
fragments. (e) Coronal CT view shows the sigmoid notch disruption.
(f) Arthroscopic view of joint surface showing the degree of com-
minution. (g) A percutaneous is inserted through the ulna to capture
and control the medial fragment. (h) Percutaneous reduction of dor-
sal tilt. (i) Fluoroscopic appearance.
24 D. J. Slutsky

j l n

k m

Fig.2.8 (continued) (j) Arthroscopic view following reduction months with restored radial height and tilt. (n) Congruent joint
and pinning. (k) Fluoroscopic view after arthroscopic reduction. space with neutral lateral tilt (Copyright by Dr. Slutsky [23])
(l) Application of nonbridging external fixator. (m) Result at 6

Postoperative splinting in supination in between ther-

apy helps prevent a pronation contracture.

Four-Part Fractures

In four-part fractures, the lunate facet is split into volar

and dorsal fragments. The volarmedial fragment must
usually be reduced through an open incision since
wrist traction rotates this fragment and prevents reduc-
tion by closed means (Fig. 2.9). The radial styloid
fragment is reduced with ligamentotaxis and tempo-
rarily held with K-wires. A standard volar approach or
a limited volar ulnar incision can be made. The volar-
medial fragment is reduced under direct observation
by pinning it back to the shaft and the radial styloid
fragment. A 2.4mm volar locking plate is provision-
ally applied to hold the reduction. The reduction is
checked through the 6R and VR portals. The dorsome-
dial fragment is then elevated back to the radial styloid
and reduced to the volarmedial fragment, which is
Fig. 2.9 Arthroscopic view from the 45 portal of a rotated
volar medial fragment (Copyright by Slutsky [23])
utilized as a landmark. A small locking dorsal plate
can be applied at this point, or alternatively, the distal
screws of the volar plate can be used to lag the volar-
medial and dorsomedial fragments. In this event, one
or more of the distal screws should be placed in a non-
locking fashion to help compress the fragments.
Wiesler et al. however have described a method for
2 Portals and Methodology
treating four-part fractures arthroscopically. After a
Freer elevator is introduced dorsally to disimpact the
fragments, a nerve hook is used to reduce the volar
lunate facet which is then pinned to the radial styloid.
The remaining fragments are reduced with interfrag-
mentary pin fixation, and the reconstructed articular
surface is then pinned to the radial metaphysis [27].
Ulnar Styloid Fractures
Peripheral TFCC tears are assessed arthroscopically. In
a study of arthroscopically-treated distal radius frac-
tures, Lindau found that 10/11 with complete peripheral
TFCC tears had DRUJ instability at the 1 year follow-
up examination compared with 7 of the 32 patients with
only partial or no peripheral tears. Patients with insta-
bility of the DRUJ had a worse Gartland and Werley
wrist score [12]. In this regard, large TFCC tears may
be repaired with open or arthroscopic technique at the
preference of the surgeon. The diagnosis of a foveal
detachment of the deep fibers of the TFCC requires a
high index of suspicion. Arthroscopic confirmation is
difficult, since the fovea cannot be seen through the
standard radiocarpal portals. Berger has described using
a probe to pull on the TFCC in multiple directions in an
attempt to elicit the displacement of the triangular fibro-
cartilage which he believes is indicative of a foveal dis-
ruption [25]. Atzei and Luchetti describe the hook test
which consists of applying traction to the ulnar-most
border of the TFCC with the probe inserted through the
45 or 6-R portal. The test is positive when the TFCC
can be pulled upwards and radially towards the center
of the radiocarpal joint [2]. Basi-ulnar styloid fractures
with initial displacement of more than 2mm should be
repaired if there is residual DRUJ instability following
fixation of the radius. It is my preference to use either
2K-wires with tension band wiring or headless screw
fixation. (see also Chap. 6).
Summary
The use of wrist arthroscopy continues to expand the
indications and treatment options for distal radius
fractures. A systematic approach and a thorough
25
understanding of the topographical and internal
anatomy of the wrist are integral to minimizing com-
plications while maximizing the chances for a suc-
cessful outcome.
References
1. Abrams RA, Petersen M, Botte MJ. Arthroscopic portals of
the wrist: an anatomic study. J Hand Surg [Am]. 1994;19:
9404
2. Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic
foveal repair of triangular fibrocartilage complex peripheral
lesion with distal radioulnar joint instability. Tech Hand Up
Extrem Surg. 2008;12:22635
3. Balogh B, Valencak J, Vesely M, Flammer M, Gruber H,
Piza-Katzer H. The nerve of Henle: an anatomic and immu-
nohistochemical study. J Hand Surg [Am]. 1999;24:
11038
4. Botte MJ, Cohen MS, Lavernia CJ, von Schroeder HP,
Gellman H, Zinberg EM. The dorsal branch of the ulnar
nerve: an anatomic study. J Hand Surg [Am]. 1990;15:
6037
5. DaSilva MF, Moore DC, Weiss AP, Akelman E, Sikirica M.
Anatomy of the palmar cutaneous branch of the median
nerve: clinical significance. J Hand Surg [Am]. 1996; 21:
63943
6. del Pial F, Garcia-Bernal FJ, Pisani D, Regalado J, Ayala
H, Studer A. Dry arthroscopy of the wrist: surgical tech-
nique. J Hand Surg [Am]. 2007;32:11923
7. Dicpinigaitis P, Wolinsky P, Hiebert R, Egol K, Koval K,
Tejwani N. Can external fixation maintain reduction after
distal radius fractures? J Trauma. 2004;57:84550
8. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intra-
articular fractures of the distal aspect of the radius:
arthroscopically assisted reduction compared with open
reduction and internal fixation. J Bone Joint Surg Am. 1999;
81:1093110
9. Gelberman RH, Panagis JS, Taleisnik J, Baumgaertner M.
The arterial anatomy of the human carpus. Part I: the
extraosseous vascularity. J Hand Surg [Am]. 1983;8:
36775
10. Kamei K, Ide Y, Kimura T. A new free thenar flap. Plast
Reconstr Surg. 1993;92:13804
11. Lindau T, Arner M, Hagberg L. Intraarticular lesions in dis-
tal fractures of the radius in young adults. A descriptive
arthroscopic study in 50 patients. J Hand Surg [Br].
1997;22:63843
12. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of
the triangular fibrocartilage complex cause distal radioulnar
joint instability after distal radial fractures. J Hand Surg
[Am]. 2000;25:4648
13. Mackinnon SE, Dellon AL. The overlap pattern of the lat-
eral antebrachial cutaneous nerve and the superficial branch
of the radial nerve. J Hand Surg [Am]. 1985;10:5226
26
14. Martin CH, Seiler JG III, Lesesne JS. The cutaneous
innervation of the palm: an anatomic study of the ulnar and
median nerves. J Hand Surg [Am]. 1996;21:6348
15. McCabe SJ, Kleinert JM. The nerve of Henle. J Hand Surg
[Am]. 1990;15:7848
16. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of
intra-articular fractures of the distal radius. An arthroscopi-
cally-assisted approach. J Bone Joint Surg Br. 2000;82:
7986
17. Omokawa S, Ryu J, Tang JB, Han J. Vascular and neural
anatomy of the thenar area of the hand: its surgical applica-
tions. Plast Reconstr Surg. 1997;99:11621
18. Ruch DS, Vallee J, Poehling GG, Smith BP, Kuzma GR.
Arthroscopic reduction versus fluoroscopic reduction in the
management of intra-articular distal radius fractures.
Arthroscopy. 2004;20:22530
19. Slutsky D. Wrist arthroscopy: portals and procedures. In:
Trumble T (ed). Hand surgery update IV. American Society
for Surgery of the Hand; 2007
20. Slutsky DJ. Wrist arthroscopy through a volar radial portal.
Arthroscopy. 2002;18:62430
D. J. Slutsky
21. Slutsky DJ. Clinical applications of volar portals in
wrist arthroscopy. Tech Hand Up Extrem Surg. 2004;8:
22938
22. Slutsky DJ. The use of a volar ulnar portal in wrist arthros-
copy. Arthroscopy. 2004;20:15863
23. Slutsky DJ. Wrist arthroscopy portals. In: Slutsky DJ,
Nagle DJ, editors. Techniques in hand and wrist arthros-
copy. Amsterdam: Elsevier; 2007
24. Steinberg BD, Plancher KD, Idler RS. Percutaneous
Kirschner wire fixation through the snuff box: an anatomic
study. J Hand Surg [Am]. 1995;20:5762
25. Tay SC, Tomita K, Berger RA. The ulnar fovea sign for
defining ulnar wrist pain: an analysis of sensitivity and spec-
ificity. J Hand Surg [Am]. 2007;32:43844
26. Trumble TE, Gilbert M, Vedder N. Isolated tears of the tri-
angular fibrocartilage: management by early arthroscopic
repair. J Hand Surg [Am]. 1997;22:5765
27. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR.
Arthroscopic management of volar lunate facet fractures of
the distal radius. Tech Hand Up Extrem Surg. 2006;10:
13944.
 Management of Simple Articular Fractures
Ferdinando Battistella
Introduction
Wrist arthroscopy is a continuously expanding field,
bringing up new controversies and challenges.
The use of new portals (both dorsal and volar)
means that the wrist joint can be viewed from virtually
any perspective (box concept). Indications for wrist
arthroscopy continue expanding and include diagnos-
tic and reparative procedures, and more recently,
reconstructive, soft tissue, and bony procedures.
Recent advances in wrist arthroscopic surgery tech-
niques and instrumentation have enabled the surgeon
to improve the treatment of intraarticular distal radius
fractures. The clinical outcome of an intraarticular dis-
tal radius fracture will be affected by the amount of
radial shortening, residual extraarticular angulation,
joint congruity (radiocarpal and ulnocarpal joints), and
associated soft-tissue injuries [6, 17]. Arthroscopic-
assisted treatment of the distal radius fracture will be
useful only if it is able to influence these factors.
The potential advantages of arthroscopic technique
over more traditional techniques include:
1. Accurate assessment of the status of the articular
surface by direct visual inspection, under a bright
light and magnification, which is superior to fluo-
roscopy [1218]. Particularly, rotation of the frac-
ture fragments, which is difficult to judge under
fluoroscopy, may be detected arthroscopically and
corrected.
F. Battistella
Clinical and Research Center of Upper Arm Disease, General
Hospital Legnano, Via Torino 7/a, 20025 Legnano, Milan, Italy
e-mail: ferdy@ferdinandobattistella.it
F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures,
DOI: 10.1007/978-3-642-05354-2_3, Springer-Verlag Berlin Heidelberg 2010
3
2. Identification and repair of chondral and ligamen-
tous lesions, which have been shown to occur with
distal radius fractures.
3. Washing out of fracture hematoma and debris may
allow for improved range of motion [2].
4. Minimally invasive technique causing less tissue
damage (skin, tendons, capsule, and fewer fracture
fragments will be devitalized).
The potential disadvantages of arthroscopic-assisted
management may be that it is technically demanding, and
in some cases, it does not allow for rigid stable fixation.
Fracture Classification
A number of authors have proposed systems for the
classification of fractures of the distal aspect of the
radius, such as the Mayo [3], Melone [13], Fernandez
[7] (Fig. 3.1), and AO classification systems [14]
(Fig.3.2).
They are helpful in describing the fractures but may
not correspond directly to the status of intraarticular
fragments, which is the key information required for
accurate reconstruction of the distal aspect of radius.
A system will be most useful if it can describe the
relative severity of the fracture and the corresponding
treatment options.
In other words, the principal significance of any
classification is to provide guidelines for treatment as
well as to facilitate evaluation and comparison of
results.
Complete understanding of the detailed status of distal
radius surface, such as the direction and degree of dis-
placement or comminution, is of vital importance to any
well-ordered reduction and immobilization. Unfortu
nately, most of the existing classification systems focus
27
28 F. Battistella

Fig.3.1 The classification of

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

only on the mechanism of injury or the geometry of the
fracture and are based only on radiography.
Computerized tomography and a newly developed
3-dimensional reconstruction technique (3D CT) solve
the limitation of plain radiography.
On the basis of preoperative 3D CT scanning, Doi
etal. classified intraarticular distal radial fractures into
2, 3, and 4-part types, according to the number of main
fracture fragments involved in the joint surface [5]
(Fig.3.3). Two-part fractures had three subtypes, based
on the direction of the fracture line (vertical, horizon-
tal, or at the dorsal rim). Three-part fractures are com-
posed of a significant radial styloid fragment and two
main fragments in the lunate facet.
A 4-part fracture involves two main fragments in
both the lunate and scaphoid fossae. Severe comminuted
cases, namely AO type C3 fractures, are categorized as
4-part fractures in this system. Compared with other
3 Management of Simple Articular Fractures 29

Fig.3.2 Mller AO classification. Group B partial articular frac- articular simple, metaphyseal simple; C2 articular simple, meta-
ture. B1 radius, sagittal; B2 radius, frontal, dorsal rim; B3 radius, physeal multifragmentary; and C3 articular multifragmentary
frontal, volar rim. Group C complete articular fracture of radius. C1

Fig.3.3 The classification of Doi: 2-part fractures. (a) Vertical line; (b) horizontal line; (c) dorsal rim; (d) 3-part fractures; and (e)
4-part fractures
30
classifications, this system simply and accurately
describes the status of the joint surface, thereby provid-
ing an intuitive and practical guideline for the arthros-
copy and reduction-fixation procedure.
Indications and Contraindications
Relative indications include:
1. Age between 16 and 65years without evidence of
metabolic bone disease.
2. A 2, 3, or 4-part type fracture of the distal radius
with an articular step-off of equal to or greater than
1 mm that remains irreducible after adequate at-
tempts at closed reduction.
3. Additional fracture patterns include lunate die-
punch fractures.
4. Radiographic signs of concomitant injury, includ-
ing diastasis of intercarpal joint spaces, sublux-
ation of distal radioulnar joint, or a broken carpal
arch.
5. The best time interval after injury is within 37days.
If reduction is attempted earlier than 2days, bleed-
ing from the fresh fracture may potentially compli-
cate the procedure; and furthermore, the fresh
fracture and ligament tears may precipitate the
extravasation of arthroscopic fluid into soft tissues.
After 7 days postinjury, the fracture fragments
would have started to consolidate and may become
too difficult to manipulate. If a dry technique
arthroscopy is used [4], the waiting period can be
reduced to 0days.
Relative contraindications include:
1. Marked metaphyseal comminution or radial styloid
comminution. These were considered classically as
contraindications, but indications have now wid-
ened as shown in Chap. 4.
2. Infection.
3. Open injuries. Again this is a relative contraindica-
tion if the dry technique is used.
4. Extensive soft-tissue damage.
5. Unreduced carpal dislocations were also considered
as a contraindication, but again, views have changed
dramatically in recent years (see Chap. 11).
6. Median nerve involvement. This is not a contrain-
dication when using the dry technique.
F. Battistella
7. Compartment syndrome in the forearm or hand.
8. Associated injuries or fractures of the upper arm
that do not allow traction of the wrist or the verti-
cal or horizontal position for arthroscopy.
Surgical Technique
The 2-part type fractures with three subtypes are the
more common articular fractures of the wrist.
Preoperative planning is based on X-ray and CT
scan, which is indispensable to assess the 3D picture of
the displaced fragments (frontal, sagittal, and axial
planes) and 3D reconstruction for classification.
Arthroscopy is usually performed under axillary
block or general anesthesia; the choice is based on
patients and anesthesiologists preference.
Vertical and horizontal traction may be used. We use
a traction system that we had customized, that allows us
to change from vertical to horizontal easily and with no
surrounding impediments, in order to facilitate the
simultaneous performance of arthroscopic instrumenta-
tion and fluoroscope transillumination. This system
allows the surgeon to flex, extend, and radial and ulnar
deviate the wrist while keeping constant traction. When
the best position to reduce the fractured fragment is
achieved, the wrist is blocked (Fig.3.4). Longitudinal
traction is applied with the wrist in a slightly flexed and
ulnar-deviated position, with the amount of traction
slightly more than normally used for wrist arthroscopy,
as this was found to facilitate reduction via the effects
of ligamentotaxis. The use of traction with a tower or
another system for wrist arthroscopy helps reduce the
fracture and achieve the right length of the radius [9].
A pneumatic tourniquet is applied on the upper arm
and inflated to 250mmHg when the arthroscopic pro-
cedure starts.
Before prepping and draping, we use fluoroscopy to
control the traction (maximum 56kg) of the wrist. It
must not be too much because we may overreduce the
fragments.
The normal bony landmarks for the portals are often
distorted as a result of swelling in distal radial frac-
tures, and so, it is helpful to place an 18-gauge needle
into the joint before making the skin incision to locate
the portal. Furthermore, fluoroscopy may be needed in
the more complicated cases to avoid entrance into the
fracture itself.
3 Management of Simple Articular Fractures
Fig. 3.4 Authors system of traction provides stable traction
with virtually unrestricted access to the wrist during arthroscopic
and fracture reduction procedures. The system can be easily
maneuvered to allow fluoroscopic imaging, and can be tilted or
rotated down to a horizontal position to support management of
fractures
Precautions are applied to minimize arthroscopic
fluid extravasation into the soft tissues: (1) the forearm
is wrapped in a compressive dressing, (2) irrigation and
washing is controlled by the use of pressurized pump
inflow and outflow at 20mmHg, and (3) the portals are
created just slightly larger than standard arthroscopic
procedure, so that the water can go out easily without
extravasation into soft tissues.
The fracture is approached initially from the dorsal
side, the 34 portal is preferred for initial visualization
(2.7mm/30 small joint arthroscope) along with the 45,
and 6-R portals for instrumentation (2.7mm arthroscopic
shaver/probe and punch for the removal of hematoma
and fragments). During the arthroscopic procedure, the
viewing portal may be changed to the 6R if needed.
Blood clot, debris, and detached synovial tissue that
obstruct full visualization with the arthroscope are
cleared away using arthroscopic aspiration, shaver,
and punch. Continuous inflow with saline solution is
31
introduced via the trocar of the arthroscope. Low-
pressure mechanical pumping is used to facilitate irri-
gation and space expansion, but the intraarticular
pressure is kept as low as possible to avoid extravasa-
tion and the risk of compartment syndrome.
Having cleared the view, the examination of the
wrist starts by performing radiocarpal assessment of
the injuries to the scapholunate (SL) and lunotriquetral
ligaments and classification of the injuries to the trian-
gular fibrocartilage complex (TFCC). This procedure
is required in order to plan the surgery time.
Then the degree of comminution, separation, and
depression of the fracture fragments are assessed. It is
not uncommon to find that the fragments are tilted in
the sagittal plain, but this is not appreciated on lateral
fluoroscopy because of the overlap of the ulna, sca-
phoid, and lunate fossae and the biconcave configura-
tion of the distal radius [19].
In addition, gap separation and step-off displacement
can be accurately evaluated with the tip of the probe.
Reduction of the Fracture
The technique varies according to the fracture type.
Two-Part Fractures
The simple 2-part type fracture can sometimes be easily
reduced by traction with the tower and manual compres-
sion because radial styloid is normally reduced through
ligamentotaxis while the arm is suspended in the traction
tower, and the quality of reduction is controlled with
arthroscopy. Next, the fracture is fixed with Kirschner
wire (K-wire) and cannulated screw (Figs.3.5 and 3.6).
Sometimes, this technique is not sufficient, and so
we need to add percutaneous K-wire manipulation.
The K-wires are placed into the fracture plane under
fluoroscopy. These wires elevate, reduce, and buttress
the distal fragment. K-wires are driven into larger frag-
ments, such as the radial styloid, acting as joysticks. In
these techniques, the wires are positioned under fluo-
roscopy and then manipulated as the distal articular
surface of the radius is arthroscopically assessed. The
wires are advanced once anatomical reduction is
obtained and if the fracture needs compression we
insert a cannulated screw (Fig.3.7).
32
a b
Fig.3.5 (a) Two-part fracture vertical rim. (b) The reduction is
made by ligamentotaxis with the traction system and with exter-
nal compression with surgeons thumb. (c) The fracture is fixed
Fig.3.6 Fluoroscopic final control, before removing the tempo-
rary K-wire that was inserted to avoid the rotation of the frac-
tures fragment driving the screw
F. Battistella
with K-wire and cannulated screw while the reduction is con-
trolled by arthroscopic view
It is important that while the screw is inserted into
the styloid, the K-wire used before as a joystick must
be advanced temporarily into the ulna to avoid the
rotation of the fragment. The best portal to view the
rotation of the radial styloid fragment is 45 or 6R.
The volar fragment of the 2-part type fracture with a
horizontal rim tends to rotate dorsally during traction
because of ligamentotaxis. Longitudinal traction is
released slightly, and the wrist is placed in slight flex-
ion. The fracture is reduced using a target compass
(Fig.3.8) to get the right position of the K-wire and to
make compression of the fragments. The fragments are
gently compressed together and maintained with the tip
of the compass, while oblique K-wires are placed to fix
intraarticular fragments to the radial shaft (Fig.3.9).
If the volar fragment is elevated or dislocated we use
arthroscopic manipulation. An arthroscopic probe or ele-
vator is used to manipulate bony fragments via the
3 Management of Simple Articular Fractures 33

Fig.3.7 (a) Two-part

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

a b

instrumental portal, particularly those involving the lunate

Fig.3.8 Compass. It is used to drive the K-wires exactly where
we need in easy way and contemporarily to compress the frac-
tures fragment. The target compass reduces the time to use the
fluoroscopy
fossa. Once acceptable realignment is achieved, K-wires
are introduced percutaneously for fixation (Fig.3.10).
In case of 2-part type subgroup dorsal rim, the frag-
ment is difficult to view from the dorsal portals even
by moving the scope from 3 to 4 portal to 6R. In such
cases we need to add a volar portal. This is done under
direct vision through a 1cm longitudinal skin incision
between the flexor carpi radialis tendon and the radial
artery. The volar aspect of the capsule is exposed after
blunt dissection, and a small (3mm) incision is made
parallel to the capsular fibers (Fig.3.11).
The arthroscope is therefore placed through the volar
portal (Fig.3.12), and the dorsal rim fragment is reduced
34
a b
Fig. 3.9 (a) Two-part fracture horizontal rim. (b) Reduction
with the tip of compass and contemporarily external compres-
sion with surgeons thumb and internal cannulated cylinder of
a b
Fig. 3.10 (a) Two-part fracture horizontal rim with elevated
volar fragment. (b) Arthoscopic manipulation of the articular
fragment using elevator. (c) Positioning the K-wire while the
by dorsal compression with the wrist in slight flexion,
and a single K-wire is used with the aim of percutaneus
manipulation and immobilizing the dorsal die-punch
fragment (Fig.3.13). In case of a large dorsal die-punch
fragment a cannulated cancellous screw is used.
Three-Part Fractures
Reduction of articular congruity is initiated by the ele-
vation of the die-punch fragments and depression of
the articular surface, and by the control of the mobility
of the articular fragment.
We start reducing the radial styloid fragment in
the same way as 2-part fractures. The styloid is pinned
F. Battistella
c
the compass. (c) The K-wire is placed to fix the articular frag-
ment to the radial shaft
c
reduction of the volar fragment is maintained by the elevator and
the fracture is compressed by the compass
percutaneously under fluoroscopic visualization cross-
ing the fracture line by only 67mm to obtain a tempo-
rary stabilization. The radial styloid fragment is used
as an intraarticular landmark to elevate arthroscopi-
cally the depressed lunate facet fragments with the
arthroscopic probe. Then, using the compass guide, a
K-wire is placed into the bone under the depressed
volar lunate fragment and is used to elevate the frag-
ment percutaneously. When the depressed fragment is
leveled and the reduction of the volar lunate fragment is
judged arthroscopically acceptable, the K-wire is
pushed through the styloid and fixed to the radial cor-
tex, and the volar lunate fragment is fixed definitively.
Then, the dorsal lunate fragment is reduced and pinned
in the same way. The use of a compass guide is useful
not only for the easy and correct positioning of the
3 Management of Simple Articular Fractures
Fig. 3.11 Skin incision for arthroscopic radial volar portal
between the flexor carpi radial (FRC) and radial artery (RA)
a b
Fig.3.13 (a) Two-part fracture dorsal rim. (b) The volar radial
portal is relatively easy to use and is an ideal portal for evalua-
tion and to assist the reduction of the dorsal fragment of the
K-wire, but also to reduce any sagittal gap that may
exist between the radial styloid and depressed lunate
facet fragment (Fig.3.14). In fact, the external blunt tip
of the compass is placed on the radial styloid and the
internal tip is placed on the border of the lunate facet
fragments to close the sagittal gap.
If the size of the articular fragment of the styloid is not
big enough to obtain a good reduction and a rigid
35
Fig.3.12 Arthroscopic radial volar access between the flexor
carpi radial (FRC) and radial artery (RA)
c
fracture. The reduction is made using a K-wire with joystick
technique and external compression with the surgeons thumb.
(c) The dorsal articular fragment is fixed with K-wire
stabilization, we use a modification of Pials technique
[15]. (see also Chap. 4).
We start with the position of the arm in the traction
system in horizontal way with only 3kg of traction. The
approach to the radial is with the open standard volar
technique. The volar locking plate is placed and fixed
temporarily only with a screw placed in the elliptical
hole; this will allow us some adjustment at the time of
36
a b
d e
Fig. 3.14 (a) Three-part fracture. (b) Percutaneous K-wire
manipulation: the K-wire is used like a joystick to reduce the
styloid fragment under fluoroscopic control and arthroscopic
view. Temporary stabilization with the K-wire that cross the
fracture plan only of 67mm. (c) The volar lunate fragment is
elevated using an elevator and the reduction is checked with the
radial styloid fragment as an inside articular landmark. (d) The
final plate positioning. The manual reduction of the
fracture is performed using a progressive traction and
volar flexion using the traction system, and then, the
wrist is positioned in 57kg of traction and light (10) the related articular fragment, and moving the plate a
flexion. The articular fracture fragments are preliminary
fixed with two K-wires to the plate under fluoroscopic
control through the auxiliary holes. It is important to
control that the plate is not positioned too distally or too
proximally because this will also condition the correct
positioning of the screws or pegs in the subcondral bone
and to control that the traction is not too much to avoid
displacement of the articular dorsal fragments caused
by overdistraction. Then, we move the traction system
from horizontal to the vertical position and start the
arthroscopic procedure performing 34 portal for the
scope and 6R for the motor and probe. When the joint is
washed and a clear view of the joint is achieved, all
articular fragments are evaluated. Then, we move the
scope from 3 to 4 to the 6R portal. We perform
arthroscopic fine-tuning of the reduction starting from
F. Battistella
c
f
volar lunate fragment is reduced using the arthroscopic probe.
(e) A K-wire is positioned, with the use of compass, into the
bone of volar lunate fragment and the final reduction of the frag-
ment is made with little movement of the K-wire. Then the
K-wire that temporarily fixed the radial styloid is pushed on and
fixed to the radial cortex; and (f) the dorsal lunate fragment is
reduced and fixed with K-wire
the ulnar side of the radial fracture using the tip of the
arthroscopic probe or elevator and using the K-wire as a
joystick, backing out or advancing as needed to move
few degrees with external dorsal compression with the
thumb of surgeon. When the reduction is judged opti-
mal, at least another screw is inserted into the stem of
the plate to lock it well in its final position. Then, while
the reduction is maintained or using the dedicated com-
pass, the first and second K-wires are pushed onto the
dorsal cortex and locking pegs or locking screws are
positioned under arthroscopic control (Fig.3.15).
Four-Part Fractures
Four-part fractures are always managed through a
combination of open reduction for placing the volar
locking plate with arthroscopic-assisted reduction of
3 Management of Simple Articular Fractures
a b
d e
Fig. 3.15 (a) Three-part fracture with small articular styloid
fragment. (b) Open surgery: the volar locking plate is placed and
fixed temporary only with a screw in the elliptical hole and the
articular fragments are fixed to the plate with two K-wires
through dedicated holes. (c) Arthroscopic-assisted reduction of
the articular fragments moving the two K-wires or the plate.
articular fragments. The technique is similar to those
explained in Three-Part Fractures but more complex
because of the four articular fragments and because
some are depressed and some are elevated and the pre-
cise placement of the volar plate is much more impor-
tant for the reduction and for fixation of the fragments
(see also Chap. 4).
Associated Injuries
Articular distal radial fractures exhibit a high inci-
dence of associated injuries: chondral and soft tissue
injuries, interosseous ligament injuries, and TFCC
lesions [8].
The most commonly associated injury of a 2-part
type fracture is SL ligament injury (average 31%), [11]
because of the great transmission of energy to the joint
37
c
f
(d) Arthroscopic fine-tuning, the reduction of the two fragments
of lunate fossae is maintained using a compass while the two
K-wires are pushed on to the dorsal cortex of the radius. (e)
Locking screws are driven into the bone. (f) Final arthroscopic
control when all screws are placed
at the time of fracture, involving not only the surround-
ing fractured radius but also the intercarpal joints. SL
ligament disruption results from an avulsion fracture
of the radial styloid process due to ulnar deviation of
the wrist (Fig.3.16a) or a trauma force that is used to
break the distal radius due to carpal supination
(Fig. 3.16b). For management of associated injuries
see Chap. 8.
Complications
Complications of arthroscopic-assisted treatment sec-
ondary to the arthroscopy itself are minimal in reported
cases. However, potential complications include: (1)
settling of the fracture fragments resulting in loss of
reduction (2) pin track infection, (3) pin loosening,
and (4) sensory nerve irritation.
38
Fig.3.16 (a) Scapholunate
disruption caused by avulsion
fracture of styloid. (b)
Scapholunate disruption
caused by carpal supination
Results
Several studies [1, 9, 18] have evidenced the effective-
ness and safety of arthroscopic-assisted treatment of
articular distal radius fractures even if there are no pro-
spective randomized double-blind studies.
In 1999, Doi etal. reported a long-term outcome of
arthroscopically-assisted reduction of intraarticular
fractures of the distal end of the radius, and demon-
strated better range of motion and grip strength than
those treated by conventional procedures [5].
In 2004, Ruch etal., in a prospective cohort study,
evidenced that the arthroscopic-assisted (A.A.) reduc-
tion and fixation permits a more thorough inspection of
the ulnar-sided components of the injury. At follow-up
evaluation, patients who underwent AA procedures had
a greater degree of supination, flexion, and extension
than those undergoing fluoroscopically assisted (FA)
surgery [16].
In 2007, Hattori, in a clinical study, reported the
result on 28 patients older than 70years with AO type C
fracture of the distal radius that were treated with
arthroscopically-assisted reduction combined with volar
plating or external fixation. The study concluded that
arthroscopically-assisted reduction combined with volar
plating or external fixation is one of the useful options
for the treatment of a displaced intraarticular fracture of
the distal radius in elderly patients who are physiologi-
cally young or active [10].
In 2008, Varitimidis, in a randomized prospective
study, reported that the patients who underwent
arthroscopically-assisted treatment had significantly bet-
ter supination, extension, and flexion at all time points
than those who had fluoroscopically-assisted surgery. The
mean DASH scores were similar for both the groups at
24months, whereas the difference in the mean modified
Mayo wrist scores remained statistically significant [18].
F. Battistella
a b
Clinical Experience and Personal Results
From 2001 to 2008, we treated 124 patients with
arthroscopic-assisted technique for distal articular
radius fractures. On the basis of our prospective com-
parative study, we found that the arthroscopically-
guided procedure was superior to the conventional
open procedure with regard to several parameters.
Specifically, the scores for outcome as assessed
with the system of Gartland and Werley and the modi-
fied system of Green and OBrien, the range of flexion-
extension and that of radial-ulnar deviation of the
wrist, and the grip strength were better in the group
managed with the arthroscopically-guided procedure.
Conclusion
Traditional methods of traction and ligamentotaxis
cannot control and elevate the die-punched fragments
and correct the articular step-off. Conventional open
reduction and internal fixation generally yields poor
functional outcome.
An arthroscopically-guided operation achieves an
accurate reduction of intraarticular fractures of the dis-
tal aspect of the radius and treats associated lesions,
both of which are necessary for regaining anatomic
structure and satisfactory function. Minimal capsular
and adjacent soft-tissue scarring reduces postoperative
contracture, which improves the overall functional
results. Arthroscopically-guided reduction is a feasible
procedure, but it requires meticulous technique, and
despite a steep learning curve, is an invaluable method.
We recommend arthroscopically-assisted technique
for any active patients, not only for young adults but
also for all the patients who have an intraarticular
3 Management of Simple Articular Fractures
fracture of the distal part of the radius with more than
1mm of displacement on plain radiographs.
References
1. Chen AC, Chan YS, Yuan LJ, Ye WL, Lee MS, Chao EK.
Arthroscopically assisted osteosynthesis of complex intra-
articular fractures of the distal radius. J Trauma. 2002;53(2):
3549
2. Cognet JM, Martinache X, Mathoulin C. Arthroscopic man-
agement of intra-articular fractures of the distal radius. Chir
Main. 2008;27(4):1719
3. Cooney WP. Fractures of the distal radius: a modern treat-
ment based classification. Orthop Clin North Am. 1993;24:
2116
4. Del Pial F, Garca-Bernal FJ, Pisani D, Regalado J, Ayala H,
Studer A. Dry arthroscopy of the wrist: surgical technique.
J Hand Surg. 2007;32A:11923
5. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intra-
articular fractures of the distal aspect of the radius:
arthroscopically assisted reduction compared with open
reduction and internal fixation. J Bone Joint Surg. 1999;81A:
1093110
6. Fernandez DL, Geissler WB. Treatment of displaced articu-
lar fractures of the radius. J Hand Surg. 1991;16A:37584
7. Fernandez DL, Geissler WB. Percutaneous and limited open
reduction of the articular surface of the distal radius. J Orthop
Trauma. 1991;5(3):25564
8. Forward DP, Lindau TR, Melsom DS. Intercarpal ligament
injuries associated with fractures of the distal part of the
radius. J Bone Joint Surg. 2007;89A:233440
39
9. Geissler WB. Intra-articular distal radius fractures: the role
of arthroscopy? Hand Clin. 2005;21:40716
10. Hattori Y, Doi K, Estrella EP, Chen G. Arthroscopically
assisted reduction with volar plating or external fixation for
displaced intra-articular fractures of the distal radius in the
elderly patients. Hand Surg. 2007;12(1):112
11. Kordasiewicz B, Pomianowski S, Orowski J, Rapaa K.
Interosseous ligaments and TFCC lesions in intraarticular
distal radius fractures - radiographic versus arthroscopic
evaluation. Ortop Traumatol Rehabil. 2006;8:2637
12. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of
intra-articular fractures of the distal radius. An arthroscopi-
cally-assisted approach. J Bone Joint Surg. 2000;82B: 7986
13. Melone CP. Articular fractures of the distal radius. Orthop
Clin North Am. 1984;15:21736
14. Mller ME, Nazarian S, Koch P, Schatzker J. The compre-
hensive classification of fractures of long bones. New York:
Springer; 1990
15. Pial F. Dry arthroscopy of the wrist: Its role in the manage-
ment of articular distal radius fractures. Scand J Surg.2008;
97:298304
16. Ruch DS, Vallee J, Poehling GG, Smith BP, Kuzma GR.
Arthroscopic reduction versus fluoroscopic reduction in the
management of intra-articular distal radius fractures.
Arthroscopy. 2004;20(3):22530
17. Trumble TE, Schmitt SR, Vedder NB. Factors affecting
functional outcome of displaced intra-articular distal radius
fractures. J Hand Surg. 1994;19A:32540
18. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME.
Treatment of intra-articular fractures of the distal radius:
fluoroscopic or arthroscopic reduction? J Bone Joint Surg.
2008;90B:77885
19. Wiesler ER, Chloros GD, Mahirogullari M, Kuzma GR.
Arthroscopic management of volar lunate facet of distal
radius fractures. Tech Hand Upper Extrem Surg. 2006;10(3):
13944
 Treatment of Explosion-Type Distal
Radius Fractures 4
Francisco del Pial

We have defined explosion-type distal radius fracture

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

Fig.4.1 An explosion-type distal radius fracture (DRF) that has

F. del Pial more than four articular fragments and also a free osteochondral
Head of Hand and Plastic Surgery, Private practice Hospital fragment. (1: volar rim of the scaphoid fossa; 2: dorsal rim; 3:
Mutua Montaesa, Caldern de la Barca 16-entlo, posterior lunate (dorso-ulnar) fragment; 4: anterior lunate (volar-
39002-Santander, Spain ulnar) fragment; 5: free osteochondral fragment at the scaphoid
e-mail: drpinal@drpinal.com fossa) (Copyright by Dr. Pial, 2009)

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 41

DOI: 10.1007/978-3-642-05354-2_4, Springer-Verlag Berlin Heidelberg 2010
42
AARIF in explosion-type fractures is a lengthy
operation and all personnel should be appropriately
trained in order not to run out of tourniquet time and
overstress. By paying attention to logistics and keeping
order in this seemingly chaotic procedure, it can be
transformed into a friendly exercise. The first rule
(common to all fracture types) is never to carry out a
definitive fixation until after an arthroscopic control of
the reduction has been performed. In this sense, another
of the most common causes of frustration and finding
the AARIF useless is to introduce the arthroscope at the
end of the operation once all the rigid fixation has been
done in order to confirm the anatomic reduction. At
this stage, correcting any misplaced fragment and
achieving stable fixation is a nearly impossible endeavor,
leaving the surgeon with the difficult decision of accept-
ing an inaccurate reduction or having to transform the
ideal rigid fixation into a voodoo-type exercise, with
Kirschner-wires (K-wires) maintaining a tenuous fixa-
tion. This problem underscores how important logistics
are, more so the more complex the fracture is. It is
imperative to follow the correct sequence in order to be
able to modify the fixation should the need arise. We
suggest the following: preliminary volar locking plate
application, reversible fixation (K-wires though the
plate), arthroscopic (dry) tuning, and then stable (lock-
ing pegs) fixation under arthroscopic guidance.
The Dry Technique
In the authors opinion, a key factor in making this
operation friendlier is to carry out the arthroscopic part
of the procedure without infusing water inside the joint,
the so-called dry arthroscopy [7]. Not only will one
avoid the risk of compartment syndrome [1], but much
more importantly, the soft tissue extravasation is elimi-
nated, facilitating any combined open surgery as the
tissues maintain their original properties. Additionally,
portals can be made much larger, and the constant loss
of vision due to leakage and bubbles is avoided.
The main shortcoming comes from the fact that if
one is not able to get rid of the blood and splashes that
obscure vision in an expeditious manner, the surgery
will be a nightmare and one will give up the dry tech-
nique. Intuitively, one would think that removing the
scope and wiping off the lens with a wet sponge is a
good way of having a clear vision. Although effective,
this maneuver is time consuming and, in a fracture,
F. del Pial
there may be so much blood that the maneuver may
need to be repeated an exasperating number of times.
Based on our experience with more than 500 dry wrist
arthroscopies, but more important seeing how others in
the laboratory struggle with the same difficulties over
and over, I can recommend the following tips that are
critical for a smooth procedure:
Keep the valve of the sheath of the scope open at all
times as to allow the air to circulate freely inside the
joint. Otherwise, either the suction of the shaver
will not function properly or the capsule will col-
lapse in by the power of the suction, blocking vision.
Hence, in classic wet arthroscopy, a common source
of obscure vision is leaving the water closed; here it
is the opposite. The valve should be left open at
all times (Fig.4.2).
After a fracture, there is a fair amount of blood and
clots that need to be removed before the articular
fragments are identified. Although one can patiently
aspirate all the debris with the synoviotome, it is both
slow and cumbersome to do it dry. A much quicker
method of doing so is to connect a syringe with
510mL of saline into the side valve of the scope
and then aspirate it with the synoviotome. Pressure
on the plunger of the syringe is unnecessary, as the
negative pressure exerted by the shaver will suck the
saline into the joint. Once all the water has been aspi-
rated, the syringe is removed, and again the suction
power of the shaver is enough to dry out the joint suf-
ficiently to allow the surgeon to work on the reduc-
tion. This maneuver should be repeated as necessary
Fig.4.2 The importance of keeping the valve of the sheath of
the arthroscope open at all times to allow free circulation of air
cannot be overemphasized
4 Treatment of Explosion-Type Distal Radius Fractures
Fig.4.3 Method used to wash out the joint and clear it of blood.
Notice that the negative pressure exerted by the shaver is suffi-
cient to aspirate the saline without extravasation of water
throughout the procedure, as it is much quicker than
struggling with blood in the joint (Fig.4.3).
If an absolute dry field is needed, as to see a gap or
a step, we then recommend to dry out the joint. For
this we use small (1313 mm) or medium
(2525mm) surgical patties (Ref: 80004000. size:
, Ref: 80004003. size: 11 (2525mm) and wastes valuable time. Actually, most of the
Neuray, Xomed, Jacksonville, FL). The small
patty can be directly rolled and introduced into the
joint by a grasper. The large patties have to be
slightly modified by cutting them into the shape of a
triangle, which facilitates removal from the joint. If
the patties become entangled, they can be removed
by pulling on the tail or by retrieval with a grasper
(Fig. 4.4). I must underscore that we now rarely
resort to this technique. In order to reduce operative
time, we trust more the irrigationsuction just
explained above, and accepting a poorer vision.
Avoid getting too close with the tip of the scope
when working with burrs or osteotomes in order to
avert splashes that might block your vision. It is
preferable to first inspect the area of interest and
43
then slightly pull the scope back prior to inserting
your working instrument. For the same reason,
avoid touching the tip of the scope with your instru-
ments (probe, synoviotomes).
In case a minor splash at the tip of your scope blocks
the vision, it can be removed by gently rubbing the
tip of scope on the local soft tissue (capsule, fat).
This maneuver will clear the view sufficiently.
If the arthroscopy is carried out immediately after
elevating the tourniquet, vision can be poor, as con-
densation appears at the tip of the scope. This is due
to the difference of temperature between the room
temperature (usually 2123C) and the still warm
wrist. Although this improves as times goes by, as
the exsanguinated limb cools down, a quick way of
avoiding it is by immersing the tip of the scope in
warm saline for few minutes before beginning the
surgery. Alternatively, fogged vision can be accepted
for a moment as the problem disappears once the
joint is irrigated with room temperature saline.
An important waste of time occurs when the syn-
oviotome, burr, or any other instrument connected
to a suction machine clogs because the aspirated
debris dries out. When this happens, the operation
has to be stopped in order to dismount and irrigate
the synoviotome for dislodging the debris. This is
to be avoided at all costs by clearing the tubing with
periodic saline aspiration from an external basin, or
irrigating the joint as explained above.
Finally, one must understand that at most times the
vision will never be completely clear but still suffi-
cient to safely accomplish the goals of the proce-
dure. Having a completely clear field except for
specific times during the procedure is unnecessary
times, particularly in fractures, we do irrigate with
35mL, aspirate, and then work for sometime with-
out any difficulty, and once the blood level rises in
the joint, the irrigationsuction cycle is repeated.
So, in truth, we have moved from wet arthroscopy
to the dry, and now somewhat moist arthroscopy
(so named after Tommy Lindaus suggestion).
Management of the Fracture
I have found delaying the operation neither necessary nor
beneficial. Fractures with a delay in treatment longer than
3 weeks are considered healed [6, 18] and are managed
44 F. del Pial

Fig.4.4 Arthrosponge and

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

by arthroscopic-assisted osteotomy (see Chap. 14). As a
matter of fact, we proceed as soon as the CT scan is avail-
able (immediately or some days after the accident). The
CT is indispensable to assess the three-dimensional pic-
ture of the displacement (frontal, sagittal, and axial
planes). The axial view is paramount to understand the
position of each articular fragment (see Chap. 1).
The operation is performed under axillary block on
an outpatient basis, and preferably with the assistance
of another surgeon. Admittedly, most hand surgery is
carried out as a solo practice, and one may feel crowded
out with another surgeon nearby. However, the help of
an experienced surgeon is invaluable for a smooth
operation, until one is skilled in the procedure. Logistics
are fundamental in this complex operation, and with
minimal modifications the following steps should be
followed at all times:
(a) Volar locking plate application and manual reduc-
tion of the articular fragments
(b) Preliminary fixation of the articular fracture with
K-wires to the plate under fluoroscopic control
(c) Arthroscopic fine-tuning of the reduction
(d) Rigid articular fragment fixation under arthro
scopic guidance
4 Treatment of Explosion-Type Distal Radius Fractures 45

(e) Final fixation with the hand lying on the operat- a

ing table
(f) Arthroscopic DRUJ and midcarpal exploration
In essence, the operation can be divided into a clas-
sic and an arthroscopic part. It should be under-
stood that the arthroscope is just a tool to improve the
reduction, and expertise in the management of DRF
treatment in a standard way is probably more impor-
tant than the arthroscopic part itself.

Classic Part b

The arm is exsanguinated and a tourniquet applied. For

the most common explosion fracture, access to the
radius is carried out through a 68cm incision radial to
the flexor carpi radialis sheath (FCR) with a 1 cm
radial-directed back cut in the proximal wrist crease.
By dissecting with a knife on the radial aspect of the
FCR sheath, the sheath can usually be preserved intact,
but more importantly, the radial artery will stay safely
radial (Fig. 4.5a). The space between the FCR and
radial vessels is developed. A large direct constant
branch from the radial vessels to the radial aspect of
the pronator quadratus should be identified and coagu-
lated. In the distal aspect of the incision, a constant
transverse carpal artery [19] similarly needs to be iso-
lated and coagulated. The radial artery and its palmar
branch can, and should, both be preserved. Dissection
should expose distally the most distal aspect of the
radius past the watershed area (a soft tissue interface
distal to the pronator quadratus insertion) but obvi-
ously not violating the volar ligaments. The muscle is
then sharply elevated subperiosteally and reflected
ulnarly. Proximally, some fibers of the flexor pollicis
longus are reflected ulnarly. A wide exposure of the
fracture site, distally nearly up to the articular line,
including the most ulnar volar corner of the radius, is
required in order to accurately place the volar plate.
A volar locking plate is provisionally applied and
stabilized by inserting only the screw into the elliptical
hole on the stem of the plate, as this will allow some
adjustment at the time of final plate setting. The reduc-
tion of the volar metaphyseal fragments is done by
standard maneuvers: traction and volar flexion. The
dorsal fragments are manually compressed to the plate
that acts as a mold. Customarily, several attempts and
maneuvers are needed before the best reduction is
Fig.4.5 (a) Close dissection with a knife will keep the sheath of
the FCR intact (asterisks), and sufficient fat will be provided for
protection of the radial artery (arrow). (b) Reduction of the meta-
physeal component has to be assured prior to insertion of the
Kirschner wire (K-wire) to the plate. The fracture with the screws
inserted in the stem and the K-wires (two or more) maintaining
the articular reduction are now ready for arthroscopic fine-tuning
obtained, as judged by fluoroscopic views, and by
direct observation of the metaphyseal component of the
fracture. The articular fragments are then secured to the
transverse component of the plate by inserting K-wires
through the auxiliary holes (Fig.4.5b). Once the reduc-
tion is considered ideal and/or that no improvement is
attainable without carrying out an arthrotomy, the sur-
geon should proceed to assess the joint under arthros-
copy (Fig.4.6). Prior to suspending the hand, however,
and in order to avoid secondary displacement by trac-
tion of the plate, at least another screw should be
inserted in the stem of the plate to lock it in position.
Although it may be considered a waste of space to
expend a paragraph on plate placement in an arthros-
copy book, I should underscore that there is not much
room for error in the placement of a volar locking plate
in an explosion-type DRF. If the plate is not in the right
spot, there are likely to be problems in fixation and
46
Fig.4.6 Two K-wires
maintain the fragments
temporarily reduced in this
explosion-type DRF. From a
fluoroscopy standpoint, the
reduction can be considered
anatomically reduced. See
also Fig.4.9 (DVR plate.
Hand Innovations)
(Copyright by Dr. Pial,
2009)
in the end result. One should pay particular attention to
the position of the distal edge of the plate in relation to
the rim of the radius. If the plate is too distal, the screws
may be lodged inside the joint and/or the flexor tendons
irritated by the edge of the plate. On the other hand, if
placed too proximally, the locking screws/pegs will sit
too far from the subchondral bone, providing minimal
support to the articular fragments. Subsidence of the
fragments will be more likely if more comminution
exists, as is the case in this type of fracture. Similarly,
the plate position should also be checked in relation to
the lateral and medial aspect of the epiphysis. It should
not surpass the radius ulnarly, as the pegs will penetrate
into the distal radio-ulnar joint. Nor should it surpass
the radius radially, as it will be palpable and painful,
requiring a further operation for plate removal.
Arthroscopic Part
The hand is suspended from a bow, the fingers pointing
to the ceiling, with a custom-made system that allows
easy connection and disconnection from the bow with-
out losing sterility (Fig. 4.7) [6]. Counter traction is
usually 710kg, but can be more in tight wrists. No
adverse effects have been noticed perhaps because the
traction is evenly distributed to all fingers. This system
F. del Pial
has the advantage of its availability and price (8 for
each karabiner). Furthermore, it is very easy to fasten
and unfasten for fluoroscopy checking. However, it
requires, at times, a hand to stabilize the wrist.
I personally prefer the 2.7 mm/30 angle scope for
most of my cases. Seldom, in tight wrists, do I use a
1.9mm/30 angle, as the field of vision is reduced. I start
the procedure through a 34 portal. Portals after fractures
are slightly more difficult to create than in a standard
arthroscopy case. Deep palpation and bony landmarks
recommended by Slutsky in Chap. 2 are used. To create
my portals, I prefer small transverse incisions as they
heal with a minimal scar and do not require suturing at
the end of the operation. After enlarging the entrance
with a mosquito forceps, the scope is introduced and
directed ulnarly to establish the 6R portal. This portal is
best made by inserting a needle percutaneously in the
expected 6R position under arthroscopic control from
the 34 portal. This trick is important, as sometimes
detachment of the TFC directs the surgeon to the DRUJ
instead of the radiocarpal joint. Although vision at this
stage may also be obscured by blood, in general it is pos-
sible to see the needle introduced in 6R, assuring that one
stays distal to the TFC. A straight hemostat is used to
dilate the portal. Alternatively, if this proves unsuccess-
ful, the surgeon might go blindly making the portal radial
to the ECU, just proximal to the triquetrum, and direct-
ing the hemostat radially inside the joint.
4 Treatment of Explosion-Type Distal Radius Fractures
Fig.4.7 The sequence of suspending the hand from the pole is
shown from left to right. The pink ring (circled) is unsterile and
will be stabilized by the OR personnel for the surgeon (hidden
behind the operating field, arrow). The upper karabiner is con-
sidered unsterile from the moment of hooking to the ring. The
upper ring of the figure-of-eight, although probably sterile at all
times, is considered contaminated too. However, the lower ring
of the figure-of-eight and the karabiner closer to the hand are
A 2.9mm shaver is inserted in 6R to aspirate blood
and debris. As stated before, the valve on the arthro-
scope sheath should be left open at all times to allow the
air to circulate freely in the joint and avoid capsular col-
lapse while suctioning. The joint can be washed of blood
as required during the procedure by connecting a 10mL
syringe to the valve of the scope. The negative pressure
exerted by the shaver will suck the saline from the
syringe without extravasation of fluid outside the joint.
Once the elements that need to be mobilized are iden-
tified from the 34 view, the scope is swapped to 6R,
Fig.4.8 If the scope is placed
in 6R, it will rest on top of the
ulnar head providing a stable
platform from which to work,
thus avoiding conflict with the
reduction (left). Instability of
the scope and conflict of space
during the reduction (yellow
and red arrows) are inevitable
when the scope is placed in
any other portal (right)
(Copyright by Dr. Pial, 2009)
47
sterile throughout the procedure. At this lower position, the hand
may be released from and hooked to traction as many times as
required during the operation. In the far right picture, the radio-
carpal portals have been established and the joint has been
cleared of blood as can be seen on the monitor screen. Notice
that the whole process, including pictures, has taken less than
5 min on the OR clock! (Karabiners and figure-of-eight are
available in any climbing shop, for around 8 each)
where it will stay until the entire fixation is done. Inthis
position, on top of the ulnar head, the scope will have a
steady point to rest upon, and will not impede reduction
or displace reduced fragments (Fig.4.8 left). If the scope
is left in the 34 (or 45) portal, it will rest upon an unsta-
ble point, will create space conflict during the reduction,
and will tend to displace the reduced fragments (Fig.4.8
right). Although useful for assessing the dorsal rim frac-
tures, the volar-radial portal can be supplanted by the 6R
portal. The scope simply needs to be put volarly, and
from there, pointed dorsally. Doing so avoids changing
48
of portals, and the risk of redisplacement of reduced (but
not yet rigidly fixed) volar fragments.
With the scope inside and with a clear view of the
joint, the surgeons can face three situations.
1. Joint Acceptably Reduced
In this most ideal scenario, there would be no fragment to
be reduced. The fracture has to be stabilized by introduc-
ing the pegs in the plate under arthroscopic control. The
operation follows by assessing now the ulnar part of the
joint, by swapping the scope to the 34 portal, and resting
on the unyielding reduced and fixed radius. Finally, the
midcarpal joint is explored, and the whole joint is irri-
gated abundantly and the water suctioned with the shaver.
I must warn that this idyllic scenario can be seen in sim-
a b
Fig.4.9 Corresponding arthroscopic view of the case shown in
Fig. 4.6. Notice there that the joint appeared to be correctly
reduced under fluoroscopy. (a) The antero-ulnar fragment is
depressed in relation to the dorsal fragment and elevated in rela-
tion to the central lunate fragment in the background on the right
Fig.4.10 Reduction of a depressed fragment in the scaphoid
fossa (same patient as in Fig.4.1). From left to right: The shoul-
der probe is gauging the step-off (3mm), hooking the depressed
fragment, elevating it, and leveling it to the rest of the joint
F. del Pial
pler fracture cases, but has never been found in our con-
trolled series of explosion fractures [8] (Fig.4.9).
2. One or Two Fragments Displaced
Most frequently, one or two fragments need to be spe-
cifically addressed. Depressed, elevated, or free osteo-
chondral fragments (FOFs) may need attention.
(a) Depressed fragments represent most of the dis-
placed cases and can be relatively easy to manage.
Most respond to hooking them with the tip of a
shoulder or knee arthroscopy probe introduced from
the 34 portal and pulling distally (Fig.4.10).
The mechanics of the reduction is always the same no
matter whether the misplaced fragment is located
(the scope is in 6R looking dorsally in this left wrist). (b)
Looking volarly now: the probe is now passing underneath the
anterior fragment to highlight the deformity (FOF free osteo-
chondral fragment) (Copyright by Dr. Pial, 2009)
(scope in 6R, viewing radially in a right wrist. 1: volar rim of the
scaphoid fossa; 2: dorsal rim; 5: scaphoid fossa) (Copyright by
Dr. Pial, 2009)
4 Treatment of Explosion-Type Distal Radius Fractures 49

Fig.4.11 Authors technique to reduce depressed fragments (see text for details) (Copyright by Dr. Pial, 2009)

radially or ulnarly (Fig.4.11). The fragment is released

from the plate by backing out the specific K-wire that
kept it secured, and then hooked and lifted with the
shoulder probe, slightly overreducing it. At this point,
the surgeon maintains the reduction by compressing
volarwards the reduced fragment with the thumb while
the other surgeon pushes in the K-wire slowly to the
dorsal cortex, taking care not to impale the extensor
tendons (or the other surgeons thumb!) (Fig. 4.12).
The remaining part of the procedure, common to all
fracture types, consists of maintaining the reduction
with a bone clamp while locking pegs/half screws are
inserted under arthroscopic control.

(b) Elevated fragments nearly always correspond to

dorsal rim fragments that due to the effect of
traction are overdistracted (Fig.4.13). More rarely,
the whole radial styloid may behave similarly as a
consequence of the rich ligament insertions on it.
Overdistracted fragments are easily repositioned
by decreasing traction while the surgeon levels
them with the probe or a Freer elevator. Once the
fragment is reduced, it is held in position with a
bone tenaculum or the surgeons thumb, and stabi-
lized by pushing the corresponding K-wire in the
plate again (Fig. 4.14). At times, when large Fig. 4.12 The critical moment of stabilizing a reduced
enough, rim fragments can be stabilized by the fragment is shown in this figure. Surgeon #1 is maintaining a
locking pegs/screws of the plate itself, or by the fragment reduced that has been elevated with the shoulder
pressure exerted by the extensor tendons, when probe, right hand, while with his left thumb is pushing it
against the volar fragment (arrow). At the same time, Surgeon
very small. If they still remain unstable, one should #2 is holding the scope introduced in 6R with his right hand,
avoid using the pegs or screws to engage them as while pushing in the K-wire to fix the reduced fragment with
even minimally proud screws or pegs may create his left hand
50
Fig.4.13 Technique of arthroscopic reduction of elevated dorsal rim fragments. Notice that a Freer elevator is used to level the
fragment, while with the thumb the surgeon closes the gap
Fig.4.14 Fixation of a rim fragment. The bone is held by a bone
clamp and the probe while a K-wire is being introduced (in this
case all instruments were introduced through the 34 portal)
extensor tendon irritation and rupture. We prefer
hence specific fragment fixation with K-wires
introduced dorsal to the palmar. These K-wires are
left percutaneously and are removed in the office at
3 weeks. In aftercare, wrist flexion is encouraged,
but extension is avoided until the K-wire is removed
F. del Pial
to avoid skin irritation (Fig.4.15). The addition of
extra fixation can be considered a less elegant pro-
cedure than direct fixation by the locking pegs, but
one should be very cautious as fluoroscopy has
been found inaccurate to assess peg length in rela-
tion to the dorsal rim of the radius. In fact the pegs
should always be about 2 mm shorter than mea-
sured to avoid dorsal cortex penetration [27].
It is very important to stress that large dorsal fragments
that look distracted on fluoroscopy are rarely so. What
in fact happens is that the anterior fragment (generally
the volar-ulnar fragment) remains dorsally rotated.
Clues to recognize this deformity are the absence of col-
lapse in the dorsal cortex, and the loss of angulation of
the so-called Medoffs teardrop angle [20] (Fig.4.16).
It is imperative that in those cases the anterior frag-
ment is derotated and elevated to the dorsal fragment
rather than depressing the dorsal one in an attempt to
level the joint. This is done in a similar way as to that
used for dorsal depressed fragments (see Fig. 4.11),
but obviously the K-wire should be removed com-
pletely from the plate before this anterior fragment can
be mobilized (Figs.4.17 and 4.18).
(c) FOF (Free ostechondral fragments) are extremely
unstable and when repositioned, sink into the meta-
physeal void. To prevent this from occurring, we
create a supporting hammock by inserting the dis-
tal layer of locking pegs in the plate. The fragments
are kept slightly overreduced, and then impacted
by using a Freer elevator, or by releasing the trac-
tion and using the corresponding carpal bone as a
mold. A grasper can be useful to grab and twist a
severely displaced fragment (Figs.4.19 and 4.20).
4 Treatment of Explosion-Type Distal Radius Fractures 51

a b c

Fig.4.15 (a) The posterior ulnar (PU) fragment could be easily
stabilized by the plate pegs. However, the dorsal central rim
fragment (corresponding approximately to Listers tubercle (L))
and the small rim fragments (r) are too small to be fixed by the
pegs without incurring risky dorsal penetration. (b) The frag-
ment L was fixed with a K-wire, while r was stable at the
end of the fixation. (c, d) Flexion of the wrist and extension to
neutral are encouraged despite the K-wire being percutaneously
located (arrow) (2 weeks postoperative)

Fig.4.16 (a) Fluoroscopic

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

3. Many Fragments Remain Unreduced
This fortunately occurs rarely even in the most commi-
nuted cases. Backing out all the K-wires and attempting
to reduce and fix all fragments at the same time is an
impossible endeavor in our hands. We recommend a
step-by-step procedure beginning from ulnar to radial
(Fig. 4.21). With the scope sitting on top of the ulnar
head, the keystone lunate fossa is first re-reduced. At this
stage only the K-wires of the lunate fossa are backed out,
the radial ones are left in place, because although imper-
fect they serve as a much better reference than if all the
fragments are free. The technique for reducing the lunate
fossa is similar to that for a single fragment reposition:
52
Fig.4.17 Authors technique
for reduction of an anterior
malrotated fragment. Notice
that reduction of this
fragment requires complete
removal (not just partial
backing out) of the corres
ponding K-wire (see text for
details) (Copyright by
Dr. Pial, 2009)
Fig.4.18 Correction of a pseudoelevated dorsal fragment. (a)
Despite the fact that the dorsal lunate fossa fragment is appar-
ently elevated and responsible for a step-off of about 3mm, the
displacement is actually due to malrotation of the anterior ulnar
fragment of the lunate fossa (AU) and less so of the anterior
backing out the corresponding K-wire, arthroscopic
reduction, and pushing in the K-wire (Fig.4.21a).
Before the scope is advanced radially, the lunate
fossa is made stable by inserting one or two locking
pegs in the ulnar part of the plate (Fig. 4.21b). The
radial part of the joint is now fine-tuned under
arthroscopic guidance (Fig. 4.21c). Once reduced,
locking screws are inserted to stabilize the scaphoid
fossa, providing a stable articular surface (Fig.4.21d).
Inserting locking pegs/screws into critical spots
under arthroscopic guidance is paramount in order to
achieve a stable joint, and this has to be done before the
ulnar joint is explored. This part of the operation is
quite awkward as the flexor tendons are in tension
blocking the vision of the plate. The task may be some-
what eased by an assistant retracting the tendons
F. del Pial
central lunate fossa (AC). (b) With a shoulder probe inserted
through the 34 portal, the anterior fragment is being derotated.
(c) The two volar components of the lunate fossa (AU, AC) are
now leveled to the dorsal fragment (see Fig.4.17 and text for
technical details) (Copyright by Dr. Pial, 2009)
ulnarly, while reducing the traction to release tension
in the flexor tendons (Fig.4.22). As soon as the major
articular fragments are stable to probe palpation, the
hand is released from the traction, and laid flat on the
operating table, as in this position the rest of the pegs
and screws can be inserted expeditiously.
In my experience, I rarely start the reduction from
radial to ulnar, unless the degree of comminution is minor
radially and a stable foundation can be created there. In
those cases, the scope is inserted in the 34 portal, direct-
ing the reduction from radial to ulnar. As explained
before I also rarely use a volar portal [9, 26]. Bone graft
was not used in any of these patients, as it is our belief
that a locking plate provides sufficient support.
Once the radius fixation is finished, the hand is
again put in traction to explore the ulnar part of the
4 Treatment of Explosion-Type Distal Radius Fractures
Fig.4.19 Management of FOFs according to the authors technique (see text for details) (Copyright by Dr. Pial, 2009)
a b
Fig.4.20 (a) A FOF has sunk into a metaphyseal void in the
scaphoid fossa. After several attempts of reduction, without sup-
port, the fragment did not resist the stress of the probe, and sank
joint, by inserting the arthroscope in the 34 portal and
the working instruments in 6R. Whatever work that
needs to be done there can now be safely carried out as
the radius is firmly fixed (Fig.4.23).
Similarly, midcarpal portals are established to rule
out interosseous ligament injuries. Throughout the
procedure the hand is released from traction, and fluo-
roscopy is used as necessary before definitive fixation
is carried out. Similarly, the joint is flushed as required
with the method presented (Fig. 4.3) as minimal
extravasation is expected with the dry arthroscopy
technique (Fig.4.24).
The pronator quadratus is sutured radially to its
remnants or to the brachioradialis tendon with two or
three resorbable stitches. The volar skin is closed in a
single layer with a subcuticular 3/0 nylon.
53
c
again every time. (b) After a supporting hammock of locking
pegs had been created, the FOF is now shown overreduced prior
to being leveled by the probe (c)
Aftercare
The operations are carried out as an outpatient proce-
dure. Twenty-four to forty-eight hours later the splint
is removed, and self-directed active and assisted exer-
cises are encouraged. A removable plastic splint is fab-
ricated, to be worn only when at risk of further trauma.
After 4 or 5 weeks any limitation of arc of motion is
addressed by assisted exercises under the supervision
of a physiotherapist. Exceptions are made in the cases
of additional fixation required for dorsal rim fixation
where 3 weeks of extension blocking is required. Other
exceptions are the associated distal radio-ulnar derange-
ment where my preference is a sugar-tong splint,
blocking prono-supination but leaving the radiocarpal
joint free (Fig.4.25).
54
Fig.4.21 (ad) Technique
for reduction when many
fragments remain unreduced
(see text)
Special Situations
So far the standard management of an explosion-
type DRF has been presented. Quite frequently, how-
ever, special situations challenge the most experienced
surgeons. Associated metaphyseal comminution,
localized comminution at the scaphoid fossa, the
control of small volar-ulnar fragments, and manage-
ment of loose osteoligamentous fragments are among
some of them. Other considerations such as manage-
ment of the carpal tunnel are also discussed in this
section.
Severe Metaphyseal Comminution
Volar locking plates act as internal fixator devices,
making the use of an external fixator unnecessary in
the aftercare of a DRF. Nevertheless, the use of a
F. del Pial
temporary external fixator (intraoperatively) may prove
extremely valuable in severely comminuted metaphy-
seal fractures (C32 of the AO classification) to avoid
loss of the extra-articular reduction during the opera-
tion. Under those circumstances, the metaphyseal sup-
port may be so feeble that the K-wires may pull through
the comminuted metaphyseal fragments and/ or the
whole epiphysisK-wire complex may toggle on the
plate, during the arthroscopy. The stage is set for disas-
ter when the surgeon only pays attention to the articu-
lar component, and inserts the locking pegs and screws
distally on the plate without fluoroscopic control
(Fig.4.26). The end result will be a reasonable articu-
lar reduction but a poor metaphyseal reduction, and a
too prominent distal edge of the plate (quite a worrying
scenario for the flexor tendons) (Fig.4.27).
To avoid this complication, a simple frame external
fixator is installed temporarily as recommended by
Fernandez and Jupiter [12]. Alternatively, a locking
4 Treatment of Explosion-Type Distal Radius Fractures 55

The Small Volar-Ulnar Fragment

Fig. 4.22 While the surgeon (red gloves) is maintaining the
reduction with the help of a bone clamp and the shoulder probe,
the other surgeon (green gloves) is inserting critical locking
pegs into the plate
peg (rather than a K-wire) can be inserted in the less
comminuted part of the metaphysis under fluoroscopy.
This peg will support all the reconstruction, and during
the arthroscopy, the surgeon will build up the joint to
this fixed portion.
The volar-ulnar fragment was a source of major prob-
lems and sequelae in DRFs. Melone drew attention to
the importance of detecting malrotation of this frag-
ment [22]. Apergis etal. [3], on the other hand, showed
that even deceptively small fragments can cause late
volar radiocarpal dislocation if not appropriately
addressed.
The typical volar-ulnar fragment of the four-part-
type articular fracture responds well to the protocol
reported previously. It can be easily reduced from the
incision used to place the plate and, after arthroscopic
fine-tuning, can be rigidly fixed with the pegs of the
plate. The difficulty comes when the fragment has a
small metaphyseal component. In those instances, the
plate offers little support, risking surpassing the distal
edge of the plate (Fig.4.28).
Although the loss of reduction can occur with any
small metaphyseal fragment all along the volar rim of
the radius, the consequences are particularly grave
when this takes place in the volar-ulnar corner of the
radius: volar dislocation of the carpus and incongru-
ence at the lunate fossa [15]. In order to fix these small
fragments with the available locking plates, one would
need to place the plate too distally and ulnarly, risking
both tendon irritation and DRUJ penetration by the
pegs [2]. Orbay modified his original plate by creating
a small tongue that extends distally and ulnarly.
However, in my experience this improvement is still
insufficient for fragments with a small metaphyseal
component. My preference is to fix these small volar-
ulnar fragments with an independent K-wire, with a
procedure derived from Fernandez and Geisslers

Fig.4.23 Ulnar exploration

is carried out with the scope
in 34 and the instruments in
6R once the radius is firmly
fixed. Right: corresponding
ulnar view of the patient
shown in Figs.4.6 and 4.9,
where an I-A tear is evident
(left wrist)
56 F. del Pial

Fig.4.24 Notice that

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

Fig.4.25 Authors preferred

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

original technique [11, 12]. They use a formal volar-
ulnar approach to apply a plate or at times a K-wire,
but such a large incision is not required when a volar
locking plate is inserted radially. A 1.5cm incision is
made radially to the ulnar neurovascular bundle at the
distal wrist crease level (Fig. 4.29). With a Stevens
tenotomy scissors, the space between the flexor ten-
dons and the ulnar pedicle is developed. Gentle retrac-
tion will permit us to reach the ulnar corner of the
radius and to place there a protective soft-tissue guide.
The volar-ulnar fragment is now reduced from the
radial approach and stabilized with a bone hook, and at
the same time the surgeon exerts pressure on the drill
guide to keep it stably reduced. Flexion of the wrist at
this stage is recommended in order to relax the short
radiolunate ligament. The K-wire is introduced and
left percutaneously. The operation continues as usual,
i.e., volar plate application, arthroscopy etc. At 4 weeks
the Kirschner is removed in the office, and a range of
motion started (Fig.4.30).
4 Treatment of Explosion-Type Distal Radius Fractures
Fig.4.26 The possibility of
intraoperative collapse during
arthroscopic reduction is
particularly feasible when
metaphyseal comminution
exists and frequent fluoro-
scopic controls are not made
(see text for details)
Fig.4.27 (ac) The extra-articular reduction was lost during
the arthroscopic part of the operation in this patient who had a
severe C32 fracture. Despite the correct articular reduction,
Scaphoid Fossa Comminution
Styloid fractures represent an extremely wide group
ranging from truly simple fractures (B11of the AO clas-
sification) [23] to more complex fractures that involve
the scaphoid fossa only (B12), or the volar or dorsal rim
of the radius in combination with the styloid itself (vari-
ations of types B31 and B33, and B22, respectively).
Recognition of the subtypes bears a critical importance
for the treatment as it is, in my view, responsible for
some of the bad results of the styloid fracture (Fig.4.31).
In fact, while simple styloid fractures are readily acces-
sible to arthroscopic treatment and ideal for beginners,
57
both shortening (arrow) and dorsal tilting negatively influenced
the clinical outcome
the other subtypes are challenging for the experienced
arthroscopist. An exact assessment of the areas involved
is paramount for the appropriate treatment of these
fractures. However simple or uncomplicated fractures
may appear to be at first sight, in my experience, both
preoperative CT scan and intraoperative arthroscopy
are fundamental in the decision making process.
For the single fragment situation I prefer cannulated
screws inserted under arthroscopic guidance (Fig.4.31a).
A 2 cm transverse incision slightly distal to the radial
styloid is made. Two K-wires are preplaced under fluo-
roscopic control, with the hand lying flat on the operat-
ing table, on each side of the first extensor compartment.
58
Fig.4.28 Volar-ulnar
fragments with a small
metaphyseal component (m)
bear a high risk of volar
radiocarpal dislocation
The hand is now suspended and under arthroscopic guid-
ance (scope in 6R working instruments in 34), reduc-
tion of the fragment is carried out with a shoulder probe
and manual external pressure. A bone clamp maintains
the reduction while the K-wires are pushed in. The hand
is taken out from traction and cannulated screws are
inserted with the hand flat on the table (Fig.4.32).
As the comminution increases, and the fracture pat-
tern gets more intricate towards a mixture of styloid-
volar or dorsal Bartons fracture, the approach
presented before will bring about untoward deformity:
compression directed ulnarly by the screws will cause
crumbling of the central fragments (Fig.4.31b). This
can be managed arthroscopically by a combination of
K-wires, bone graft supporting the reduction, and an
external fixator to avoid early collapse. My preferred
fixation method, however, is buttressing plates that
allow a fixation rigid enough to start early range of
motion without the need of bone graft support.
Unfortunately, available radial volar-locking plates at
best send two pegs to the styloid providing a poor fixa-
tion when there is severe comminution of the scaphoid
F. del Pial
fossa. My first choice is a classic 2.7 mm AO steel
plate (which has a very low profile) applied with the
buttressing principle, much the same as that recom-
mended by Jupiter etal. for volar Barton fractures [16].
I use an L- or a T-shaped plate depending on the con-
figuration of the fracture. The idea is that the volar
fragments are supported by the distal component of the
plate, the latter being placed as proximal as possible as
to avoid flexor tendon irritation (Fig.4.31c).
Through a limited radial approach, the most distal
portion of the pronator quadratus is reflected ulnarly.
Manual reduction of the fragments is carried out, and
the plate is applied over the area of comminution, try-
ing to encompass all the metaphyseal fragments with
its distal limb (Fig.4.33).
Minimal shaping is required, except molding of the
distal edge to avoid flexor tendon irritation, as the more
separated the plate is at its center the more pressure it
will exert as the central screws are tightened. It is
important to take into account that the distal edge of
the plate will recede several millimeters when the cen-
tral screw is tightened as the plate has to adapt to the
4 Treatment of Explosion-Type Distal Radius Fractures 59

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

a c d

Fig.4.30 (a, b) Explosion-type DRF. The volar-ulnar fragment fragments with such a little metaphyseal component (m) cannot
is displaced into the middle of the lunate fossa (arrow). On the be appropriately addressed with the available locking plates.
sagittal section, it is clearly seen that it has a 90 rotation. (c, d) Radiological result. Notice that the proximal rim of the
Reduction will not be a problem from the radial incision but fragment is actually distal to the plate

concavity of the radius. To compensate for this proxi-
mal migration, the plate should be placed slightly dis-
tal to the intended area of fixation.
Once the plate is applied and the middle screw starts
to get hold of the fragments, the hand is then placed in
traction, and the joint explored with the arthroscope
inserted in a portal away from the area affected, so as
not to disturb the reduction (Scope in 6R or 45 portals;
instruments in 34 portal). The screw is loosened just
enough to enable manipulation of any misplaced frag-
ments. Usually, there may be a combination of
depressed and elevated fragments. For the former, we
use a shoulder probe, and for the latter, a Freer elevator
that keeps the fragments reduced while the central
screw is tightened. Once the articular surface is reduced
and supported by this screw, the surgeon tests the
60 F. del Pial

Fig.4.31 The treatment of a

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

rigidity of the fixation. If satisfactory, the rest of screws early range of motion, in a much less invasive manner
are introduced with the hand on the operating table than a standard volar-locking plate (Fig.4.34).
(Fig. 4.33). Despite the apparent fragility of these A supporting bony structure is needed opposite the
plates, they provide sufficiently rigid fixation to allow plate for the buttress principle to take effect. When
4 Treatment of Explosion-Type Distal Radius Fractures
Fig.4.32 Authors preferred
approach for a simple styloid
fracture. (a) The cannulated
screw is being inserted volar
to the abductor pollicis
longus, and the other guide
wire is dorsal to the extensor
pollicis brevis. (b)
Fluoroscopic view prior to
insertion of the second
cannulated screw
comminution also affects the dorsal rim of the sca-
phoid fossa, use of an under-contoured volar buttress
plate will lead to dorsal displacement of the whole sca-
phoid fossa complex (Fig. 4.31d). For this scenario,
our preference is a standard volar-locking plate. The
latter is not ideal, as it requires a larger approach, is
more expensive, and provides a more tenuous fixation
as referred to above. Nevertheless, this option is, in our
opinion, better than the external fixator and K-wires
alternative. Some subsidence of the smaller styloid
fragments is sometimes unavoidable, but probably is
inconsequential (a similar effect to a stylodectomy)
provided the main fragments of the scaphoid fossa
remain reduced (Fig.4.35).
Osteochondral Fragments with Attached
Ligaments
Severely displaced osteochondral fragments with
attached ligaments are commonly seen after radiocarpal
dislocations; they are responsible for persistent dislo-
cations if not specifically addressed (see Chap. 11).
[10, 17]. When the bone portion is sizable, a screw or a
K-wire would be appropriate as mentioned previously
61
for the dorsal rim fractures. When the fragment is small
and contains a major articular fragment or a major liga-
ment portion, however, all efforts have to be made to
achieve fixation and avoid the risk of redislocation.
Chin and Jupiter recommended reattaching such rim
fragments by means of a figure-of-eight wiresuture in
order to minimize manipulation and osteonecrosis [4].
The technique we have used is to spear the fragment
by means of an epidural-type needle (Touhy or
Rodieras needle) inserted from the 34 portal
(Figs. 4.36 and 4.37). The needle is loaded with the
thread from the volar-radial incision (needed for the
plate). Now the needle is slowly withdrawn and, once
in the joint, the fragment is speared again and the nee-
dle pushed volarly. In this way, a mattress stitch will be
located intraarticularly, while both suture ends will be
located palmarly, ready to be tied.
Preventive Opening of the Carpal Tunnel
Minimal swelling is seen after a dry arthroscopy (Fig.
4.24). Our policy is not to open the carpal tunnel unless
preoperatively there were symptoms that pointed to an
acute carpal tunnel syndrome. Additionally, all our
62 F. del Pial

Fig.4.33 (ac) Comminuted scaphoid fossa with a depressed of buttressing, and an additional screw was used for the larger
free fragment (F) but an intact dorsal rim to apply counter pres- styloid fragment
sure (arrows). (d) A 2.7mm plate was applied with the principle

Fig.4.34 The incision

required to fix a styloid
fracture with a volar buttress
plate has been highlighted
with dots. Notice that the
transverse back-cut is slightly
longer and the longitudinal
part of the incision much
shorter than in the standard
radial approach. The fixation
with a 2.7mm buttress plate
is stable enough to allow
early range of motion (result
at 8 weeks) (same patient as
in Fig.4.33)
4 Treatment of Explosion-Type Distal Radius Fractures
Fig.4.35 (a, b) Comminuted scaphoid fossa with involvement
of the dorsal rim of the radius (arrowheads) that contraindicates
the use of the buttressing principle (Fig. 4.31d). (c) A volar
Fig.4.36 Artistic representation of the technique for osteochondral reattachment
patients are interrogated preoperatively for symptoms
that could indicate a minimally symptomatic carpal
tunnel syndrome history (awakening at night with tin-
gling, or numbness in the median nerve distribution).
Only those patients will have their carpal tunnels
opened. Otherwise, these minimally symptomatic
patients may undergo a painful postoperative period,
with reflex sympathetic dystrophy symptoms that will
not ease up until after the median nerve is decom-
pressed. In all these cases, the volar retinacular liga-
ment is opened through a minimal distal incision
(Raimondi, Piero,MD. Milan (Italy). Personal commu-
nication; 2001). The latter is never connected to the
63
locking plate supports a major portion of the scaphoid fossa, but
some subsidence is at times unavoidable
ulnar approach (when needed) in order to minimize
linear scarring.
Clinical Experience
We have operated more than 200 articular DRFs under
arthroscopic control. None of our cases were considered
a failure nor did the arthroscopy had to be abandoned. In
order to test the feasibility and outcome of the above
protocol, we extracted a subgroup of the 16 consecutive
most comminuted fractures [5, 8]. They all had explosion
64
Fig.4.37 Fixation of a volar osteoligamentous fragment with
the technique shown in Fig.4.36 (left wrist, scope in 6R). (a) A
fragment containing the short radio-lunate ligament (SRL)
remains unstable at the end of the fixation with a volar locking
plate. The unloaded Touhy needle is ready to penetrate the
fractures: more than five articular fragments and/or a
FOF. After a minimum interval of 2 years, they were
called back for the purpose of this study. Except in one
case where the extra-articular reduction was lost, in the
rest, the radiographic parameters were satisfactorily
maintained. Range of motion was 105 of flexion-exten-
sion, grip strength was 85% of the contralateral, and a
DASH of 6. This study confirms that (dry) arthroscopy
is feasible in the most severely articular comminuted C3
fractures, and our results compare favorably with other
similar case series [24, 25]. In a more recent case, out of
the study group, one patient suffered collapse of the
lunate fossa and required radiolunate arthrodesis.
References
1. Adolfsson L, Jrgsholm P. Arthroscopically-assisted reduc-
tion of intra-articular fractures of the distal radius. J Hand
Surg. 1998;23B:3915
2. Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, RingD.
The volar extension of the lunate facet of the distal radius: a
quantitative anatomic study. J Hand Surg. 2006;31A: 8925
3. Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of
the ulno-palmar distal radial fragment. J Hand Surg.
2002;27B:13945
4. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced
osteochondral fractures of the distal radius. J Hand Surg.
1999;24A:52533
F. del Pial
f ragment. (b) The needle has been pulled back now loaded, and
is ready to spear the fragment again. (c) The final reduction is
shown after the suture has been tied volarly. The horizontal mat-
tress stitch has been marked by an arrow
5. del Pial F. Dry arthroscopy of the wrist: Its role in the man-
agement of articular distal radius fractures. Scand J Surg.
2008;97:298304
6. del Pial F, Garca-Bernal FJ, Delgado J, Sanmartn M,
Regalado J, Cerezal L. Correction of malunited intra-articular
distal radius fractures with an inside-out osteotomy tech-
nique. J Hand Surg. 2006;31A:1029234
7. del Pial F, Garca-Bernal FJ, Pisani D, Regalado J, Ayala H,
Studer A. Dry arthroscopy of the wrist: surgical technique.
J Hand Surg. 2007;32A:11923
8. del Pial F, Studer A, Garca Bernal FJ, Regalado J, Cagigal L,
Thams C. Explosion type articular distal radius fractures: tech-
nique and results of volar locking plate under dry arthroscopic
guidance. FESSH Congress. Poznan, Poland. 2009
9. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intra-
articular fractures of the distal aspect of the radius:
arthroscopically assisted reduction compared with open
reduction and internal fixation. J Bone Joint Surg. 1999;81A:
1093110
10. Dumontier C, Meyer zu Reckendorf G, Sautet A, Lenoble E,
Saffar P, Allieu Y. Radiocarpal dislocations: classification
and proposal for treatment. A review of twenty-seven cases.
J Bone Joint Surg. 2001;83A:21218
11. Fernandez DL, Geissler WB. Treatment of displaced articu-
lar fractures of the radius. J Hand Surg. 1991;16A:37584
12. Fernandez DL, Jupiter JB. Surgical techniques. In: Fractures
of the distal radius. A practical approach to management.
2nd ed. New York: Springer; 2002. p. 71127
13. Geissler WB. Intra-articular distal radius fractures: the role
of arthroscopy? Hand Clin. 2005;21:40716
14. Guofen C, Doi K, Hattori Y, Kitajima I. Arthroscopically
assisted reduction and immobilization of intraarticular frac-
ture of the distal end of the radius: several options of reduc-
tion and immobilization. Tech Hand Up Extrem Surg.
2005;9:8490
4 Treatment of Explosion-Type Distal Radius Fractures
15. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez
DL. Loss of fixation of the volar lunate facet fragment in
fractures of the distal part of the radius. J Bone Joint Surg.
2004;86A:19008
16. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D.
Operative treatment of volar intra-articular fractures of the
distal end of the radius. J Bone Joint Surg. 1996;78A:
181728
17. Lozano-Caldern SA, Doornberg J, Ring D. Fractures of the
dorsal articular margin of the distal part of the radius with
dorsal radiocarpal subluxation. J Bone Joint Surg. 2006;
88A:148693
18. Marx RG, Axelrod TS. Intraarticular osteotomy of distal
radius malunions. Clin Orthop. 1996;327:1527
19. Mathoulin C, Haerle M. Vascularized bone graft from the
palmar carpal artery for treatment of scaphoid nonunion.
J Hand Surg. 1998;23B:31823
20. Medoff RJ. Essential radiographic evaluation for distal
radius fractures. Hand Clin. 2005;21:27988
21. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of
intra-articular fractures of the distal radius. An arthroscopi-
cally-assisted approach. J Bone Joint Surg. 2000;82B: 7986
65
22. Melone CP Jr. Distal radius fractures: patterns of articular
fragmentation. Orthop Clin North Am. 1993;24:23953
23. Mller ME, Nazarian S, Koch P, Schatzker J. The compre-
hensive classification of fractures of long bones. New York:
Springer; 1990
24. Ring D, Prommersberger K, Jupiter JB. Combined dorsal
and volar plate fixation of complex fractures of the distal
part of the radius. J Bone Joint Surg. 2004;86-A:164652
25. Rogachefsky RA, Lipson SR, Applegate B, Ouellette EA,
Savenor AM, McAuliffe JA. Treatment of severely commi-
nuted intra-articular fractures of the distal end of the radius
by open reduction and combined internal and external fixa-
tion. J Bone Joint Surg. 2001;83A:50919
26. Slutsky DJ. Clinical applications of volar portals in wrist
arthroscopy. Tech Hand Up Extrem Surg. 2004;8:22938
27. Thomas AD, Greenberg JA. Use of fluoroscopy in determin-
ing screw overshoot in the dorsal distal radius: a cadaveric
study. J Hand Surg. 2009;34A:25861
28. Wiesler ER, Chloros GD, Mahirogullari M, Kuzma GR.
Arthroscopic management of distal radius fractures. J Hand
Surg. 2006;31A:151626
 Management of Distal Radius
Fracture-Associated TFCC Lesions 5
Without DRUJ Instability

Alejandro Badia

Introduction thorough evaluation of the articular comminution, and

facilitates correction of gaps and/or step-offs with
minimal disruption of soft tissues [1, 2, 3, 1012, 16,
Fractures of the distal end of radius account for nearly
23, 29]. Blood, debris, and small loose bodies can be
20% of all fractures seen in a routine emergency room
identified and removed with arthroscopy. Moreover, it
and are commonly associated with intercarpal liga-
is also possible to identify and treat injuries of TFCC
mentous injuries and other soft tissue disruptions [6].
and intercarpal ligaments during the same sitting [13,
The structure most frequently injured in distal radial
15, 18]. This chapter focuses on arthroscopic manage-
fractures is the triangular fibrocartilage complex
ment of TFCC injuries, without distal radioulnar joint
(TFCC) [15, 21, 24, 27]. In one cadaveric study where
(DRUJ) instability, while surgically treating the ubiq-
a hyperextension force was applied to cadaveric wrists
uitous distal radial fracture.
until a distal radial fracture occurred, an injury to the
TFCC occurred in 63% of the specimens followed by
injuries to scapholunate ligament (32%) and to lunotri-
quetral ligament (17%) [20]. The TFCC consists of the Indications for TFCC Repair
central fibrocartilage, the dorsal and palmar distal radi-
oulnar ligaments, the sheath of extensor carpi ulnaris Central tears of TFCC warrant simple debridement and
tendon, the ulnar collateral ligaments, and the ulnocar- perhaps radio frequency shrinkage to further stabilize tis-
pal ligaments. It works as a single unit that aids in sues and minimize redundancy, while in a peripheral tear
movements, stability, and load sharing at the wrist.
The central area of TFCC is avascular and called the
debridement zone, whereas, the peripheral zone enjoys
an extensive blood supply and is termed the repair
zone [25] (Fig.5.1).
Anatomic reduction of the articular surface of the
distal radius and treatment of the associated injuries
are the primary goals when treating fractures of distal
radius. Appropriate assessment of intraarticular reduc-
tion and of the associated injuries is difficult when per-
forming open reduction and internal fixation without
having to open the joint capsule. Arthroscopy provides
excellent direct visualization of the entire joint, allows

A. Badia, MD, FACS Fig.5.1 Histologic coronal view of the TFCC anatomy showing the
Badia Hand to Shoulder Center, Baptist Hospital of Miami, deep fibers (ligamentum subcruentum) and superficial (capsular inser-
3650 NW 82nd Ave. Suite 103, Doral, Florida 33166, USA tion) fibers of the articular disc. Lesion to the latter is the subject of
e-mail: alejandro@drbadia.com current discussion. Note the proximity of the lunotriquetral ligament

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 67

DOI: 10.1007/978-3-642-05354-2_5, Springer-Verlag Berlin Heidelberg 2010
68 A. Badia

with the loss of the trampoline effect on disc palpation, a per the previously mentioned authors. Therefore, one
suture repair is indicated [5]. A Palmer 1B [19] tear is the can likely conclude that arthroscopic-assisted TFCC
most frequent indication, and the size of the tear deter- debridement alone may suffice for many of the previ-
mines the number of sutures to be placed. Repair of ously unrecognized lesions, but suture repair should
radial sided tears (1D) is controversial since the blood be performed in the large tears that may also explain
supply in this region of the TFCC articular disc is tenu- the occasional persistent ulnar wrist pain in prior
ous. This matter will be discussed in Chap.7. patients, despite a well-healed fracture and adequate
rehabilitation. Large tears can be defined as the ones
where there is a loss of the trampoline effect of the
articular disc, or a sizeable defect remains after debri-
Contraindications for TFCC Repair dement that cannot be expected to heal without
approximating the edges (Fig. 5.2). Small peripheral
A grossly unstable DRUJ with obvious complete loss lesions can be expected to heal when the edges present
of foveal attachment will require a more aggressive no diastasis (Fig.5.3). Arthroscopy now gives us the
repair and will not be addressed in the current discus-
sion. This requires reattachment of the entire TFCC
complex to the fovea using bone anchor or drill holes.
An arthroscopic-assisted technique for this is possible,
but the standard repair of the 6th compartment floor (as
described herein) is not adequate for this profound
instability (see Chap. 6).
Central tears are of course not repaired due to the
lack of propensity for healing. Debridement of central
tears, as for any degenerative TFCC lesion, should be
down to stable edges taking care not to disrupt the
critical volar and dorsal radioulnar ligaments. This can
be best accomplished using radiofrequency which can
provide a more stable edge after initial mechanical Fig.5.2 Large peripheral tear of the articular disc (arrows) with
subsequent loss of the trampoline effect. One must confirm that
debridement. the deeper fibers are not torn via physical examination and pos-
There is also a relative contraindication that ulti- sibly DRUJ undersurface arthroscopy
mately relies upon the surgeons judgment and per-
spective when discussing TFCC lesions associated
with wrist fractures that is in the small peripheral tear
that has equivocal instability, or loss of trampoline like
tension. It is the authors opinion that smaller periph-
eral tears may not require peripheral suture repair
since the very environment of a healing fracture may
provide the necessary hyperemia to augment healing
of smaller cartilage lesions, given no gross instability,
of course. The act of debridement alone will certainly
promote fibrous healing of the torn edge and the sur-
geon must decide intraoperatively if suture repair is
truly necessary. One must remember that the distal
radius fracture itself will also be immobilized postop-
eratively; hence, further healing is generated in this
scenario. This may explain why many patients with
Fig.5.3 Small peripheral tear with minimal displacement has
significant fractures in the past have not had ulnar-
good propensity to heal due to visible vascularity, minimal gap-
sided wrist issues in the long term despite the correla- ping, and period of immobilization implicit in managing the
tion of TFCC lesions, now found arthroscopically, as concomitant distal radius fracture
5 Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability
tool to improve our outcomes in this common, but
troublesome, fracture.
Surgical Technique
The patient is placed in the supine position and a shoul-
der support is secured to the surgical table on the ipsilat-
eral side of the injured wrist. The senior author prefers
to use a regional block, using the three nerves blocking
technique at the elbow level. This prevents complica-
tions caused by the use of axillary blocks [7, 26]. Once
anesthetized, we hold the wrist in supination and a non-
sterile tourniquet is applied to the upper arm, along
with a strap to provide countertraction. The upper
extremity is prepped, draped, and then exsanguinated
with an Eschmarch and the tourniquet is inflated to
250 mmHg. Intravenous sedation is used for tourni-
quet pain. As a part of my surgical protocol, endo-
scopic carpal tunnel release using the single portal
technique (Microaire, Carpal Tunnel Release System,
Charlottesville, VA) is performed at this time if dis-
placement of the metaphyseal fragment is not severe
[2, 4]. However, if the displacement and deformity are
severe, the carpal tunnel is released after the fracture is
reduced, to facilitate safe placement of the scope within
the canal. This carpal tunnel release is performed to
not only decompress the median nerve, but also to
release the flexor tendons which are also under pres-
sure with the tunnel, particularly in the scenario of an
articular distal radius fracture where blood is often
seen within the carpal tunnel. The author notes that
this may decrease the incidence of painful dystrophies
in his experience and the issue of late posttraumatic
CTS is, of course, resolved during the index procedure.
Future prospective studies would be useful to deter-
mine the place for carpal tunnel prophylactic release in
the setting of distal radius fractures, particularly intraar-
ticular fractures.
Via a separate incision, the extended flexor carpi
radialis approach is used for distal radius open reduc-
tion and subsequent fixation [17]. Once the fracture has
been securely stabilized, longitudinal wrist traction is
achieved by placing finger traps on the index and mid-
dle fingers along with 10 lb of weight suspended
through a pulley system, which is secured to the shoul-
der holder. We do not use the traction tower because
almost always there will be a need to use fluoroscopy
69
throughout the procedure and it can be more cumber-
some. An 18-gauge needle is then used to identify the
radiocarpal joint, because Listers tubercle is usually
displaced and hence cannot be reliably used as an ana-
tomic landmark. The 34 portal is utilized to introduce
either the 2.4 or 2.7 mm scope. A full radius shaver
placed through the 45 or 6R portal is used to remove
blood clots and small intraarticular fragments to com-
plete reduction of the joint surface.
A small probe is used to palpate the joint surface in
search of articular gaps and/or step-offs and to test the
integrity of the carpal ligaments and the TFCC.
Management of a TFCC Tear
Type IB tears [19] (ulnar avulsion with or without
ulnar styloid fractures) of the TFCC are usually seen in
significant fracture displacement. Small central tears
are managed with debridement, and larger tears with
the loss of the trampoline effect require percutaneous
suture repair.
A 0.5cm longitudinal incision is made directly over
the area of TFCC detachment as determined by exter-
nal palpation and arthroscopic visualization. A needle
is passed through this incision and a small joint grasper
is inserted to retrieve the suture. It is important to
extend longitudinally and ensure the safety of dorsal
sensory branch of the ulnar nerve.
The TFCC perforation and suture passing can be
performed with commercially available instruments or
a simple 18-gauge needle. The needle is passed within
the longitudinal incision, into the tear and then across
the edge of the visualized TFCC detachment in a prox-
imal to distal direction. The more volar edge is first
perforated and a 20 pds suture is passed through this
needle and retrieved more distally above the disk with
a small joint grabber or small straight clamp. It is
important to pull out the 18-gauge needle before
retrieving the suture, while grabbing the suture, to
avoid cutting it on the bevel of the needle. Once a sim-
ple suture is passed, traction is applied and the second
needle is more easily passed through the now taut
TFCC disk. This second suture is passed more dorsally
and that is usually all required to close the defect. Both
these sutures pass just volar to the sixth compartment
and additional sutures, if required should be passed
across the floor of the compartment by opening the
70 A. Badia

sheath and retracting the extensor carpi ulnaris tendon Regardless of the suture securing method used, a
volarly (Fig.5.4a). sugar-tong plaster splint is then applied over generous
Two 20 pds sutures are now spanning the tear and cast padding while the wrist is held in supination with
tension should be applied to them (Fig.5.4b), while the elbow in 90 flexion (Fig.5.6). TFCC simple debride-
wrist is held in full supination, since the ulnar head will ments, without suture repair, are immobilized in a
sit more ventrally within the sigmoid notch in supination simple volar splint, allowing early pronosupination. In
and this allows for a tighter repair of the detached disk. the recovery room, immediate digital flexion/extension
This is an important maneuver as it allows the wrist to be is encouraged. One week after the surgery, the splint is
in an advantageous position of supination during the converted to a muenster-type fiberglass cast in supina-
healing process, while shoulder abduction can be used tion to permit some elbow flexion/extension while
to compensate for the limited pronation during the reha-
bilitation period. The sutures are manually tied so that
the knots sit on the floor of the sixth extensor compart-
ment and are generally not an issue. However, due to
occasional complaints of subcutaneous knot irritation, a
novel technique of suture welding has been used [5]
(Fig.5.5). At the time of this publication, the technology
of ultrasound suture welding is being reviewed and is
currently not commercially available. Thermal welding
has been considered, allowing a variety of suture mate-
rial to be used, and is in the investigational phases.

Fig.5.5 Suture welding technique which eliminates subcutane-

ous knots that often cause irritation

Fig. 5.4 (a) Arthroscopic view showing sutures spanning the

TFCC tear, without tension and loss of trampoline effect.
(b) Arthroscopic view showing suture spanning the tear, now
under tension. Note the loss of concavity on the disc signifying Fig. 5.6 Intraoperative sugar-tong splint holding the wrist in
the restoration of trampoline effect supination at the time of TFCC suture repair
5 Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability
restricting pronation/supination in TFCC repair proto-
cols. Cast removal 5weeks later should be followed by
48 weeks of physical therapy with active range of
motion and strengthening. In cases of TFCC debride-
ment alone, the short arm cast is usually removed
between 3 and 5 weeks depending upon the fracture
stability after fixation.
Discussion
The operative management of distal radial fractures
continues to evolve and the recent research is focused
on anatomic congruency, TFCC injuries, and resultant
DRUJ instability. Many studies have suggested that
arthroscopic-assisted fixation of distal radial fractures
is the best alternative to assess the joint surface and
residual step-offs once reduction and fixation have
been obtained Moreover, associated intercarpal and
ligamentous injuries can also be assessed and man-
aged [1, 2, 1013, 15, 16, 18, 23, 29]. Arthroscopy
has been demonstrated to be more reliable for the
diagnosis and treatment of such injuries when com-
pared to cinearthrography [28] and MRI [22] with
minimal disturbance of the soft tissues. A prospective
cohort study by Ruch et al. [23] showed that the
patients who underwent assisted arthroscopic proce-
dures had a greater degree of supination, flexion, and
extension than the patients undergoing fluoroscopic-
assisted surgery. Better management of associated
injuries influences the outcome to a great extent.
Lindau et al. performed a prospective study on 51
patients with displaced distal radius fractures [14].
Arthroscopy at the time of fracture showed complete
or partial TFCC tears in 43 patients (24 peripheral
tears, 10 central perforations, and 9 combined tears).
At 1-year follow-up, 10 patients with complete periph-
eral TFCC tears and 7 with partial or no peripheral
tears had DRUJ instability. Shih et al. [24] reported
their results using arthroscopy to treat 33 patients of
distal radius fractures with soft tissue injuries. In their
series, the TFCC was torn in 18 patients. All the
peripheral TFCC tears were repaired and the cases
with SL instability were treated by arthroscopic deb-
ridement and transfixation of the joint interval with
Kirschner wires. At final follow-up, 11 patients
achieved excellent results and 22 patients had good
results according to the Mayo modified wrist score.
71
Osterman and Vanduzer in their series of 56 patients
reported restoration of 95% of rotational arc at 5years
of follow-up [18]. Cheng et al. [9] concluded that
healed radial fractures were often complicated by
chronic debilitating wrist pain and one of the important
causes being TFCC tears with or without DRUJ insta-
bility. Bohringer etal. [8] concluded that arthroscopic
treatment of TFCC tears in acute radius fractures is
possible with good results. Varitimidis et al. [27] in
their prospective study concluded that addition of
arthroscopy to the fluoroscopically-assisted treatment
of intraarticular distal radius fractures improves the
outcome. They further commented that the effective
management of intraarticular injuries could be the key
to the successful outcome.
Acknowledgement The author acknowledges Dr. Prakash
Khanchandani assistance in reviewing the literature and writing
this article.
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70614
 Arthroscopic Management of DRUJ
Instability Following TFCC Ulnar Tears 6
Andrea Atzei

Introduction of the DRUJ ligaments and that most of their insertion is

located in the fovea ulnaris rather than in the styloid.
These studies confirm the role of the proximal part of the
Distal radius fractures (DRF) are usually the result of a
TFCC as the main stabilizer of the DRUJ, as opposed to
high-energy injury to the whole wrist joint.
the distal part, which consists of the distal hammock
The wrist is a complex joint: not only is it com-
structure and the ulnar collateral ligament (Fig.6.1). It
posed of the distal radius and ulna, of eight carpal
also implies that DRUJ instability may occur regardless
bones (including the pisiform), and multiple articular
of the presence of an ulnar styloid fracture, and on the
surfaces, but also of as many as 28 intrinsic and extrin-
contrary, that DRUJ may remain stable even when the
sic ligaments along with the triangular fibrocartilage
ulnar styloid is fractured [10].
complex (TFCC), all within a 5-cm interval. For this
Pathomechanics of DRF were simulated using a mate-
reason, DRF are frequently associated to intraarticular
rials testing machine on 63 prepared cadaver wrists that
soft-tissue injuries that, when overlooked, often lead to
were subsequently examined by conventional radiology
more problems than the fracture itself.
and computer tomography and by dissection [23]. DRUJ
As recognized by many authors [18, 32], distal radi-
oulnar joint (DRUJ) dysfunction is one of the most
frequent complaints following DRF.
Among the different causes of DRUJ dysfunction,
DRUJ instability was a relatively uncommon finding
when DRF were treated by prolonged long arm cast
immobilization, but it became a more common prob-
lem after the introduction of new fixation devices,
especially volar locking plates, and more aggressive
postoperative protocols [7].
Recent acquisitions on the anatomy of DRUJ stabi-
lizing mechanism and on the pathomechanics of the
hyperextension injury of the wrist have improved the
management of DRUJ instability, in terms of early rec-
ognition and efficacy of its treatment.
Nakamura et al.s [10, 22, 23] anatomical studies
showed that the proximal part of the TFCC, also described
with the term ligamentum subcruentum [14], is made up
Fig.6.1 Artists rendering of the ulnar portion of the TFCC. It is
separated into the distal component (dc-TFCC) formed by the
A. Atzei, MD UCL and the distal hammock structure, and the proximal com-
Hand Surgery Unit, Policlinico G.B. Rossi, P.le L.A. Scuro, ponent (pc-TFCC), represented by the proximal triangular liga-
10, 37100 Verona, Italy ment, or ligamentum subcruentum, which originates from the
e-mail: andreatzei@libero.it ulnar fovea and the proximal styloid and stabilizes the DRUJ

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 73

DOI: 10.1007/978-3-642-05354-2_6, Springer-Verlag Berlin Heidelberg 2010
74
instability was the concomitant lesion most frequently
found (44.5%). It resulted from a complete or partial lac-
eration of the proximal part of the TFCC at its ulnar
insertion: either in the form of an ulnar styloid fracture
(19 cases, 67.8% of all DRUJ instability), or an ulnar
avulsion of its ligamentous insertion (8 cases, 28.6% of
all DRUJ instability); in only one case was the disk
sheared from its radial insertion. DRUJ instability resulted
from the pressure-related widening of the wrist, with
maximum rotation and deviation of the forearm. Poor
bone quality, as in older specimens with demineralized
bone, correlated to the presence of an ulnar styloid frac-
ture, rather than TFCC tearing.
Other laboratory cadaver studies [33] demonstrate
that following DRF with the ulnar styloid and TFCC
intact, the distal radius can achieve only certain losses
of radius length, palmar tilt, angle of inclination, or all
the three. Only when ulnar styloid was cut through its
base (and the TFCC detached consequently), the frac-
tured distal radius achieved displacement greater than:
1. 4mm of shortening
2. 0 of radial inclination
3. 10 of dorsal tilt (Fig.6.2)
Fig.6.2 Disruption of DRUJ stabilizing mechanism usually fol-
lows fracture displacement greater than (1) 4mm of shortening,
(2) 0 of radial inclination, and (3) 10 of dorsal tilt. It may be
produced due to a pure ligamentous rupture or through the avul-
sion of the ulnar styloid
A. Atzei
This has important clinical implications, since it
suggests that a DRF with metaphyseal collapse and
shortening or dorsal tilt beyond the above values is
most likely to be associated to DRUJ instability. This
supposition is supported by the observation of Richards
etal. [28], that injury to the TFCC was associated with
greater shortening and dorsal angulation of the radius
at the time of injury.
A further corollary is that, in order to restore proper
tension of the TFCC, the distal radius should be
reduced to at least (1) 2mm of shortening, (2) 10 of
radial inclination, and (3) 0 of dorsal tilt.
Fernandez [6] considered radiographic evidence of
ulnar head subluxation or dislocation and intraarticular
fracture of the sigmoid notch or ulnar head as key fac-
tors for a prognostic and treatment-oriented classifica-
tion of DRUJ instability (Table6.1).
This classification system describes the pathoanat-
omy of the lesions, considering even the most severe
cases of ulnar head and sigmoid notch explosion frac-
ture, and provides prognosis and guidelines for a
comprehensive treatment. Major implication of this
classification system is that DRUJ instability should be
assessed after adequate restoration of the anatomic
relationship between ulnar head and sigmoid notch,
i.e., subsequent to DRF reduction and fixation.
Presence of an ulnar styloid fracture is no longer
considered as an absolute indicator of DRUJ instabil-
ity, but only as a risk factor [17, 20, 31], regardless of
fragment size and displacement.
The supposition by Hauck [8] that DRUJ is unstable
when the styloid is fractured at the base, and the oppo-
site when the fracture is at the tip, is not confirmed by
several arthroscopic studies [1517, 28], that did not
find any predictable correlation between ulnar styloid
fractures and TFCC tears. Although ulnar styloid frac-
ture is related to the pattern and magnitude of the injury
sustained, it also depends on the bone quality and the
relative strength of the ligaments. Thus, styloid frac-
ture is more common in cases of an osteoporotic bone,
giving reasons for the scarcity of isolated ligamentous
injury in the elderly, compared to young active patients,
in which DRUJ instability often results from a midsub-
stance tear of the TFCC [23].
In very rare cases, DRUJ instability results from the
avulsion fracture of the TFCC foveal insertion and is asso-
ciated to a small bony flake from the foveal area [12].
The variable combination of styloid fractures and
ligamentous injuries of the ulnar side of the wrist has
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears 75

Table6.1 Classification of DRUJ lesions associated to DRF according to Fernandez [6]. The pathoanatomy of TFCC tear and ulnar
head and sigmoid notch fracture is described, providing prognosis and guidelines for a comprehensive treatment
Type Joint surface Prognosis Recommended treatment
involvement
Type I
Stable (following None Good A+B: functional after
reduction of the treatment
radius, the DRUJ Encourage early pronation
is congruous and supination excercises
stable) Note: extraarticular unstable
fractures of the ulna at the
A: fracture of B: stable fracture metaphyseal level or distal
the ulnar of the ulnar neck shaft require stable plate
styloid tip fixation
Type II
Unstable None Chronic instability A: closed treatment
(subluxation or reduce subluxation. sugar
dislocation of the tong splint in 45 supination
ulnar head is 16 weeks
present) Painful limitation A+B: operative treatment
of supination if left repair triangular fibrocarti-
A: tear of B: avulsion unreduced lage complex or fix ulnar
TFCC and/or fracture of the styloid with tension band
palmar and base of the ulnar wiring
dorsal capsular styloid Possible late Immobilize wrist and elbow
ligaments arthritic changes in supination (cast) or transfix
ulna/radius with Kwire and
forearm cast
Type III
Potentially Present Dorsal subluxation A: anatomic reduction of
unstable palmar and dorsal sigmoid
(subluxation notch fragments if residual
possible) subluxation tendency is
present immobilize as in type
II injury
Possible together B: functional after treatment
A: intraarticu- B: intraarticular with dorsally to enhance remodeling of
lar procedure fracture of the displaced die punch ulnar head
at a later date ulnar head or dorsoulnar
fracture of the fragment
sigmoid notch Risk of early If DRUJ remains painful:
degenerative partial ulnar resection,
changes and severe Darrach or SauveKapandji
limitation of procedure at a later date
forearm rotation if
left unreduced

been explained recently by del Pial [24] and defined
as a constellation of ligamentous, osseous, and cap-
sular damage [25].
A special condition is represented by the Galeazzi
fracture-subluxation. When the fracture is localized
within 7.5 cm of the distal epiphysis of the radius,
DRUJ instability is frequently associated and requires
repair [27].
Radiographic measurement of distal radius displace-
ment, presence of DRUJ widening, or ulnar styloid
76 A. Atzei

Table 6.2 Risk factors for DRUJ disruption as seen on plain

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

fracture, may only give a hint of an associated DRUJ

instability (Table6.2). However, DRUJ instability still
remains a challenging issue complicating DRF, espe-
cially in young patients, in whom preoperative clinical
assessment and imaging often fails to provide reliable
indications. When arthroscopic evaluation is performed
during DRF treatment, a more accurate definition of
the TFCC ruptures may be obtained, whether they are
isolated or associated to osseous avulsions, either from
the radius or ulna.
The aim of this chapter is to illustrate the arthroscopic
management of DRUJ instability following TFCC
ulnar tears.
Clinical Assessment and Arthroscopic
Findings
After reduction and stable fixation of any DRF, either
intraarticular or extraarticular, it is strongly recom-
mended that DRUJ laxity is assessed intraoperatively
by the ballottement test (Fig.6.3) that has proven to be
simple and reliable [21]. This test consists of the pas-
sive anteroposterior translation of the ulna on the radius
in neutral rotation, full supination, and pronation.
Abnormal translation in neutral rotation suggests com-
plete TFCC disruption. If the translation is abnormal
when the forearm is held in full supination, then the
dorsal DRUJ ligament is ruptured. On the other hand,
when the translation is abnormal in full pronation, then
Fig.6.3 The ballottement test is a stress test to evaluate DRUJ
stability. The radius is grasped by the examiner and the distal
ulna, fixed between the examiners thumb and index finger, and
moved in dorsal and palmar directions with respect to the radius.
If the ulna shows an increased displacement relative to the con-
tralateral side associated with a soft end-point resistance, it is
likely to develop a symptomatic DRUJ instability, i.e., cause
patients complaint when left untreated
the palmar DRUJ ligament is incompetent. The
increased amount of radioulnar translation is compared
to the opposite side and may be graded as: slight, when
less than 5 mm; mild, when 510 mm; and severe,
when greater than 10mm. Evaluation of the resistance
at the end point of the increased translation is of utmost
importance, since its loss correlates with clinical DRUJ
instability. Though hyperlax, the DRUJ showing a
firm end point is unlikely to progress toward a clini-
cally symptomatic instability. However, the DRUJ
showing an increased passive anteroposterior laxity
with a soft end-point resistance is prone to develop a
clinical instability, i.e., cause a patients complaint
when left untreated.
TFCC laceration may occur either at its radial inser-
tion, or more frequently, at its ulnar end. (Radial tear of
the TFCC will be discussed in Chap 7). Ulnar disrup-
tion can result from a midsubstance tear, commonly in
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears
the young patient, or from an avulsion fracture of the
bony insertion, i.e., ulnar styloid fracture, or a combi-
nation of both, depending on the direction and severity
of traumatic forces acting across the wrist [24].
Therefore, when the ballottement test is positive,
regardless of the radiological evidence of a concomi-
tant ulnar styloid fracture, arthroscopy of the radiocar-
pal joint is advisable to evaluate the extent of TFCC
involvement.
Arthroscopic exploration of the wrist is recom-
mended to assist operative treatment of DRF in order
to improve reduction of intraarticular step-offs, or to
detect chondral and ligamentous lesions.
Arthroscopy permits accurate definition of the dif-
ferent conditions affecting the TFCC. According to
Palmers classification of TFCC tears, a type 1-B
injury (ulnar detachment) should be visualized from
the 34 portal in the dorsoulnar edge of the TFCC.
The TFCC tension is evaluated by the trampoline test
[11] and the hook test. The trampoline test assesses
the TFCC tautness by applying a compressive load
across it with the probe (Fig.6.4). The test is positive
Fig.6.4 The trampoline test: the probe inserted through 6-R
(or 45) portal applies a pressure across the TFCC and shows
lack of the normal resilience when the TFCC is lacerated. This
test may be misleading when using the dry technique, probably
due to the lack of fluid distention that reduces TFCC resilience
77
when the TFCC is soft and compliant and suggests a
peripheral TFCC tear.
The hook test is a less known test whose use has
been advocated to evaluate foveal avulsion of the proxi-
mal component of the TFCC [2, 5, 29]. It consists of
applying traction to the ulnar-most border of the TFCC
with the probe inserted through the 45 or 6-R portal,
and is considered positive when the TFCC can be lifted
distally and radially toward the center of the radiocarpal
joint (Fig.6.5). In my early experience with this test, I
used DRUJ arthroscopy to confirm the foveal disruption
of the proximal component of the TFCC and found a
high correspondence between the positive hook test and
the proximal detachment of the TFCC. Thus, in my
practice, the positive hook test is a consistent indicator
of TFCC foveal avulsion, and a confirmatory DRUJ
arthroscopy is no longer required. However, DRUJ
arthroscopy is still advisable to detect any posttraumatic
chondromalacia or even cartilage loss of the distal ulna
Fig.6.5 The hook test: the probe is inserted through 6-R portal
into the prestyloid recessus in an attempt to pull the TFCC in
multiple directions. The TFCC can be displaced towards the
center of the radiocarpal joint only when the proximal compo-
nent of the TFCC is torn or avulsed from the fovea. In this case,
the test is considered positive
78
or sigmoid notch that may be the cause of a poor out-
come after TFCC foveal repair [1, 4].
Assessment of TFCC disorders includes preopera-
tive evaluation of normal X-rays that may show an
ulnar styloid with no/tip or basilar fracture and consid-
ers the following intraoperative parameters:
Clinical DRUJ laxity: the ballottement test allows
grading as none, slight, mild, and severe laxity. Soft or
firm end-point resistance is also evaluated.
Arthroscopic assessment of the TFCC distal compo-
nent: as visualized through the 34 portal during radio-
carpal arthroscopy, that may show either an intact surface
or a tear usually on the dorsoulnar edge of the TFCC.
Arthroscopic assessment of the TFCC proximal
component: according to the hook test, that may show
either an intact (negative hook test) or a torn proximal
TFCC (positive hook test). DRUJ arthroscopy through
the Distal DRUJ portal may help doubtful cases.
Correlation of radiographic, clinical, and arthroscopic
findings associated to fresh DRF allow to arrange different
conditions in a treatment-oriented classification, which
results from the outline proposed for chronic peripheral
TFCC tears [1] (Table6.3).
Generally speaking, in fresh DRF, the TFCC tear is
easily reducible and shows a good healing. However,
following high-energy injuries or due to the coexis-
tence of previous TFCC disorders, radiocarpal arthros-
copy may show TFCC extensive laceration or frayed
edges that cannot be repaired in the acute setting.
In addition, high-energy injuries may cause carti-
lage loss or posttraumatic chondropathy of either the
sigmoid notch or the ulnar head, whose presence should
be investigated by DRUJ arthroscopy, as they may be
responsible for a poor long-term outcome [16].
Indications
In most instances, anatomic reduction of the distal
radius, especially arthroscopically assisted, permits res-
toration of DRUJ stability, regardless of the presence of
any ulnar styloid fracture. In this case, the ballottement
test may still show slight increase of radioulnar transla-
tion, but the surgeon can clearly appreciate a firm end-
point resistance, witnessing ligament tautness. No
further treatment is required in Class 0 lesions (Table6.3),
unless wrist arthroscopy discloses a sizeable laceration
A. Atzei
of the distal portion of the TFCC (Class 1) that should be
treated with arthroscopic suture of the peripheral TFCC
to the ulnar wrist capsule (see Chap. 5).
However, a ballottement test showing an increased
radioulnar translation with a soft end-point resis-
tance reveals an actual insufficiency of the stabilizing
structures. The latter condition is produced as a result
of variable pathoanatomy and requires appropriate
treatment to prevent the development of symptomatic
DRUJ instability. Wrist arthroscopy permits precise
visualization of the ruptured structures and reliable
testing of its tautness, notably by the hook test, and
hence it is decisive in the definition of appropriate
treatment strategy (Table6.3.).
DRUJ laxity, as defined by a positive ballottement
test, correlates to a positive hook test and may have
arthroscopic evidence of a peripheral TFCC tear on
radiocarpal exploration. This condition follows a com-
plete peripheral TFCC tear, i.e., involving both the
proximal and distal components of the TFCC, and the
ulnar styloid may be intact, have a tip fracture, or a
large styloid fracture (Class 2). The last setting, in
which the TFCC is avulsed from the fovea and the
ulnar styloid, fractured at its mid- to proximal-height,
retains only a few ligamentous fibers, represents a par-
ticular condition that I call floating styloid. In Class
2 lesions, the TFCC should be repaired to the fovea,
and the floating styloid (the large styloid fragment with
few ligamentous attachments), may require styloid
excision.
Alternatively, though with a positive ballottement
and hook test, radiocarpal arthroscopy may show no
TFCC tear, regardless of the type of ulnar styloid frac-
ture. These conditions are the consequence of an iso-
lated tear of the proximal portion of the TFCC (Class 3),
whose diagnosis is often challenging.
In Class 3, when the ulnar styloid shows no or a tip
fracture or when it shows limited size or quality to
retain any fixation device, TFCC foveal refixation is
recommended, by transosseous sutures or suture
anchor, and the smaller or comminuted ulnar styloid
is left in situ and rarely removed. Although it may
develop a radiographic appearance of nonunion, when
DRF reduction is acceptable and DRUJ instability is
restored, the nonrepaired ulnar styloid is seldom the
cause of pain and should eventually be treated when it
becomes symptomatic (see Chap. 13). However, when
the ulnar styloid is fractured closer to its base, usually
Table6.3 Comprehensive classification of TFCC peripheral tears and associated ulnar styloid fractures considers radiographic, clinical, and arthroscopic findings
Class 0 Class 1 Class 2 Class 3 Class 4 Class 5
No TFCC tear Distal Complete Proximal Nonrepairable DRUJ
Isolated styloid Fx TFCC tear TFCC tear TFCC tear TFCC tear Chondral loss
arthritis
Ulnar styloid
intact or
tip fracture

Ulnar styloid
basilar fracture

(Floating styloida) Class 3-Ab

avulsion fracture
of TFCC insertion
Intraoperative Negative Slight laxity Mild to severe laxity Variable
ballottement test (hard end point) (soft end point)
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears

Distal TFCC Intact Ulnar tear Intact Ulnar tear Variable

appearance
(RC arthroscopy)
Proximal TFCC Taut Loose Variable
tension (negative) (positive)
(hook test)
Suggested None TFCC suture TFCC foveal repair Styloid fixation Tendon graft after Arthroplasty
treatment fracture healing when symptomatic
Two basic conditions are defined according to the radiographic evidence of the ulnar styloid showing no or tip fracture and a basilar fracture. After fracture reduction and fixation,
residual DRUJ instability is tested by the ballottement test and TFCC is evaluated by arthroscopic inspection and the hook test. Treatment is suggested according to the different
classes
a
Class 2 floating styloid may require styloid excision
b
Class 3-A requires ulnar styloid fixation by K-wires and tension band or cannulated headless mini-screw fixation
79
80 A. Atzei

due to an avulsion mechanism by the TFCC itself,

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

Technique

Operative Setup and Diagnostic

Arthroscopy

Repair of DRUJ instability associated to DRF is an
essential part of the surgical treatment of DRF and is
performed using the same operative setup as
arthroscopic-assisted DRF reduction and fixation.
The wrist is suspended by finger traps using a wrist
traction tower in a standard arthroscopic setup ([3], see
also Chaps. 2 and 3). Joint distension is usually not required
and the use of the dry technique [26] is advisable, since it
benefits complex and long-lasting procedures.
The wrist is systematically evaluated by radiocarpal
arthroscopy using a 2.7-mm arthroscope as a routine,
reserving the 1.9-mm arthroscope for smaller wrists.
The scope is introduced through the 34 portal and
care is taken to detect any associated disorders of the
intercarpal ligaments.
Tears of the distal component of the TFCC are seen on
the dorsal-ulnar aspect, and depending on the delay of
treatment, are frequently covered by coagulated hematoma
or granulation tissue, which is removed with a shaver.
A probe is inserted in the 6-R portal to assess the
tension of the TFCC using the trampoline test and
especially the hook test.
My experience agrees with that of del Pial [24],
that the trampoline test is often misleading, especially
when using the dry technique, probably due to the lack
of fluid distention of the ulnar wrist that reduces TFCC
resilience. Therefore, my diagnosis of TFCC peripheral
Fig.6.6 Arthroscopic portals required for complete exploration
of the wrist and foveal repair of the TFCC. R-MC radial mid-
carpal portal; U-MC ulnar mid-carpal portal; D-DRUJ distal
DRUJ portal; and DF direct foveal portal
tear, particularly foveal avulsions, relies on the positiv-
ity of the hook test, even when the radiocarpal explora-
tion shows an intact distal component of the TFCC.
According to the approach suggested in Table6.3,
repair of DRUJ instability is performed by direct reat-
tachment of the proximal component of the TFCC into
the fovea, with a suture anchor or screw in Class 2 and
3, or by ulnar styloid refixation with a small cannulated
screw, K-wires, and/or tension band in Class 3-A.
Arthroscopic reattachment of the foveal insertion of
the TFCC requires a separate portal to provide access
to the fovea ulnaris. A dedicated working portal named
the direct foveal (DF) portal [5] has been devised to
debride the coagulated hematoma and ligamentous
remnants from the foveal area, prepare the bone, and to
drill and insert the suture screw or anchor (Fig.6.6).
Direct Foveal Portal
The DF portal is located approximately 1cm proximal
to the 6-U portal and is performed with the forearm in
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears 81

Fig.6.7 Artists rendering of

a b
the anatomical relationship of
the ulnar wrist in neutral
prono-supination (a) and full
supination (b). Following
supination (b), the ulnar
styloid and the ECU tendon
displace dorsally and the
fovea and the ulnar-most area
of the distal ulna become
subcutaneous. Full forearm
supination is required to
create the direct foveal (DF)
portal

(Fig.6.8). The DF portal is easier than the volar ulnar

Fig. 6.8 The direct foveal (DF) portal is located about 1 cm
proximal to the 6-U portal and allows exposure of the basi-
styloid and foveal area. It can also be prepared as a mini-open
approach through an oblique skin incision between the ECU and
FCU tendons, protection of the dorsal branch of the ulnar nerve,
and splitting of the extensor retinaculum
portal [30], but it is used only as a working portal.
After confirming the 6-U portal with an 18-gauge
needle, the DF portal is created with a mini-open expo-
sure of the ulnar wrist. A 2- to 2.5-cm oblique skin
incision is made between the ECU and the flexor carpi
ulnaris that extends proximally to the 6-U portal. The
dorsal sensory branches of the ulnar nerve (DSBUN)
are identified by subcutaneous dissection and protected
by two small Ragnells retractors. The risk of damag-
ing the nerve is further reduced by forearm supination
because the nerve is displaced palmarly.
The extensor retinaculum is exposed and split along
its fibers. The DRUJ capsule is incised longitudinally
to reach the distal articular surface of the ulnar head
under the TFCC. The fovea is located palmarly at the
base of the ulnar styloid, just lateral to the capsule as
an area of soft bone.
Through the DF portal, a small shaver or curette is
used to debride the torn or avulsed ligament, remove
adherent clots from the fovea, and prepare it for suture,
screw, or anchor insertion. Curettage of the fovea can also
be performed as an arthroscopic procedure, with the
scope viewing through the distal DRUJ portal (Fig.6.9).

full supination, because this produces dorsal displace-
ment of the ulnar styloid and the ECU tendon and
uncovers the palmar aspect of the distal ulna (Fig.6.7).
The fovea and the basi-styloid area of the distal ulna
become subcutaneous and can be easily exposed [5]
Technique of Suture Anchor Foveal Repair
In order to pass a suture through each limb of the liga-
ment, a screw or anchor with a pair of sutures is pre-
ferred. Using two sutures will also recreate a broader
82 A. Atzei

footprint for a faster healing of the proximal compo-
nent of the TFCC [19].
In fresh TFCC avulsions, I prefer to use a 2.8 or 3.2
titanium screw with two preloaded nonabsorbable 2-0
ultrabraid sutures (Twinfix, ref. 72202067, Smith &
Fig. 6.9 The direct foveal (DF) portal is a working portal to
provide access to the area of the ulnar styloid and fovea. With
the scope in the distal DRUJ portal, a small shaver is inserted
through the DF portal to debride the torn/avulsed ligament and
the fovea
Nephew, Andover, MA) because of the low friction of
the sutures inside the eyelet, that reduces the risk of
suture breakage during knot-tying, and the high tensile
strength of the suture material.
After the suture screw is inserted, the forearm is
placed in neutral rotation, so that the screw head lies
under the TFCCs ulnar-most part and the sutures exit
the DF portal from under the TFCC (Fig.6.10).
With the scope in the 34 portal, the sutures are
inserted in an outside-in fashion from the DF portal,
using the suture loop technique [2, 9], in which the
suture end is inserted into the tip of a 25-G hypodermic
or Tuohy needle so that it creates a loop inside the joint
(Fig.6.11).
The first suture is placed close to the TFCCs pal-
mar edge to hold the palmar limb of the ligament, and
the second one close to the TFCCs dorsal edge to hold
the dorsal limb. The sutures are retrieved with a grasper
inserted through the 6-U portal (Fig.6.12).
The wrist traction is released and an assistant main-
tains the ulnar head in a reduced position with the fore-
arm in neutral rotation. The sutures are tied under
arthroscopic vision using a sliding knot and a small
knot pusher (Fig.6.13). Knots are located at the pre-
styloid recess or just outside the DRUJ capsule. Due to
the ease of knot placement and reduced bulkiness, I
favor the use of the SMC flip knot (Fig.6.14) followed
by two alternating half-hitch throws [13].
Complete tear closure is confirmed. Even in larger
Class 2 TFCC peripheral tears, further ligament-to-cap-
sule sutures are seldom necessary to repair the distal

Fig.6.10 The suture screw

is inserted through the DF
portal into the fovea, which is
located palmarly at the base
of the ulnar styloid, just
lateral to the capsule as an
area of soft bone. The sutures
exit from below the TFCC
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears
Fig.6.11 The extremity of the first suture is introduced into the
tip of a 25-G Tuohy needle. With the scope in the 34 portal, the
needle is inserted outside-in via the DF portal to perforate
TFCCs palmar contour. The second suture is placed on TFCCs
dorsal contour using the same procedure
Fig.6.12 A grasper is inserted through the 6-U portal and used
to retrieve the sutures, so that one extremity of both the sutures
exit from the 6-U portal and the other one from the DF portal
component of the TFCC. The DRUJ is assessed for the
range of forearm rotation and residual laxity. The DRUJ
capsule and the opening between retinaculum fibers are
approximated and the skin is closed (Fig.6.15).
83
Fig.6.13 After the wrist traction is released, the forearm is held
in neutral rotation and the ulnar head in reduced by the assistant,
the sutures are tied using a sliding knot and a small knot pusher.
At the end of the procedure, the probe assesses the restoration of
proper tension of the TFCC (Hook test)
Fig.6.14 The SMC flip knot: a short post strand and a longer loop
strand are prepared. The first underhand throw is made with the
loop strand under both the loop and the post strands (a). The sec-
ond underhand throw is made with the loop strand under the post
strand (b). The loop strand is brought behind the second throw and
an underhand throw is made with the loop strand under the post
strand (c). By pulling the post strand, the knot is introduced into
the joint without difficulty with the aid of a knot pusher. The post
strand is tightened until the snug knot is established. Then, the loop
strand is pulled until the locking loop is incorporated into the knot
84
a b
d e
Fig. 6.15 Illustrative case of the technique of arthroscopic
refixation of TFCC foveal avulsion in DRF (ah). A 26-year-old
man suffered from an unstable AO type 3.2 fracture of the right
distal radius (a). Arthroscopic exploration of the TFCC showed
a complete peripheral tear (b) and a positive hook test (c). A
Twinfix suture screw (Smith & Nephew, Andover, MA) was
inserted through the DF portal using a mini-open approach (d).
The two 20 ultrabraid sutures were introduced outside-in and
A. Atzei
retrieved through the 6-U portal with a grasper (e). After knot-
tying, proper tension of the suture on the palmar (black arrow-
heads) and dorsal DRUJ ligament (white arrowheads) restored
TFCC tautness (f). Postoperative X-rays show fracture fixation
with fixed-angle palmar plate (Matrix; Stryker) and proper
placement of the Twinfix screw into the fovea ulnaris (g), with
functional restoration of the pronosupination after 3months (h)
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears
g h
Fig.6.15 (continued)
Technique of Styloid Fixation
After arthroscopic-assisted reduction of the DRF and
diagnostic arthroscopy confirming the Class 3-A
lesion, the wrist is suspended by finger traps using a
wrist traction tower in a standard arthroscopic setup
[3], with an assistant holding the hand in supination, so
that the distal ulna and the styloid become subcutane-
ous. The fracture site can be easily approached through
an oblique skin incision between the ECU and FCU ten-
dons, in a manner similar to the preparation of the DF
portal, only slightly dorsal and proximal (Fig.6.16).
Great care must be taken to protect the DSBUN,
which courses very close to the level of the ulnar sty-
loid. The extensor retinaculum is split along its fibers,
and then the distal ulnar styloid, the fracture line, and
a few millimeters of the distal ulna are exposed subpe-
riosteally. Gentle traction is exerted on the styloid to
confirm if it is still firmly attached to the TFCC (Class
3-A) and exclude the presence of a Class 2 Floating
styloid. In Class 3-A lesion, the styloid is reduced
with the aid of a skin hook and temporarily stabilized
with a K-wires under fluoroscopy. Definitive fixation
is achieved by multiple K-wires and/or tension band or
by a cannulated mini headless screw (Fig. 6.16a and
b). DRUJ translation returns to normal ranges and the
85
ballottement and hook tests become negative
(Fig.6.17). On the contrary, in Class 2, styloid refix-
ation is not effective on DRUJ stability and the ballot-
tement and hook tests still remain positive after
fixation. In this case, TFCC refixation with a suture
screw is recommended, eventually associating styloid
resection.
Aftercare
The patient is placed in a long arm splint in neutral
forearm rotation for the first week, and a Munster-type
splint (a short arm splint that extends to the epicondyle,
allowing elbow flexion and extension but restricted
forearm rotation) is worn day and night for another
week, to be removed only for physical therapy. Two
weeks after the operation and according to the postop-
erative protocol of the DRF, wrist flexion/extension is
allowed. Gentle forearm rotation in a painless range of
motion may be started as early as 2weeks postopera-
tively, as tolerated by the patient. The splint is still
worn between exercises for another week, after which
it is reduced to a wrist splint and the patient is instructed
to wear the splint the following week, when in public
86 A. Atzei

Fig.6.16 Exposure of the

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

a b c

Fig.6.17 Illustrative case of the technique of ulnar styloid fixation in DRF. Stable fixation of the complex TFC-ulnar styloid by a
cannulated mini headless screw, allowed immediate ROM with this clinical result at 4weeks. (Courtesy dr. F. del Pial)
6 Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears
Fig.6.17 (continued)
d e
or sleeping. Recovery of full range of motion is pro-
gressively achieved in the next 6weeks, during which
resisted movements are not permitted. Finally, pro-
gressive resisted wrist and hand strengthening exer-
cises are begun. Return to full work duties or contact
sports is not allowed for 3months postoperatively.
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16. Lindau T, Arner M, Hagberg L. Chondral and ligamentous
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18. Lindau T, Aspenberg P, Adlercreutz C, etal. Instability of
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19. Lo IKY, Burkhart SS. Double-row arthroscopic rotator cuff
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 Radial Side Tear of the Triangular
Fibrocartilage Complex 7
Toshiyasu Nakamura

Introduction (Fig.7.1). The TFCC has an important role in the stabil-

ity between the ulnocarpal and DRUJs, distribution of
load between ulna and ulnar carpus and smooth wrist
Distal radius fracture induces various soft tissue dis-
motion and forearm rotation [7, 12].
ruptions. Radial tear of the triangular fibrocartilage
Connection from the hyaline cartilage of the radius
complex (TFCC) is a typical soft tissue injury associ-
to the TFC indicates decrease of the cartilage cells and
ated with the distal radius fracture. The radial tear of
matrix, indicating a rather weaker connection histo-
the TFCC includes fibrocartilage central tear and dorsal
logically than the ligamentbone connection (Fig.7.2a)
or palmar rim tear; the latter two may induce distal
[6, 9]. The radioulnar ligaments rise nearly vertically
radioulnar joint (DRUJ) instability [3]. Intrafibro
from the fovea and the base of the styloid process of
cartilage tear of the TFC may not be associated with
the ulna, and after coalescing, bifurcate dorsally and
DRUJ instability. When the DRUJ indicates severe insta-
palmary to pass on the proximal side of the TFCC.
bility in the radial tear of the TFCC, the rim area must be
Finally, they insert in the very dorsal and very palmar
repaired, as opposed to the tear inside the fibrocartilage
area which just needs arthroscopic partial resection.

Anatomy of the TFCC

The TFCC consists of the triangular fibrocartilage (TFC),

meniscus homologue, ulnar collateral ligament, radioul-
nar ligament, ulnolunate ligament, and ulnotriquetral
ligament [6, 7, 911]. The TFCC is a three-dimensional
structure, where the distal portion is a hammock-like
structure supporting the ulnar carpus, the proximal por-
tion is the radioulnar ligament, direct primary stabilizing
ligament of the DRUJ, and the ulnar portion is a func-
tional ulnar collateral ligament consisting of the sheath
floor of the extensor carpi ulnaris (ECU) and the thick-
ened ulnar joint capsule corresponding to the 6-U portal

T. Nakamura, MD, PhD

Department of Orthopaedic Surgery, School of Medicine,
Keio University, 35, Shinanomachi, Shinjuku-ku, Fig.7.1 Three-dimensional structure of the TFCC consists of a
Tokyo 160-8582, Japan distal hammock-like structure, radioulnar ligament, and func-
e-mail: tosiyasu@sc.itc.keio.ac.jp tional ulnar collateral ligament including ECU sheath floor

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 89

DOI: 10.1007/978-3-642-05354-2_7, Springer-Verlag Berlin Heidelberg 2010
90 T. Nakamura

Fig.7.2 Histological section

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

edge of the sigmoid notch of the radius with Sharpeys
fibers (Fig.7.2b, c). The meniscus homologue is just
the internal wall of the distal hammock-like structure
made of the synovial tissue, which can be easily elon-
gated and folded with radial and ulnar deviation
motion. The prestyloid recess is a pit between the apex
of the TFC and meniscus homologue, which functions
as an absorber of the deformity occurred around the
TFC during forearm rotation.
Classification of the Radial Tear
of the TFCC
Palmer [10] classified TFCC injury into two classes,
traumatic (Class 1) and degenerative (Class 2), and
further subdivided traumatic tears according to their
site of injury: a central slit as 1A, ulnar tear as 1B,
distal tear as 1C, and radial tear as 1D.
The radial tear of the TFCC is usually found as a
small slit on the radiocarpal arthroscopy [2, 13], rather
than what was represented in the figure of Palmers
classification [10], where the 1D tear was showed as a
wide radial avulsion injury with or without a fragment
of the sigmoid notch of the ulna. In my experience, the
radial tear of the TFCC can be subdivided into: (a)
fibrocartilage tear between the hyaline cartilage of the
sigmoid notch of the radius and TFC (Fig.7.3a), (b)
dorsal edge tear between the dorsal edge of the sig-
moid notch of the radius and dorsal portion of the radi-
oulnar ligament (Fig. 7.3b), (c) the palmar edge tear
between the palmar edge of the sigmoid notch of the
radius and palmar portion of the radioulnar ligament
(Fig.7.3b), (d) combination of (a) + (b) (Fig.7.3c), (e)
7 Radial Side Tear of the Triangular Fibrocartilage Complex 91

Fig.7.3 Classification of the

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

combination of (a) + (c), and (f) complete detachment
of the TFCC from the sigmoid notch of the radius
(Fig.7.3d).
As the strong connection of the TFCC and radius
was found in the very dorsal and palmar edges of the
sigmoid notch of the radius [4, 6, 8], the type 1D-a
may not be associated with DRUJ instability, while
type 1D-bf can induce DRUJ instability.
Mechanism of the Radial Side
of the TFCC
The common radial-sided TFC tear is considered to be
detached from the radius when the wrist is in extended
and/or ulnar deviated position on the ground with axial
load applied and supination/pronation force is applied
from the body during the fall [1]. In this position, the
TFC is pressed between the lunate and ulna. Different
directional force may be applied both on the proximal
and distal surfaces of the TFC, i.e., flexion-extension
or radial-ulnar deviation forces may come from the
carpal side and a rotational force may come from the
ulnar head. Avulsion fracture of the sigmoid notch of
the radius is extremely rare; only the dorsal side of the
sigmoid notch has been reported [4]. The radioulnar
ligament was outstretched from the dorsal side of the
radial sigmoid notch by a pronation force with flexion,
extension or rotational force, a small bone fragment of
the radial sigmoid notch had been avulsed from its dor-
sal edge, while the palmar over half of the TFCC
remained attached to the radius. Total avulsion of the
TFC from the radial sigmoid notch with or without sig-
moid notch fracture may occur with compression
forces on the ulnocarpal joint with twisting torque from
the rotating ulnar head with the outstretched wrist.
Diagnosis and Evaluation
with Physical Examination
Radiographs cannot demonstrate any injury of the
TFCC directly, because it is a soft tissue. If the radial
side of the TFCC is completely ruptured, radioulnar
92
Fig.7.4 (a) Radiograph of the avulsion fracture of the dorsodis-
tal part of the sigmoid notch of the radius. (b) CT finding of the
avulsion fracture of the dorsal margin of the sigmoid notch of
the radius. White arrow indicates fragment
dissociation may occur resulting in a widening of the
DRUJ in the radiograms. The avulsion fracture of the
sigmoid notch can be recognized with careful check-
ing of the radiograph, or CT (Fig.7.4a, b) [4]. Diagnosis
of the radial avulsion of the TFCC without the avul-
sion fracture is very difficult.
T. Nakamura
Fig.7.5 Arthrogram indicates radial avulsion tear of the TFCC.
The dye intrudes from the radiocarpal joint to the DRUJ through
the radial slit tear of the TFCC
Classic arthrogram is useful to demonstrate the
radial tear of the TFCC (Fig. 7.5). The dye intrudes
from the radiocarpal joint into the DRUJ through the
radial slit. In the case of fresh distal radius fracture,
however, the dye expands into the fracture and it is dif-
ficult to clearly demonstrate the radial tear.
Recent advances in high-resolution MRI now make
it possible to delineate the fine structures inside the
joint [8, 14]. The TFCC is demonstrated as a low sig-
nal intensity between the ulna, radius, lunate, and tri-
quetrum [8, 12] (Fig.7.6). Radial slit tear is delineated
with a line close to the high signal intensity area of the
hyaline cartilage of the sigmoid notch of the radius.
Arthroscopy is a very useful tool for diagnosing the
radial-sided TFCC tear. It provides a direct view of
theTFCC. Probing of the torn TFCC is also useful to
test the tension of the TFC, which is closely related
with DRUJ instability. After exploration of the TFCC,
7 Radial Side Tear of the Triangular Fibrocartilage Complex
Fig.7.6 T2* weighted MRI delineates the TFCC well as a low
signal structure between the radius, ulna, lunate, and triquetrum.
White arrow indicates radial slit tear of the TFCC. Do not con-
fuse the high signal area of the hyaline cartilage of the radial
sigmoid notch with the radial slit tear of the TFCC
depending on the findings, one may opt to undertake
an arthroscopic debridement or repair of the TFCC.
Treatment
Treatment of the radial tear of the TFCC depends on
the tear location.
Fibrocartilage-Radius Interface Tear
Seldom will this type of TFCC tear induce DRUJ insta-
bility, because the radioulnar ligaments are not found in
this location. The radial side of the fibrocartilage area of
93
the TFCC is an avascular area, with minimal healing
potential. Although some have recommended repair of
the radial-sided TFCC tear [1, 2], in my opinion, the
flapped or irregular margin of the radial tear of the TFCC
can be debrided or excised arthroscopically [1, 2].
The scope is inserted through the 34 portal, and
the instrument is inserted through the 45 or 6R portal.
First, the loss of tension of the TFC is confirmed with
a probe (Fig. 7.7a). Then the basket punch is used
toresect the flapped area of the fibrocartilage from the
tear site of the TFC. The resected area should be kept
to a minimum, avoiding injury to the DRUJ ligaments.
A shaver or electric high-frequency probe is finally
used to smooth the rough surface of the disc
(Fig.7.7bd).
Avulsion Fracture of the Dorsal Sigmoid
Notch of the Radius Including the Dorsal
Radioulnar Ligament
The peripheral attachment of the TFCC is important
for the DRUJ stability, because it includes the dorsal
radioulnar ligament [4]. When the fragment of the dor-
sal sigmoid notch, including the dorsal side of the
TFCC, is found on plain radiographs (Fig.7.8a, b) or
on CT (Fig.7.8c, d), fixation of the fragment through
the 45 or 6R portal can be possible through the radio-
carpal arthroscopy (Fig.7.8eg). The dorsal rim can at
times be very difficult to assess from the radiocarpal or
DRUJ arthroscopic exploration. In these cases, open
repair and internal fixation is recommended.
In the dorsoradial avulsion of the TFCC, the tension
of the TFC decreases, and obvious avulsion fragment
at the dorsal margin of the radius is seen (Fig.7.8e).
Through the radiocarpal dry arthroscopy, the avul-
sion fragment, including the dorsal side of the TFCC
from the radius, can be reduced (Fig. 7.8eg) and
fixed with the K-wire from the 45 or 6R portal
(Fig.7.8h, i). If there is simple avulsion of the TFCC
from the radial sigmoid notch, this area can be
sutured with a suture anchor. After arthroscopic
reduction and internal fixation of the dorsoradial
fragment of the sigmoid notch, there should be no
instability of the DRUJ with full range of rotation
(Fig.7.8j, k).
When an open repair is judged necessary the
incision is made on the dorsal side of the TFCC
(Fig. 7.9). The fifth compartment is opened and the
94 T. Nakamura

Fig.7.7 (a) Arthroscopic

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

c d

extensor digitorum quinti (EDQ) is removed from the
compartment. After a longitudinal incision on the
radial sheath floor of the EDQ is made, the dorsal rim
area of the TFCC, including the avulsion fracture of
the sigmoid notch of the dorsal radius, is revealed
(Fig.7.9e). The avulsed fragment can be repaired with
a pull-out soft wire or a suture anchor to the original
side of the sigmoid notch (Fig.7.9f). If the dorsal tear
of the TFCC is present, open repair of the TFCC can
be done in the same fashion.
Combination Injury of the Fibrocartilage
Tear and either the Dorsal or Palmar
Rim Avulsion of the TFCC Including
Avulsion Fracture of the Sigmoid Notch
of the Radius
There is also no report of this type injury in the litera-
ture. The radial avulsion of the TFC can be sutured
arthroscopically and 6 weeks of immobilization may
induce repair of the rim tear, or open repair of the dor-
sal or palmar avulsion is needed.

Avulsion Fracture of the Palmar Sigmoid

Notch of the Radius Including Palmar
Portion of the Radioulnar Ligament
There is no report of this avulsion tear in the literature.
In theory, when the palmar avulsion of the sigmoid
notch of the radius is recognized, the carpal tunnel is
opened [5] and the palmar portion of the TFCC can be
repaired with a bone anchor.
Total Avulsion of the TFCC
at its Radial Insertion
Although Palmer described total avulsion of the TFCC
(Fig.7.3d), this tear is very rare. The TFC area is very
difficult to repair in open fashion, and so, the author
recommends arthroscopic repair of the total radial avul-
sion of the TFCC.
7 Radial Side Tear of the Triangular Fibrocartilage Complex 95

Fig.7.8 (a, b) Preoperative

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

e f g
96 T. Nakamura

Fig.7.8 (continued)
h i

j k

A small 12 cm longitudinal incision is carried
out on the radial side of the radius, between the first
and second compartment. Careful attention is paid to
avoid any damage on the sensory branch of the radial
nerve. The tip of the targeting device is set on the
torn surface of the sigmoid notch of the radius
through the 45 portal, then the base of the targeting
device is attached to the radial cortex of the radius,
the 1.2mm K-wire is passed from the radial cortex of
the radius to the sigmoid notch (Fig.7.10a) to make
a tunnel (Fig. 7.10b). The 21G needle with a loop
stitch is inserted into the same bone tunnel to the
radiocarpal joint (Fig.7.10c). The needle is pushed
forward to penetrate the radial side of the TFC
(Fig. 7.10d). This step is repeated four times from
different, but close positions, on the radial cortex of
the radius to the different position of the sigmoid
notch of the radius (Fig. 7.10e). Four loop stitches
are then pulled out from the radiocarpal joint through
the 45 portal with forceps. 3-0 braided polyester
stitches are switched back to the tunnel with loop
stitches induced to outside-in repair of the TFC. The
TFCC is then tightened up to the sigmoid notch
(Fig.7.10f).
7 Radial Side Tear of the Triangular Fibrocartilage Complex
b c
d e
Fig.7.9 (a) The radiocarpal arthroscopic view of the TFCC in
the dorsal avulsion fracture of the sigmoid notch of the radius
case. Only the loss of tension of the central TFC is recognized.
No positive findings of the dorsal margin of the TFCC is noted.
(b) Open exploration of the dorsal side of the DRUJ. The EDQ
tendon is removed from the fifth compartment. (c) After the
Postoperative Care
The arthroscopic partial resection may not need cast
immobilization, because it is not related with DRUJ
instability or radioulnar ligament tear. When the TFCC
is repaired either arthroscopically or in an open fash-
ion, a 23week upper arm casting (sugar tongs plaster
97
f
EDQ sheath floor is cut, avulsion of the TFCC from the dorsal
margin of the sigmoid notch is recognized. (d) Arrow indicates
avulsed fragment of the sigmoid notch of the radius. (e) Avulsion
fracture of the sigmoid notch can be repaired with bone anchor,
or (f) pull-out wiring method
is strongly recommended) is adequate followed by a
3week short arm casting. After the removal of the cast,
active ROM exercise begins for 2weeks, then passive
ROM exercise of flexion-extension, and pronation
supination. The author usually asks the patient not to
ulnar deviate the wrist in the immediate postoperative
period (usually up to 4weeks).
98
a b
d e
Fig.7.10 In the total avulsion of the TFCC from the sigmoid
notch of the radius, arthroscopic repair is an option. (a) The tar-
geting device is set on the sigmoid notch of the radius and the
radial cortex of the radius. (b) K-wire (1.2 mm ) is useful to
make a bone tunnel from the radial side of the radius to the
DRUJ. (c) A long needle with 4-0 monofilament nylon loop
stitch is inserted into the bone tunnel from the radial cortex to
Acknowledgment The author appreciates Dr Yasushi Morisawa
with his help.
References
1. Cooney W, Linscheid R, Dobyns J. Triangular fibrocartilage
tears. J Hand Surg. 1994;19A:14354
2. Fellinger M, Peicha G, Seibert FJ, etal. Radial avulsion of
the triangular fibrocartilage complex in acute wrist trauma: a
new technique for arthroscopic repair. Arthroscopy. 1997;13:
3704
3. Kihara H, Short WH, Werner FW, et al. The stabilizing
mechanism of the distal radioulnar joint during pronation
and supination. J Hand Surg. 1995;11A:798804
4. Morisawa Y, Nakamura T, Tazaki K. Dorsoradial avulsion of
the triangular fibrocartilage complex with an avulsion frac-
ture of the sigmoid notch of the radius. J Hand Surg. 2007;
32E:7058
5. Moritomo H, Murase T, Arimitsu S, etal. Changes in length
of the ulnocarpal ligaments during radiocarpal motion: pos-
sible impact on triangular fibrocartilage complex foveal
tears. J Hand Surg. 2008;33A:127886
6. Nakamura T, Yabe Y. Histological anatomy of the triangular
fibrocartilage complex of the human wrist. Ann Anat. 2000;
182:56772
T. Nakamura
c
f
the DRUJ. (d) The needle penetrates the TFC. This process is
repeated four times. (e) Two paired loop stitches are then pulled
out from 45 or 6R portal. (f) Two 3-0 braided polyester stitches
are introduced from the DRUJ to the radial cortex of the radius
using nylon loop stitches, then the radial tear of the TFCC is
repaired by the outside-in technique
7. Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the
triangular fibrocartilage complex. J Hand Surg. 1996;21B:
5816
8. Nakamura T, Yabe Y, Horiuchi Y. Dynamic changes in the
shape of the triangular fibrocartilage complex during rota-
tion demonstrated with high resolution magnetic resonance
imaging. J Hand Surg. 1999;24B:33841
9. Nakamura T, Yabe Y, Horiuchi Y. Origins and insertions of
the triangular fibrocartilage complex: a histological study. J
Hand Surg. 2001;26B:44654
10. Palmer AK. Triangular fibrocartilage complex lesions: a
classification. J Hand Surg. 1989;14A:594606
11. Palmer AK, Werner FW. The triangular fibrocartilage com-
plex of the wrist anatomy and function. J Hand Surg. 1981;
6:15362
12. Skahen JR, Palmer AK, Levinsohn EM, etal. Magnetic res-
onance imaging of the triangular fibrocartilage complex.
JHand Surg. 1990;15A:5527
13. Trumble TE, Gilbert M, Vedder N. Isolated tears of the trian-
gular fibrocartilage: management by early arthroscopic
repair. J Hand Surg. 1997;22A:5765
14. Yoshioka H, Ueno T, Tanaka T, etal. High-resolution MR
Imaging of triangular fibrocartilage complex (TFCC): com-
parison of microscopy coils and a conventional small surface
coil. Skeletal Radiol. 2003;32:57581
 Arthroscopic Management
of Scapholunate Dissociation 8
Tommy Lindau

Introduction 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 styloid fractures may be relatively simple distal
radial fractures treated with cast immobilization pre-
radial fractures or part of an incomplete or complete
sented with symptomatic SL instability 1 year follow-
greater arch perilunate dislocation (Fig.8.1a) [11]. If it
ing injury. Their functional scores were significantly
is a part of a perilunate dislocation, all of us are aware
worse than those who did not show signs of SL joint
about the need to assess and fully treat both the radial
disruption on initial radiographs [20]. It is therefore
and ulnar-sided injuries. It is therefore surprising that
obviously important to detect associated SL ligament
we still struggle to identify associated injuries with all
injuries and manage them in an appropriate manner.
other distal radius fractures (Fig. 8.1ad). These
Detecting SL ligament injuries should be part of a
assumptions are supported by the fact that scapholu-
modern management of distal radius fractures. In every
nate (SL) disruptions are more common with displaced
situation when various surgical treatment options are
partial articular or intra-articular (AO B and C Types)
considered, something should be done to test the SL
than extra-articular fractures [6]. In fact, the prevalence
joint. In the absence of arthroscopy, at least radio-
of SL ligamentous injury in displaced distal radius
graphic imaging in radial and ulnar deviation (Fig.8.3)
fractures have been found to be as high as 85%, but
and a traction view should be obtained as a part of
also as low as 18% (Fig. 8.2) [9, 12, 16, 18]. The
intra-operative assessment.
impact of intra-articular fracture distribution is further
With external fixation, concerns have been expressed
emphasized by the fact that late presenting symptom-
regarding distracting the carpus to achieve restoration of
atic SL dissociations have been found in patients with
radial length, as this will compromise a carpal ligamen-
arthroscopically-diagnosed grade 3 and 4 SL ligament
tous injury if it would be present [15]. Recently, there
tears at the time of the fracture (Table 8.1) [3].
has been a surge in internal fixation and early mobiliza-
Furthermore, there is a fourfold risk of such significant
tion of displaced distal radial fractures, particularly in
grade 34 SL tears with an ulnar variance of >2mm on
non-osteoporotic adults. These patients are more likely
the initial radiographs [3].
to have sustained a ligamentous injury as a consequence
Obviously, the outcome of associated carpal inju-
of a high energy injury [9]. Failure to diagnose or treat
ries in distal radius fractures will be improved with
the disruption would render the patients vulnerable to
early recognition and treatment [21]. Historically, the
the long-term adverse effects of SL instability.
majority of distal radial fractures have been treated
Therefore, whilst analyzing the radiographs of a dis-
with immobilization in plaster. The healing properties
tal radius fracture, one must not only look at the bony
of SL ligament tears are unknown, but one assumption
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
T. Lindau, MD, PhD
instability would lead to inferior long-term outcome.
Pulvertaft Hand Center, Derbyshire Royal Infirmery
London Road, DE 12 QY Derby, UK Displaced distal radial fractures in non-osteoporotic
e-mail: tommylindau@hotmail.com patients are associated with SL ligament injuries

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 99

DOI: 10.1007/978-3-642-05354-2_8, Springer-Verlag Berlin Heidelberg 2010
100 T. Lindau

Fig.8.1 (a) Greater arch

a b
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 ulnar-
sided structures, but without
the full blown perilunate
dislocation. (d) Distal radial
fracture through the radial
styloid where an associated d
SL ligament injury seems
very likely and has to be
excluded c

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
SL 4 1 1 LT [3, 16].

2
20 4
Anatomy and Biomechanics
13
The two rows of carpal bones are devoid of tendon
insertions and are bound together by intrinsic and
TFCC
extrinsic ligaments. The scaphoid, lunate and tri-
Fig.8.2 SL ligament injuries were present in 50% of displaced quetrum form the proximal row of the carpus and move
distal radial fractures in non-osteoporotic patients [9] as a unit in response to the movement of the
8 Arthroscopic Management of Scapholunate Dissociation 101

Table 8.1 Radiological (scapholunate) dissociation 1 year after arthroscopic diagnosis at the time of a displaced distal radius
fracture (Fishers exact test p=0.006) [3]
Radiological scapholunate Group I (scapholunate grade 34) Group II (scapholunate grade 02)
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)

c arpo-metacarpal joints where the tendons insert and

a 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 ini-
tiated 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 liga-
ments (radio-scapho-capitate, the long and short radiol-
unate) and the volar ulnar extrinsic ligaments (ulnolunate
and ulnotriquetral) (Fig.8.5). The scapho-trapezial liga-
ment complex plays a major role in preventing flexion
of the scaphoid (rotary subluxation) even when the SL
b ligament is disrupted [4].
SL joint disruptions, like distal radial fractures, occur
Fig.8.3 (a) Radial deviation as a stress test for inter-carpal liga-
from a fall on an outstretched hand. Hyperextension,
ment injury. (b) Ulnar deviation as a stress test for inter-carpal
ligament injury shows a widening of the SL joint diagnosing a ulnar deviation and supination of the carpus lead to fail-
SL ligament tear ure of the SL ligament [11].
102
Fig.8.5 The SL joint has many important secondary stabilizing
ligaments, mainly on the palmar aspect. The Scapho-Trapezium-
Trapezoid ligament may prevent rotatory subluxation of the sca-
phoid even if the SL ligament is torn
Scapholunate Pathology
It is important to distinguish between the terms insta-
bility 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 patients subjective
description of the problems they struggle with in rou-
tine activities or sports. Laxity or mobility is what we,
as professionals, assess. We thereafter combine the
history, our examination findings and radiological fea-
tures into a description of the condition. We even clas-
sify the patients 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.
T. Lindau
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 fluoro-
scopic assessment (Fig.8.3), but not evident on normal
radiographs. Static instability is evident with SL gap-
ping 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 radio-
graphic 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 Listers tubercle. Watsons
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 34 are four times as frequent
if there is an increase in ulnar variance of >2mm at the
time of the injury, at least in the non-osteoporotic pop-
ulation [3]. Intra-articular fractures have also been
shown to indicate SL ligament injuries grade 34 [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 3mm at the SL
joint is suggestive and 5mm 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
103
and bone bruising. MRI scans, with or without gado-
linium 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 inter-
carpal 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 radio-
graphs 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 (pre-
injury) [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 34 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
104
a b
Fig. 8.7 (a) Radiocarpal appearance of a torn scapholunate
(SL) ligament where the extent of the tear can be assessed
(Tables8.2 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 sca-
phoid (right) and the lunate (left). The gap/diastasis as well as
possible step can be measured or described (Tables8.2 and 8.3).
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) (Tables8.2 and 8.3).
The SL ligament is best viewed from the 34 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 mem-
branous 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 reg-
istered (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 (Tables8.2 and 8.3) [3, 6, 9].
T. Lindau
In a grade 4 ligament tear, the scope can be passed from the mid-
carpal joint through this dissociation into the radiocarpal joint.
This is called the drive through sign. (d) Radiocarpal assess-
ment of a complete SL tear. Scope in 34 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
SL Grading
Arthroscopic examination of the SL joint can demon-
strate 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 spe-
cific treatments for each grade, based on assumed con-
sequences and reasonable treatment options [5, 6].
Geisslers classification has been modified by quan-
tifying the amount of mobility in between the scaphoid
and the lunate as a consequence of the torn ligament
[3, 9] (Table8.3). 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 105

Table8.2 Geisslers arthroscopic classification of carpal interosseous ligament tears

Grade Description Management
I Attenuation/haemorrhage of interosseous ligament as seen from the radiocarpal joint. Immobilization
No incongruency of carpal alignment in mid-carpal space
II Attenuation/haemorrhage of interosseous ligament as seen from the radiocarpal joint. Arthroscopic
Incongruency/step-off as seen from mid-carpal space. A slight gap (less than the width of a reduction and
probe) between carpals may be present pinning
III Incongruency/step-off of carpal alignment is seen in both the radiocarpal and mid-carpal Arthroscopic/open
space. The probe may be passed through the gap between carpals reduction and
pinning
IV Incongruency/step-off of carpal alignment is seen in both the radiocarpal and mid-carpal Open reduction
spaces. Gross instability with manipulation is noted. A 2.7mm arthroscope may be passed and repair
though the gap between carpals

Table8.3 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 01 <2
3 Partial or complete tear 12 <2
4 Complete tear >2 >2

findings have made the treatment options suggested by
Geissler redundant.
The European Wrist Arthroscopy Society (EWAS)
has tried to include all SL pathology in a comprehen-
sive classification, including acute, sub-acute and even
chronic, which is under investigation by the EWAS
study group for SL injuries [13].
It therefore follows that early detection and appropri-
ate management of these injuries lead to improved
outcome. This is corroborated by reports showing
improved outcomes with early detection and stabili-
zation [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].

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.
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 mobiliza-
tion should be tempered with its potential adverse
effects on the SL tear, which in grade I is minor
(Table8.1) [3].
Grade II Injuries
Decision making is more difficult with grade II inju-
ries (Tables8.2 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 con-
firmed 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
b weeks. The wrist is further protected for another 4
Fig. 8.8 (a) AP fluoroscopic view of scapholunate (SL) pin-
ning. (b) Lateral view of SL pinning
T. Lindau
Grade III and Grade IV Injuries
It has been shown that SL grade III and grade IV inju-
ries (Tables8.2 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 inter-
vention 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 nec-
essary. A direct open repair should be considered and
the repair protected with K-wires as described above.
Concomitant dorsal capsulodesis has shown to be use-
ful in reinforcing the repair [8]. However, in our expe-
rience, 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
The wrist should be immobilized in a splint until the
removal of K-wires for 68 weeks. Our preference is 6
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)
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 prefer-
ence to attempt a direct repair, depending on the
reducibility of the joint. Autologous bone-ligament
8 Arthroscopic Management of Scapholunate Dissociation 107

Fig.8.9 (a) Scapholunate

a b
(SL) reduction can be done
with a joy stick manoeuvre
with a 1.5mm 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
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 pro-
posed 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 fol-
low-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 frac-
ture is the obvious one.
108
References
1. Berger RA. The gross and histologic anatomy of the sca-
pholunate ligament. J Hand Surg. 1996;21A:1708
2. Edwards CE II, Haraszti CJ, McGillivary GR, et al. Intra-
articular distal fractures: arthroscopic assessment of radio-
graphically assisted reduction. J Hand Surg. 2001;26A: 103641
3. Forward DP, Lindau TR, Melson DS. Intercarpal ligament
injuries associated with fractures of the distal part of the
radius. JBJS. 2007;89-A:233440
4. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenod-
esis for the treatment of scapholunate dissociation: indications
and surgical technique J. Hand Surg. 2006;31A:12534
5. Geissler WB. Intra-articular distal radius fractures: the role
of arthroscopy? Hand Clin. 2005;21:40716
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:35765
7. Kuo CE, Wolfe SW. Scapholunate instability: current con-
cepts in diagnosis and management. J Hand Surg. 2008;33A:
9981013
8. Lavernia CJ, Cohen MA, Taleisnik J. Treatment of scapholu-
nate dissociation by ligamentous repair and capsulodesis.
J Hand Surg. 1992;17A:35449
9. Lindau T, Arner M, Hagberg L. Intraarticular lesions in dis-
tal fractures of the radius in young adults. A descriptive
arthroscopic study in 50 patients. JHS. 1997;22B:63843
10. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic
instability of the wrist: diagnosis, classification and path-
omechanics. JBJS. 1972;54-A:161232
11. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal disloca-
tions: pathomechanics and progressive perilunar instability.
JHS. 1980;5A:22641
T. Lindau
12. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of
intra-articular fractures of the distal radius. An arthroscopi-
cally-assisted approach. JBJS. 2000;82 B:7986
13. Messina J, Dreant N, Luchetti R, etal. 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:
13246
15. Mudgal C, Hastings H. Scapho-lunate diastasis in fractures
of the distal radius: pathomechanics and treatment options.
J Hand Surg. 1993;18B:7259
16. Peicha G, Seibert F, Fellinger M, etal. Midterm results of
arthroscopic treatment of scapholunate ligament lesions
associated with intra-articular distal radius fractures. Knee
Surg Sports Traumatol Arthrosc. 1999;7:32733
17. Ruby LK, Cassidy C. Fractures and dislocations of the car-
pus. In: Browner BD, Jupiter JB, Levine AM, Trafton PG,
editors. Skeletal trauma. vol 2. Philadelphia: Saunders;
2003
18. Shih JT, Lee HM, Hou YT, etal. Arthroscopically-assisted
reduction of intra-articular fractures and soft-tissue manage-
ment of distal radius. Hand Surg. 2001;6:12735
19. Taleisnik J. Current concepts review carpal instability.
JBJS. 1988;70-A:12628
20. Tang JB, Shi D, Gu YQ, etal. Can cast immobilisation suc-
cessfully treat scapholunate dissociation associated with dis-
tal radius fractures? J Hand Surg. 1996;21A: 58390
21. Varitimidis SE, Basdekis GK, Dailiana ZH, etal. Treatment
of intra-articular fractures of the distal radius. Fluoroscopic
or arthroscopic reduction? JBJS. 2008;90-B:77885
22. Whipple TL. The role of arthroscopy in the treatment
of scapholunate instability. Hand Clin. 1995;11(1):
3740
 Lunotriquetral and Extrinsic Ligaments
Lesions Associated with Distal Radius 9
Fractures

Didier Fonts

Introduction associated to an ulnar mechanism of impaction contem-

porary of the fracture impaction of the distal radius.
But it has been shown by comparative prospective
Distal radius fractures (both extra- and intraarticular
studies that arthrography has only a 60% sensitivity in
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.

Incidence of Associated LTIO

and Extrinsic Ligaments Lesions
with Distal Radius Fractures

By using arthrography, studies noted a high incidence of

Fig. 9.1 Localization of lunotriquetral interosseous (LTIO)
associated intrinsic ligament injuries. Specifically, in our ligament tear
first prospective series in 1992 [3], we performed a sys-
tematic operative wrist arthrogram (Fig.9.2) during dis-
tal 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 two-
thirds of all type of fractures. Extraarticular radius frac-
tures 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. Fonts, MD
Sports clinic of Paris CMC Paris V,
36, Boulevard Saint Marcel 75005 Paris, France Fig. 9.2 Operative midcarpal arthrography showing a LTIO
e-mail: docteurfontes@noos.fr ligament tear

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 109
DOI: 10.1007/978-3-642-05354-2_9, Springer-Verlag Berlin Heidelberg 2010
110
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 intercar-
pal ligaments under direct visualization and magnifica-
tion and is currently the preferred imaging method of
many surgeons. Several arthroscopic reports (Table9.1)
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 treat-
ment 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 clas-
sification of interosseous ligament injury that is com-
monly 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 liga-
ment tear is done through the radiocarpal (Fig.9.4a) and
midcarpal portals (Fig. 9.4b). The primary treatment
Table9.1 Incidence of ligamentous lesions in wrist fractures
Study Nb and type
Fonts [4] 30 (intra and extraarticular)
Geissler etal. [8] 60 (intraarticular)
Lindau etal. [15] 50 (extra and intraarticular)
Richards etal. [22] 118 (extra- and intraarticular)
Mehta etal. [20] 31 (intraarticular)
Hanker [12] 173 (intraarticular)
D. Fonts
for isolated, stable lunotriquetral ligament tears (more
frequently the dorsal portion of the interosseous liga-
ment) is conservative (Geissler grade 12). Cast immo-
bilization 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 45 or 6R portal, scope in 34
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 articula-
tion. Arthroscopic debridement alone of isolated
lunotriquetral ligament tears may result in symptom-
atic improvement. Weiss etal. [32] reported that 43 of
43 patients with partial LT ligament tears had com-
plete or improved symptoms after arthroscopic debri-
dement 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 shrink-
age of the dorsal and palmar portions of the LTIO liga-
ments 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 liga-
ment injuries (Geissler grade 1 or 2) with a mean fol-
low-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
% TFCC % SLIO % LTIO % Extrinsic
70 40 17 17
49 32 15
78 54 16
35 (intra) 21 (intra) 7 (intra)
53 (extra) 7 (extra) 13 (extra)
58 85 61
61 8 12 70 Dorsal capsule tear
9 Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures
Fig.9.3 2D and 3D CT scan
can help in the evaluation of
associated osteoligamentous
extrinsic lesions
a b
Fig. 9.4 Geissler grade 2 LTIO ligament lesion. (a) Fibro
cartilage partial lesion of LTIO of a right wrist visualized from
45 radiocarpal portal. (b) Midcarpal stability testing through
shrinkage. It can be concluded that the electrothermal
shrinkage may play a role in the management of par-
tial 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 lunotri-
quetral 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
111
c
RMC midcarpal portal (right wrist). (c) Arthroscopic debride-
ment of fibrocartilage partial lesion of LTIO (left wrist, scope in
34 portal, full-radius shaver in 6-R portal)
and other lesions are treated at the same time
(Fig. 9.6ac). 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 lunotrique-
tral ligament tears without instability, secondary treat-
ment may involve midcarpal corticosteroid injection
and anti-inflammatory local physiotherapy. Arthroscopic
treatment of lunotriquetral ligament tears is a reason-
able option for injuries that have failed conservative
treatment [14] or for Geissler grade 24 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
112 D. Fonts

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
etal. [26] performed a retrospective review compar-
ing these three procedures. In his series, the probabil-
ity 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 undergo-
ing 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 recon-
struction groups than in the fusion group. VISI defor-
mity 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 pat-
tern of injury may be more frequently encountered as
observed during fracture dislocation of the radiocarpal
joint, as described by Jupiter and Fernandez [13].
Apure fracture dislocation of the joint may appear to
9 Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures 113

a c

Scaph Fracture

T L

LTIO

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 (radioscaphocapi-
tate, long radiolunate, and short radiolunate). Direct
reduction and stabilization of the small bony fragment
and the associated volar ligaments reestablishes stabil-
ity. 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,
intercarpal ligament may be frequently injured in asso-
ciation with distal radius fractures [3, 8]. Too often this
injury is only recognized later as a shift into volar flex-
ion 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, 46 weeks of radiocar-
pal pin stabilization may eliminate VISI pattern defor-
mity. 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 stan-
dard arthroscopic exam because it is difficult to visual-
ize 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

the dorsal radiocarpal ligament (DRCL) and dorsal crease. The flexor carpi radialis is retracted, and the
114 D. Fonts

radiocarpal space is identified with a 22-gauge needle. A underneath the lunate. A 2-0 absorbable suture is passed
blunt trochar and cannula are inserted, followed by the through a curved spinal needle that is introduced through
arthroscope. A hook probe is placed in the 34 portal. the 34 portal. The end of the suture is retrieved with a
The DRCL is visualized ulnar to the 34 portal (Fig.9.8a), grasper in the 45 portal (Fig.9.8b). After both ends of

Fig.9.7 Dorsal radio carpal

ligament (DRCL) lesion
visualized from volar portal

Fig.9.8 Slutsky procedure

for DRCL repair. (a)explora-
tion through radiocarpal volar
portal. (b) Introduction of a
PDS suture through a needle
introduced in 34 portal and
exteriorized with a 45 portal
loop-retriever. (c) The suture
is tightened. (d) After the
suture is tightened, comple-
mentary shrinkage can be
performed with radiofre-
quency device
9 Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures
Fig.9.8 (continued) c
the suture are withdrawn, dorsal traction can be seen to
pull the torn edge of the DRCL up against the dorsal cap-
sule. 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 34 or
45 portal after the wrist traction has been released
(Fig.9.8c). The repair is augmented with thermal shrink-
age (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
115
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 nor-
mally 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 frac-
ture 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 patients objective findings and
expectations, especially for young athletes, and the
surgeons own personal experience and expertise in
wrist surgery and arthroscopy [11, 24].
116
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18. Luchetti R, Papini Zorli I, Atzei A. Ruolo dellartroscopica
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 Management of Concomitant
Scaphoid Fractures
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 non-
union 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 surround-
ing 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 non-
cannulated screws were published with good results
[2, 5, 8, 9].
Using a combined arthroscopic examination proce-
dure for the wrist while treating a scaphoid fracture
was the next innovative step. Whipple first presented a
method of percutaneous screw fixation using a modi-
fied Herbert screw and control of the fracture reduction
using image intensification and arthroscopic evalua-
tion [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: cmathoulin@orange.fr
F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures,
DOI: 10.1007/978-3-642-05354-2_10, Springer-Verlag Berlin Heidelberg 2010
10
We describe our arthroscopic technique point-by-point,
illustrated in detail with an emphasis on the important sur-
gical principles. These include verification of precise frac-
ture 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 dis-
abling 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 posi-
tion, especially with regard to the radiocarpal joint.
Ideally, the patient has obtained fully informed con-
sent, 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 sport-
ing 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.
117
118 C. Mathoulin

Absolute contraindications are noncooperative The first step is to introduce (after positioning the
patients and comminuted fractures. Advanced age, cuta- wrist on the table in slight extension) a retrograde
neous lesions, suboptimal operative conditions (e.g., (from distal to proximal) 1-mm K-wire through a small
inadequate surgical equipment), and severe associated (2mm) incision to the distal tubercle of the scaphoid in
injuries (e.g., severe scapholunate dissociation) are rela- a retrograde fashion (Figs.10.110.6). We always try
tive contraindications. not to breach the scaphotrapezial joint.
The wrist is then put under traction, allowing
arthroscopic control to verify the reduction of the sca-
phoid (Figs.10.7 and 10.8). The Finochietto interdigi-
Logistics tal traction device is placed outside the arm table while
still allowing positioning of the image intensifier. First,
It is crucial in cases of scaphoid fractures associated the fracture is visualized under arthroscopy using stan-
with distal radial fractures, to ideally plan both osteo dard portals 34, 45, midcarpal ulnar (MCU), mid-
syntheses. carpal radial (MCR). The arthroscope is then introduced
in the radial midcarpal portal (MCP) through which
1. If the scaphoid fracture is undisplaced, we initially
the fracture can be assessed very easily (Figs.10.9 and
fix the scaphoid in order to avoid any secondary dis-
10.10). If necessary a debridement of the articulation
placement of the scaphoid fracture during maneu-
can be done with the shaver while cleaning the medial
vers 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 car-
tilage. With the retrograde approach, the cartilage is
left completely intact, thereby avoiding any chondral
changes in future. 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 per-

formed with locoregional anesthesia, mostly under an
axillary plexus block. The patient is placed in the
supine position on a special arm table with a tourni-
quet 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
10 Management of Concomitant Scaphoid Fractures
Fig.10.3 Clinical operative view of the percutaneous K-wiring
retrogradely
Fig. 10.4 Earlier open reduction and internal fixation of the
concomitant distal radial fracture
Fig.10.5 Fluoroscopic control of the K-wire positioned in the
proximal pole
119
Fig.10.6 Classical position of the K-wire directed 45 dorsally
and 45 ulnar deviation
Fig.10.7 Arthroscopic radiocarpal control with the K-wire in situ
(ulnar) surface of the scaphoid. If the fracture is dis-
placed, reduction of the fragments is possible with a
small retractor introduced through the STT midcarpal
portal. Therefore, under arthroscopic control, the frac-
ture 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 proxi-
mal fragment (Figs.10.1110.15). Once a satisfactory
120
Fig.10.8 Arthroscopic midcarpal view
Fig.10.9 Fracture fixation and localization of the K-wire
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 3mm
diameter tap is used for the proximal pole (Fig.10.17).
However a 3.5mm 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.
C. Mathoulin
Fig. 10.10 MCR portal visualization of the displaced frac
ture after initial K-wire fixation demonstrating unsatisfactory
reduction
Fig.10.11 Retraction of the K-wire under arthroscopic control
The screw is then inserted over the guide wire under
fluoroscopic control (Figs. 10.1910.21). The radio-
carpal compartment is then visualized arthroscopi-
cally through the 34 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 radio-
carpal compartment is inspected to assess potential
associated lesions. Midcarpal exploration allows the
10 Management of Concomitant Scaphoid Fractures 121

Fig.10.14 Postreduction, accurate fracture fixation pinning via

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

Fig. 10.15 Final result after replacement of the K-wire with

Fig.10.13 Palpation of the fracture side and reduction maneu- closure of the fracture side, seen through a MCR portal view
ver with a teaser or probe

inspection of the fracture line at the ulnar articular sur-

face 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 sur-
face (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. Fig.10.16 Fluoroscopic control while tapping the fracture
122 C. Mathoulin

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 3.5mm of the distal pole of the fractured

scaphoid over the K-wire

Fig. 10.22 Control by radiocarpal arthroscopic (34 portal)

view of the proximal pole to avoid proximal intraarticular pen-
etration of the screw

Fig.10.19 Introducing the cannulated Herbert double-threaded

screw
10 Management of Concomitant Scaphoid Fractures 123

Fig.10.25 Final midcarpal view of the fracture after compression

Fig. 10.23 Control by radiocarpal arthroscopic (34 portal)

view of the proximal pole to avoid proximal intraarticular pen-
etration 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 sepa-
rately 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 non-
exposure of the screw, i.e., nil articular surface
involvement.
124
The risks of the procedure are:
Seemingly satisfactory screw position under fluo-
roscopy, 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 pos-
sible. Radiocarpal arthroscopic control can reveal
this error, although intraoperative imaging can also
do so.
Fracture of the guide wire can occur. Arthroscopic-
guided 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 dis-
placed 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 frac-
ture. 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 etal. reported in their randomized study
(percutaneous screw fixations vs. conservative treat-
ment) a union time of 45 weeks after percutaneous
screw fixation [14].
C. Mathoulin
Wrist arthroscopy combined with percutaneous
screw fixation assists in avoiding certain complica-
tions, 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 mid-
carpal examination also allows the assessment of the
accuracy of fracture reduction after screw fixation.
We agree with Whipple that direct visual examina-
tion 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 etal. 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 main-
tain 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 scapho-
trapezial joint. Interestingly, a transtrapezial modifica-
tion of the volar percutaneous technique was recently
proposed with no degenerative changes of the scapho-
trapezial joint in a group of 41 patients with a mean fol-
low 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 (antero-
grade technique) screw insertion is done under fluoros-
copy, 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
10 Management of Concomitant Scaphoid Fractures 125

Table 10.1 Classification of scaphoid fractures according to

Schernberg
Displacement Type II Type III Type IV
None 6 24 5
<2mm 7 8
>2mm 1 2

arthroscopic-assisted percutaneous screw fixation

between 2001 and 2008 with a mean follow-up of 24.7
months (range 650 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] (Table10.1). Mean delay of time to
treatment was 8.43 days.
An arthroscopic reduction was necessary in 19
cases. Mean duration of surgery was 23.9min (range
1045min). Concomitant injuries that were identified
include one scapholunate ligament tear, one distal Fig.10.27 Case presentation of a displaced scaphoid fracture
radial fracture, and three TFCC lesions that all were preoperatively
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.10.2710.30). 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.

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 tech-
nique has its place in the specific indication of an iso-
lated 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 Fig.10.28 Postoperative X-ray with radiological consolidation
appropriate alternative. (absorbable screw)
126
Fig.10.29 Another displaced scaphoid fracture preoperatively
Fig.10.30 Nonabsorbable screw fixation with union
Acknowledgments The author acknowledges Arne Decramers
assistance in reviewing the patients and writing this article.
C. Mathoulin
References
1. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the sca-
phoid: a rational approach to management. Clin Orthop Rel
Res. 1980;149:907
2. De Vos J, Vandenberghe D. Acute percutaneous scaphoid
fixation using a non-cannulated Herbert screw. Chir Main.
2003;22:7883
3. Filan SL, Herbert TJ. Herbert screw fixation of scaphoid
fractures. J Bone Joint Surg Am. 1996;78:51929
4. Gelberman RH, Menon J. Vascularity of the scaphoid bone.
J Hand Surg Am. 1980;5:50813
5. Haddad FC, Goddard NJ. Acute percutaneous scaphoid fixa-
tion: a pilot study. J Bone Joint Surg Br. 1998;80:959
6. Herbert TJ. Internal fixation of the scaphoid history. Le
Scaphode. Sauramps; Montpellier; 2004. p. 1259
7. Herbert TJ, Fischer WE. Management of the fractured sca-
phoid using a new bone screw. J Bone Joint Surg Br. 1984;
66-B:11423
8. Inoue G, Sionoya K. Herbert screw fixation by limited access
for acute fracture of the scaphoid. J Bone Joint Surg Br.
1997;79:41821
9. Ledoux P, Chahidi N, Moermans JP, et al. Percutaneous
Herbert screw osteosynthesis of the scaphoid bone. Acta
Orthop Belg. 1995;61:437
10. Meermans G, Verstreken F. Percutaneous transtrapezial fixa-
tion of acute scaphoid fractures. J Hand Surg Br. 2008;33(6):
7916
11. Merrell GA, Slade JF III. Simultaneous fractures of the sca-
phoid and distal radius. In: Slutsky DJ, Osterman AL, edi-
tors. Fractures and injuries of the distal radius and carpus.
Philadelphia: Saunders Elsevier; 2009
12. Retig AC, Kollias SC. Internal fixation of acute stable sca-
phoid fractures in the athlete. Am J Sports Med. 1996;24:
1826
13. Shih JT, Lee HM, Hou YT, et al. Result of arthroscopic
reduction and percutaneous fixation for acute displaced sca-
phoid fractures. Arthroscopy. 2005;21:6206
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; 57 Oct
2000
15. Schernberg F. Les fractures rcentes du scaphode. Chir
Main. 2005;24:11731
16. Schernberg F, Elzein F, Gerard Y. Etude anatomo-clinique
des fractures du scaphode carpien. Problme des cals
vicieux. Rev Chir Orthop. 1984;70(II suppl):5563
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):42741
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;26:74954
20. Whipple TL. The role of arthroscopy in the treatment of
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13842
 Perilunate Dislocations and Fracture
Dislocations/Radiocarpal Dislocations 11
and Fracture Dislocations

Mark Henry

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

Radioscaphocapitate (RSC)
By virtue of its complex anatomy, the human wrist is Long radiolunate (LRL)
subject to a wide variety of injury patterns resulting Short radiolunate (SRL)
from similar mechanisms of injury. The most common Ulnolunate (UL)
mechanism of injury occurs when force is transmitted Ulnocapitate (UC)
through the wrist, ascending from a palmar contact as Ulnotriquetral (UT)
the patient resists a fall or other contact. The second Also included are the extension fibers and individual
major mechanism of injury occurs when the wrist itself additional ligaments crossing the midcarpal joint
is directly trapped between two hard objects and sub- The dorsal extrinsic ligaments (Fig.11.2):
jected to a crushing force. Other mechanisms are also
possible but less frequent. The force transmitted Dorsal radiocarpal (DRC)
through the tissues of the wrist becomes dissipated as Dorsal intercarpal (DIC)
energy is consumed to disrupt various structures, both For the purpose of this chapter, the term fracture dislo-
bony and ligamentous. The force typically travels along cations of the wrist is meant to encompass perilunate
identifiable pathways. Recognizing one injured struc-
ture that is more obvious leads the surgeon to identify-
ing 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 dis-
tal rows. Ligament structures that may be involved in
fracture dislocations of the wrist include:
The intrinsic ligaments (Fig.11.1):
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, Fig.11.1 The intrinsic carpal ligaments: scapholunate interosseous
13th Floor, Houston, TX 77004, USA (SLIL), lunotriquetral interosseous (LTIL), and the intrinsic liga-
e-mail: mhenry@houstonhand.com ments of the distal carpal row

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 127
DOI: 10.1007/978-3-642-05354-2_11, Springer-Verlag Berlin Heidelberg 2010
128 M. Henry

or ligament tissue must be considered to have sustained

Fig.11.2 The radiocarpal extrinsic ligaments: radioscaphocap-
itate (RSC), long radiolunate (LRL), short radiolunate (SRL),
ulnolunate (UL), ulnocapitate (UC), ulnotriquetral (UT), dorsal
radiocarpal (DRC)
dislocations, perilunate fracture dislocations, radiocar-
pal dislocations, and radiocarpal fracture dislocations.
Predictable patterns of injury are by far the most com-
mon, but any pattern of injury is possible. It is this pos-
sibility 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
a structural injury of the wrist until proven otherwise.
There are a number of ways to acquire sufficient evi-
dence that the patient has not sustained a structural
injury of the wrist. Lack of an acute structural disrup-
tion 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, ecchymo-
sis (release of blood implies some degree of structural
disruption), deformity, and the range of motion possi-
ble 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 appropri-
ate stress examination, judging both the pain response
and physical evidence of instability. If the patient has

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
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations
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 suffi-
cient 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 nonsurgi-
cal assessment of ligamentous injury. Magnetic reso-
nance 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 opportu-
nity to test structural integrity. The primary argument
129
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 func-
tional 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 per-
spective, complex arthroscopic wrist trauma necessi-
tates 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, observa-
tions 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 anat-
omy. In the technique descriptions that follow, the term
mini incision indicates a less than 1cm incision made
for the purpose of checking cutaneous nerves (superfi-
cial 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
2cm in length whose purpose is to directly visualize a
130
Fig.11.5 Arthroscopic set up necessary to have circumferen-
tial access to the wrist for portals and fixation from all sides.
Overhead traction boom eliminates any obstructive device on
the hand table
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.
M. Henry
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
Each disrupted anatomic structure may be consid-
ered 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 congru-
ent articulation
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
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 131

Fig.11.10 Arthroscopically reduced volar rim (VR) fracture

associated with volar radiocarpal fracture dislocation involving
lunate fossa (LF)

fractures displaced in multiple planes (Fig.11.11). The

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
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 pre-
pared 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

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
132 M. Henry

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 frag-
ment 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 fol-
lowed by a headless compression screw

while the guidewire for a headless cannulated com-

Fig.11.13 Arthroscopically reduced dorsal rim (DR) fracture
from the scaphoid fossa (SF) associated with dorsal radiocarpal
fracture dislocation
pression 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 133

Fig.11.15 (a) Some disruptions are a very complex combina- reconstructed back to the reference point of the lunate facet. (e)
tion of bone fragments in multiple planes and (b) midsubstance Ensuring a congruent radiocarpal reduction can necessitate (in
ligament failure. (c) As long as the lunate facet remains stable the most severe cases) a combination of rigid bony fixation and
relative to the proximal radius, the remaining injury can be (d) 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 itis
accomplished to assign rigid fixation status (no transar-
ticular 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 In a pure radiocarpal dislocation, intrasubstance
(Fig. 11.16). Classic texts have called for wide open tearing or marginal avulsion without a substantial bony fragment
approaches and direct suturing of the torn ligament occurs for all of the extrinsic ligaments
134
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 dis-
tal) is interposed in the joint (Fig.11.17). Viewing from
the 4,5 portal, any loose ligament tissue interposed in
thejoint 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 1.6mm K-wire for 4 weeks (Fig.11.19). This is
half the length of the time required for pinning of intrin-
sic ligament injuries (SLIL, LTIL). Once motion is
M. Henry
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
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 liga-
mentous. 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 disloca-
tion is, of course, the scaphoid, but triquetral fractures
are also frequently encountered (Fig.11.22). The eval-
uation 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 scaphoids articular cartilage fracture
interface is well-visualized arthroscopically, the frac-
ture can still be imperfectly reduced along its radial
and volar borders. The surgeon has the choice of plac-
ing 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 frac-
ture; 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 frag-
ment and resist its pronation) and the Kleinert eleva-
tors sharp end on the proximal pole (used to resist
push back during drill and screw advancement
(Fig.11.24). Even though headless screws exert com-
pression by virtue of the tapering differential pitch of
their threads, if the fracture site is not already maxi-
mally compressed when initiating the sequence of
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 135

Fig.11.19 (a) Most radiocarpal dislocations are dorsal, but any traveling volarly with the displaced carpus. (c) Stability is achieved
pattern can occur such as this volar radiocarpal dislocation. (b) through radiocarpal pinning for 4 weeks and fixation of the asso-
Note the very small flake of bone from the volar radial rim (arrow) ciated ulnar fracture (cross reference Fig.11.4)

Fig. 11.20 A late presenting radiocarpal dislocation demon- Fig. 11.21 The most common pattern of perilunate fracture
strates the reactive scar formation(center) in the interval span- dislocation occurs with the pathway of disruption passing
ning the articular surface (left) to the edge of the volar extrinsic through the scaphoid waist (SLIL remains intact) then tearing
ligament (right), prior to debridement and joint reduction the LTIL followed by sagittal plane subluxation or dislocation
136 M. Henry

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)
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 137

Fig.11.25 In a purely ligamentous perilunate dislocation, both

the SLIL and the LTIL experience intrasubstance rupture or mar-
ginal avulsion
Fig.11.24 Percutaneous techniques to control scaphoid reduc-
tion 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

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 com-
pression screw should be used. Fractures of other car-
pal 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.

Fig.11.26 A normal SLIL interval tested from the midcarpal

Intrinsic Ligament Ruptures joint, pressing on the scaphoid with the probe to attempt
displacement
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 ligaments inter-
face (Fig.11.26). This is done through the midcarpal
joint. Attempts to classify the ligament disruption only
by the appearance of local tissues and side-to-side dia-
stasis fail to evaluate the multidirectional functional
role that these unique ligaments play (Fig.11.27). A
comprehensive grading system that examines four dif-
ferent directions of stress response for each ligament
allows a more complete evaluation of ligament func-
tion or incompetence (Table 11.1). Direct reduction
and pinning is needed for grade 2 and grade 3 disrup-
tions (Fig. 11.28). Initial and final assessments are
arthroscopic, but reduction and fixation is performed
138 M. Henry

Fig. 11.27 Rotational instability in the sagittal plane of the Fig.11.28 Bleeding coming up through the SLIL cleft dorsally
lunate (L) to triquetral (T) interval, stress tested from the mid- and the drive through capacity of the probe levering apart the
carpal joint scaphoid (S) from the lunate (L)

without the arthroscope in the joint. The classic
description for reducing the SLIL interval uses joy-
sticks, 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 relation-
ships to ensure an anatomic reduction. Volar transla-
tion 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 sca-
phoid (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 1.14mm K-wires for fixation (if there is any ques-
tion regarding adequate separation of the two wires,
then a third can be added). There is no need to pin

Table11.1 Arthroscopic multidirectional stress testing classification of perilunate injuries

Grade I Grade II Grade III
Diastasis Volar diastasis <2.3mm; no Volar and dorsal diastasis >2.3mm Volar and dorsal diastasis >2.3mm
dorsal diastasis
Distraction Scaphoid/triquetrum distracts Scaphoid/triquetrum distracts under Scaphoid/triquetrum distracts under
under arthroscopic traction arthroscopic traction 1025% the arthroscopic traction >25% the
<10% the height of the SLIL/ height of the SLIL/LTIL interface height of the SLIL/LTIL interface
LTIL interface
Translation Scaphoid/triquetrum translates Scaphoid/triquetrum translates with Scaphoid/triquetrum translates with
with probe <10% the PA probe 1025% the PA dimension probe >25% the PA dimension
dimension of the SLIL/LTIL of the SLIL/LTIL interface of the SLIL/LTIL interface
interface
Rotation Scaphoid/triquetrum rotates with Scaphoid/triquetrum rotates with probe Scaphoid/triquetrum rotates with
probe <10 relative to lunate 1025 relative to lunate distal surface probe >25 relative to lunate distal
distal surface surface
Treatment Partial tear requires splint Arthroscopic reduction and pinning of Arthroscopic reduction and pinning
protected healing time but not SLIL/LTIL interface; dart-throwers of SLIL/LTIL interface; no motion
direct pinning motion at surgeons discretion until healed
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
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations
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
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-throwers
139
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 posi-
tion 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 dart-
throwers arc prior to wire removal. A confounding
variable to secure healing of an intrinsic ligament is
the late presenting patient. It has never been defini-
tively 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 stabili-
zation procedure through small incisions volar and
dorsal (Fig.11.33).
Combined Injuries
The complexity of combined injury patterns ranges
from the simple coexistence of two identifiable dis-
rupted elements to the maximum challenge of restor-
ing 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 rup-
ture (Fig.11.36). To avoid missing the ligament com-
ponent 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
140 M. Henry

Fig. 11.31 (a) Acute traumatic perilunate dislocation (as
opposed to an isolated tear of an intrinsic ligament) will demon-
strate an immediate static collapse of the scapholunate relation-
ship as demonstrated by the increased lateral SL angle and (b)
foreshortened scaphoid with ring sign on the PA view. (c) The
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 inter-
face to reach the far ulnar corner of the lunate. (d) Once healed,
the static relationship of scaphoid to lunate is restored

Fig.11.32 (a) Grade 2 and

3 perilunate dislocations
require two wires from
scaphoid to lunate, but (b)
only one wire from tri-
quetrum to lunate to
effectively control the
reduced carpal relationships
during the 8 weeks of
ligament healing
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 141

Fig.11.33 (a) In late presenting cases, slight overcorrection of the SLIL angle (b) can be combined if needed with (c) capsulor-
rhaphy 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 an element of ligament instability increases with
each element is still performed as previously described more rare variations such as axial disruptions of the
for each individual disruption. The chance of missing carpus (Fig.11.39).
142 M. Henry

perform a wide open arthrotomy instead and convince

Fig.11.35 The combination of RSC and LRL bony dissocia-
tion and a perilunate dissociation is reduced and stabilized
entirely arthroscopically apart from the mini incision used for
the entry of the screw and 1.14mm 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
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 struc-
tures 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 4.5cm 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 dislo-
cation (Fig.11.42). Yet, the surgeon should not aban-
don the rules set forth: work from proximal to distal,
fix bony injuries first, arthroscopically reevaluate liga-
ment injuries and fix each element according to the

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
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 143

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
144 M. Henry

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 Rehabilitation

every possible element occurring simultaneously: type
C distal radius fracture, radiocarpal fracture disloca- After surgery, the wrist is immobilized in a splint to
tion, carpal fracture, and intrinsic ligament rupture accommodate swelling. At the first clinic visit, there is
(Fig.11.43). The plan remains the same. an option of placing the patient in a cast (useful for
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations
Fig.11.41 (a) The next more complex combination of radius
fracture with carpal ligament injury is a radiocarpal fracture dis-
location with multiple comminuted rim fragments and a perilu-
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 car-
pal row only (no K-wires crossing the midcarpal joint)
can initiate the dart-throwers arc of motion from
extension/radial deviation to flexion/ulnar deviation
prior to pin removal at 8 weeks. Otherwise, proximal
145
nate dislocation. (b) The rim fragments can be trapped under a
buttress plate to restore radiocarpal stability. (c) Radiocarpal
congruence must be verified
row pins are removed at 8 weeks and wrist motion is
initiated at that time. By 8 weeks from initial reduc-
tion and fixation, all elements that were previously
disrupted should be securely healed. Therapy instruc-
tions 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 fol-
lowing articular trauma, but improving motion occurs
only during a limited window of opportunity follow-
ing 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 win-
dow 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.
146
Fig.11.42 (a) The next more unstable pattern of injury com-
bines (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
Discussion
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, 46, 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, dor-
sal, 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
M. Henry
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
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 compari-
son series, the early treatment group achieved an aver-
age 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 34kg follow-
ing 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 fol-
lowed for an average of 44 months demonstrated an
average arc of motion of 114 with a mean time of 16
11 Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 147

Fig.11.43 (a) The most complex combination injury includes
all the components from a type C distal radius fracture to frac-
ture 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-
location can be secured with the smallest size of headless com-
pression 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
148
weeks for the union of the scaphoid fracture [14]. A
similar concept applies to radiocarpal dislocations
where one series compared pure ligamentous radiocar-
pal 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 38kg in the bony group compared to 27kg
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 struc-
tural elements that are part of the overall injury pat-
tern will heal with varying levels of final tissue
integrity. The best is osseous union. Once healed and
remodeled, the fractured element has the same integ-
rity 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 heal-
ing. The worst are the intrinsic ligaments (SLIL and
LTIL). They are short fibrocartilaginous intraarticular
ligaments with limited blood supply bathed in a syn-
ovial 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 biol-
ogy of healing in mind, the surgeon must set out to
restore the original anatomic relationships of the car-
pus. The more accurate the surgeons 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 stabiliza-
tion. 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 arthro-
tomy. 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
M. Henry
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 pre-
dominant mechanism of injury was fall from a height
followed by motor vehicle collision, sports trauma,
and industrial crush. For perilunate fracture disloca-
tions, the scaphoid healed routinely by 8 weeks, at
which time wrist motion therapy began. Perilunate dis-
locations also progressed to motion at 8 weeks follow-
ing 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 meth-
ods detailed in this chapter has largely avoided late
collapse of the intrinsic ligaments, radiocarpal translo-
cation, and nonunion. To date, two patients with radio-
carpal fracture dislocations have gone on to
radioscapholunate fusions with midcarpal preserva-
tion. Both of them were characterized by highly com-
minuted 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 col-
lapse or shift, but not to the point of requiring second-
ary 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, preven-
tion 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 occur-
ring in addition to the already recognized elements.
One should never assume that a common pattern pre-
vails; any combination of injuries is possible. By work-
ing from proximal to distal, bone preceding ligament,
and performing a comprehensive arthroscopic evalua-
tion 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 posttrau-
matic arthritis in most cases.
References
1. Alt V, Sicre G. Dorsal transscaphoid-transtriquetral perilu-
nate dislocation in pseudarthrosis of the scaphoid. Clin
Orthop Relat Res. 2004;426:1357
2. Apergis E, Dimitrakopoulos K, Chorianopoulos K, et al.
Late management of post-traumatic palmar carpal sublux-
ation: a case report. J Bone Joint Surg Br. 1996;78:41921
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;83:21218
4. Enoki NR, Sheppard JE, Taljanovic MS. Transstyloid, trans-
lunate fracture-dislocation of the wrist: case report. J Hand
Surg Am. 2008;33:11314
5. Gellman H, Schwartz SD, Botte MJ, etal. Late treatment of
a dorsal transscaphoid, transtriquetral perilunate wrist dislo-
cation with avascular changes of the lunate. Clin Orthop
Relat Res. 1988;237:196203
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;88:67680
7. Henry MH. Arthroscopic treatment of acute scapholunate
and lunotriquetral ligament injuries. Atlas Hand Clin.
2004;9:18797
149
8. Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilu-
nate fracture-dislocations: medium-term results. J Hand
Surg Br. 2002;27:498502
9. Hildebrand KA, Ross DC, Patterson SD, etal. Dorsal perilu-
nate dislocations and fracture-dislocations: questionnaire,
clinical, and radiographic evaluation. J Hand Surg Am.
2000;25:106979
10. Ilyas AM, Mudgal CS. Radiocarpal fracture-dislocations.
JAm Acad Orthop Surg. 2008;16:64755
11. Irwin LR, Paul R, Kumaren R, etal. Complex carpal disloca-
tion. J Hand Surg Br. 1995;20:7469
12. Kaneko K, Miyazaki H, Yamaguchi T, etal. Bilateral trans-
scapholunate dislocation. Chir Main. 2000;19:2638
13. Kaulesar Sukul DM, Johannes EJ. Transscapho-transcapitate
fracture dislocation of the carpus. J Hand Surg Am.
1992;17:34853
14. Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate
fracture dislocations: results of screw fixation of the sca-
phoid and lunotriquetral repair with a dorsal approach.
JHand Surg Am. 2005;30:114552
15. Komurcu M, Kurklu M, Ozturan KE, etal. Early and delayed
treatment of dorsal transscaphoid perilunate fracture-dislo-
cations. J Orthop Trauma. 2008;22:53540
16. Mamon JF, Tan A, Pyati P, etal. Unusual volar dislocation of
the lunate into the distal forearm: case report. J Trauma.
1991;31:13168
17. Mudgal CS, Psenica J, Jupiter JB. Radiocarpal fracture-
dislocation. J Hand Surg Br. 1999;24:928
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 proxi-
mal scaphoid in a trans-scaphoid perilunate fracture disloca-
tion. A case report. Clin Orthop Relat Res. 1994;302: 1515
20. Sandoval E, Cecilia D, Garcia-Paredero E. Surgical treat-
ment of trans-scaphoid, transcapitate, transtriquetral, perilu-
nate fracture-dislocation with open reduction, internal
fixation and lunotriquetral ligament repair. J Hand Surg Eur.
2008;33:3779
21. Smith DW, Henry MH. Comprehensive management of
associated soft tissue injuries in distal radius fractures. J Am
Soc Surg Hand. 2002;2:15364
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;123:3057
23. Souer JS, Rutgers M, Andermahr J, etal. Perilunate fracture-
dislocations of the wrist: comparison of temporary screw
versus K-wire fixation. J Hand Surg Am. 2007;32:31825
24. Watanabe K, Nishikimi J. Transstyloid radiocarpal disloca-
tion. Hand Surg. 2001;6:11320
25. Weil WM, Slade JF, Trumble TE. Open and arthroscopic
treatment of perilunate injuries. Clin Orthop Relat Res.
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management of acute fracture-dislocation of the carpus.
Orthop Clin North Am. 2001;32:295305
 The Role of Arthroscopy in Postfracture
Stiffness 12
Riccardo Luchetti

Introduction radius articular surface (palmar tilt). The two condi-

tions can sometimes coexist and must be treated at the
same time. However, contemporary macroscopic and
Painful limitation of wrist range of motion (ROM) as a
minimal distal radius defects should not be treated
consequence of extraarticular and intraarticular wrist
together because the postoperative rehabilitation pro-
fractures is commonly seen in conservative as well as
tocol in both conditions is different. Wrist immobiliza-
surgical management (Table12.1) [2,21]. Wrist reha-
tion is indicated for the former; whereas immediate
bilitation for a period of over 3 months is the treatment
rehabilitation is mandatory for the latter.
of choice, when the patient has wrist stiffness. Although
Ligament tears and chondral lesions are often associ-
variable improvement is always seen in post rehabilita-
ated with wrist fractures and these further complicate
tion, the pain persists throughout and even after the
the intraoperative and postoperative treatment protocol.
treatment, thereby making the research into the causes
Finally, we must remember other causes of wrist pain
of such a condition mandatory [13,22]. Frequently,
and rigidity, i.e., neuroma of the posterior interosseous
incorrect or incomplete reduction of the distal radius
nerve, extensor and/or flexor tendons adherences, and
fracture is the cause of the painful wrist function.
algodystrophy.
Macroscopic defects, both intraarticular and extraar-
Traditionally, wrist manipulation under anesthesia
ticular malunion, need to be rectified by osteotomies of
is commonly used when the rehabilitation regime has
distal radius [10] that try to restore normal distal radius
failed to produce increased wrist range of motion.
anatomy and alignment of the articular surface of the
However, this procedure can be detrimental by provok-
radius. Minimal distal radius defects can be treated
ing further damage, such as ligamentous lesions, chon-
arthroscopically. In minimal distal radial defects, two
dral or osteochondral damage (as in dorsal radiocarpal
main conditions can contribute to painful wrist ROM
conflict) or even fractures (ulnar head fracture). Surgical
limitation: (1) capsular contracture with intraarticular
arthrolysis is a gentler option that can be performed via
fibrotic bands causing rigidity (the most frequent con-
open surgery [1] or arthroscopy [25], as often carried
dition), and (2) incorrect healing of multiple fragment
out in other joints [15, 27,32,33].
(chip) fractures of the radial dorsal border leading to a
Arthroscopic arthrolysis of the wrist [6,1619,
dorsal radiocarpal conflict (Figs. 12.1 and 12.2) or a
24,30] allows the surgeon to treat both the radiocarpal
moderate increase in palmar inclination of the distal
and intercarpal joints, without running the risk of caus-
ing secondary damage to the articulations involved,
and at the same time, permitting immediate postop
mobilization.
The goal of this chapter is to provide information
R. Luchetti (materials and methods), evidence (results) and limita-
Rimini Hand Surgery & Rehabilitation Center,
tions associated with the use of arthroscopy to improve
Rimini Multimedia Policlinic, Milano,
Via Pietro da Rimini 4, 47900 Rimini, Italy wrist function in patients affected by painful wrist
e-mail: rluc@adhoc.net rigidity and dorsal radiocarpal abutment.

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 151
DOI: 10.1007/978-3-642-05354-2_12, Springer-Verlag Berlin Heidelberg 2010
152 R. Luchetti

Table12.1 Possible causes of secondary wrist rigidity (extra- Wrist arthrolysis must be performed by using both
and/or intraarticular) traditional and more elaborate instruments (Table12.2)
Posttrauma Postsurgery (Fig.12.3). In recent times, dry arthroscopy is utilized
Fracture Dorsal wrist ganglia more often in this pathological condition [3,11].
recurrences Traditional vertical position with counter-traction
Fracture-dislocation Treatment of scaphoid at the elbow of about 3kg is frequently used to obtain
fracture or nonunion a good articular distraction and thereby open the
Dislocation Intercarpal arthrodesis (four radiocarpal joint space affected by capsular contrac-
bones fusion, etc) ture. Occasionally, the articular distraction is not suf-
Ligament lesions Ligament reconstruction ficient enough to permit the use of a 2.7 mm scope
(SL ligament, etc) even when more traction weight is applied. Hence a
Proximal row carpectomy 1.9 scope is recommended even if it is more delicate.
An eccentric traction tower (Fig.12.4) is an excellent
Prolonged immobilization
alternative to the traditional vertical position. The
Erroneous wrist immobilization
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
Technique during surgery.
Although arthroscopy starts at the level of the RC
Traditional radiocarpal (RC) portals are used for joint, the MC joint should always be thoroughly evalu-
arthroscopic arthrolysis of the wrist. Recently, two ated. When there is a loss of prono-supination articular
volar RC portals (radial and ulnar) have also been range of motion, arthrolysis of the DRUJ must also be
added to radiocarpal and ulno-carpal joint; however, performed.
these are not frequently used [15]. DRUJ joint can also In the most difficult cases, it is impossible to recog-
be involved and can be scoped and debrided by spe- nize the normal arthroscopic anatomy of the wrist due to
cific portals. Midcarpal joints are rarely involved in the presence of fibrosis that completely encloses the
wrist rigidity. However, if it is affected, traditional joint space (Fig.12.5). Difficulties could be encountered
midcarpal portals are used. while performing triangulation with the instruments.

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)
12 The Role of Arthroscopy in Postfracture Stiffness 153

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 Pial)

Table12.2 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 surgeons surgical ability is
of utmost importance.
Radiocarpal Joint
All the portals (12, 34, 45, 6R and 6U) including
the volar ones are used when needed. Inflow is permit-
ted 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 5ml 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
154 R. Luchetti

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 34 and the 12 is used as a work-
ing 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 corre-
sponds to the arthroscopic working steps through arthroscopic
arthrolysis. The ulno-carpal joint is always completely unin-
volved in fibrosis. Fibrosis (gray color) is localized in the radio-
carpal joint and in the DRUJ, under the TFCC ligament and
between the ulna head and the sigmoid notch
[full radius: 2.9mm, aggressive or incisor: 3.2mm] and
radiofrequency instruments. However, not infrequently,
difficulties are encountered in the triangulation due to
intense intraarticular fibrosis (Fig. 12.7). In these
12 The Role of Arthroscopy in Postfracture Stiffness 155

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

34 portal to the 12 portal and use the 34 portal as the
working one. The 12 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
Fig.12.10 Intraarticular arthroscopic view of the fibrotic band.
scope and not to the articular surface. As the intraartic- It determines a complete separation of the radiocarpal joint in
ular vision improves, the resection of fibrosis becomes two rooms. Shaver is working against the fibrotic band. A little
easier (Fig. 12.8). As fibrosis is completely removed hole is in the wall. Through it, it will be possible to remove the
fibrotic band producing only one joint (S scaphoid)
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 34 portal and the shaver lunate (SL) ligament and the rim between the scaphoid
into the 6R. Visualization of the shaver is frequently and lunate facet of the radius (Figs.12.10 and 12.11). It
limited by the presence of the fibrotic band. Traditionally can be partial or complete. When it is complete, it
the fibrotic band [14] is localized between the scapho- divides the radiocarpal joint into two separate rooms.
156
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
R. Luchetti
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 34 portal and scope from 34 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 osteochon-
dral 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
12 The Role of Arthroscopy in Postfracture Stiffness
Fig.12.14 Fibrotic band can be also removed with basket
Fig.12.15 Pictures of the wrist joint after fibrotic band resec-
tion. 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
157
Fig.12.17 Chondritis of the articular surface of the distal radius
that becomes evident after the resection of the fibrosis
Fig.12.18 X-ray showing a wrist operated with a Darrach pro-
cedure. The ulnar side of the wrist was completely asymptom-
atic. Patient had pain in the dorsal central side of the wrist with
limited flexion and extension ROM. Wrist rigidity was corre-
lated 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 resec-
tion is frequently sufficient enough to improve pas-
sive 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 pro-
gressing into an osteofibrotic band with progressive
evolution in subanchilosis or anchilosis of the radio-
carpal (radio-lunate) joint (Figs. 12.18 and 12.19).
158
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 com-
pletely 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; how-
ever, 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
R. Luchetti
Fig.12.20 Drawing showing image of the wrist in which the com-
plete resection of the fibrosis in the radiocarpal joint was done
to evaluate the wrist ROM obtained at the end of this
first step (Fig.12.21). Obviously, for a better evalua-
tion 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 dor-
sal 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 evidenti-
ate their origin from the distal radius border. The mini-
scalpels are carefully introduced through the dorsal
portals paying attention not to feel any resistance dur-
ing their introduction. Once inside the joint, the sur-
geon resects the volar ligaments (Fig.12.22). Many
times, the maneuver is not easy because of the articular
12 The Role of Arthroscopy in Postfracture Stiffness 159

Fig.12.21 Wrist ROM

evaluation after first part
of arthroscopic arthrolysis
procedure

deformation due to step-offs making it impossible to

Fig.12.22 Section of the volar capsule of the wrist by using a
mini-scalpel (asterisk)
reach all the areas of the capsule. It is therefore impor-
tant 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 12
portal with the scope in the 34 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 34). Identifica
tionof 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 liga-
ment. At this point, the traction is removed, and gentle

Fig.12.23 Drawing showing

the site of section of the volar
capsule and ligaments of the
wrist (red arrows)
160
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 12 portal and
resecting the dorsal capsule introducing the instru-
ments 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 12 portal. The
intraarticular position of 34 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 radiof-
requency device. Attention must be paid not to damage the tissues
(nerves, vessels and tendons) behind the ligament and capsule
R. Luchetti
capsule is very easily resected from the 12 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 liga-
ment. 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 ulno-
carpal ligaments and dorsal capsule must not be
resected (Fig.12.27). The dorsal capsule of the ulno-
carpal 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 ulno-
lunate 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 pro-
duces 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 pal-
mar ulnar ligament or the dorsal ulnar ligament com-
plexes alone can prevent ulnar translation. The
arthroscopic capsulotomy leaves the palmar ulnar liga-
ment and dorsal ulnar ligament complexes intact.
There was no clinical or radiological evidence of car-
pal instability in any of the patients treated by Verhellen
and Bain [30].
Resection of a portion of the dorsal rim of the dis-
tal radius is mandatory when wrist extension is lim-
ited 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
2.93.2 mm introduced from 6R or 12 portal.
Sometimes, a volar radial portal is used, but the ulnar-
most side of the dorsal rim cannot be completely
reached due to the carpal bones even if wrist distrac-
tion is increased. Therefore, the ulnar-most side of the
dorsal rim of the distal radius is treated mostly from
the 6R portal.
12 The Role of Arthroscopy in Postfracture Stiffness 161

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. 12.28 Arthroscopic visualization of articular step-off of

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 (12378)
that can be sectioned during the arthroscopic volar and dorsal
capsulotomy (according to Verhellen and Bain). The ulno-carpal
ligaments (45) must be preserved
Ancillary Procedures
Wrist arthrolysis permits one to discover some occult
articular, DRUJ, and carpal bone problems. Some of
the distal radius that became evident after the arthrolysis (cour-
tesy of Dr Pial)
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
1mm) must be leveled, whenever possible (Fig.12.28).
A burr of 2.93.2 mm is used at 500 revolution per
second introduced from the 6R portal maintaining the
scope in the 34 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.
162
Fig.12.29 Flexion-
extension 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 sur-
gery 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 arthros-
copy should be carried out.
The approach for this articulation is via the two por-
tals (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 per-
form and synovitis is the most frequently found pathol-
ogy in this zone. It is usually localized at the level of
the STT and TH joints. Commonly, one tends to see an
R. Luchetti
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 pro-
cedure is performed at the dorsal rim of the distal
radius through the radiocarpal arthroscopy, it is man-
datory 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 exten-
sion. The procedure is similar to that performed at
the elbow for humeral-olecranon conflict.
Distal Radioulnar Joint
A prerequisite that ensures a good arthroscopic arthroly-
sis result for the DRUJ, is the preservation of a normal
articular surface (sigmoid notch and ulnar head).
12 The Role of Arthroscopy in Postfracture Stiffness
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 osteo-
chondritis [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 nor-
mal 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 proxi-
mal portal and the instruments in the distal one. Normally,
fibrosis does not permit any visualization. Fluid is con-
stantly used to expand the joint and improve the vision.
Once some vision is achieved and the tip of the instru-
ments 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 visu-
alization by arthroscopy, and in the absence of a cen-
tral perforation of TFCC good visualization is difficult.
In these conditions, we suggest introducing a blunt dis-
sector between the TFCC and the ulnar head, and gen-
tly dissecting the adhesions. It could also be done by
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
163
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 per-
form 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-supina-
tion. 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 per-
fectly 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 pro-
cedure, a curved dissector is introduced into the joint
Fig. 12.31 Schematic drawing showing the fibrosis removal
under the TFCC
Fig.12.32 Drawing showing an axial view of the DRUJ. Dorsal
and volar capsules are sectioned (red arrows and red line)
164
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
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 pronation-
supination obtained after
arthrolysis of the DRUJ
R. Luchetti
must not be detached from the bony origin (radius and
ulnar fovea). If this happens DRUJ instability will fol-
low 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)
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 frac-
tures, but also postsurgery. Among these cases, causes
have been painful rigidity after corrective osteotomy for
distal radius malunion, proximal row carpectomy, mid-
carpal 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
12 The Role of Arthroscopy in Postfracture Stiffness 165

additional right wrist arthroscopic arthrolysis in order can be initiated 1 month after surgery under the strict
to reach the same level of improvement as that of the supervision of a physical therapist. The patient protocol
contralateral side. All the cases had wrist rigidity sec- is individualized depending on the strength require-
ondary to surgery or immobilization after wrist ments they need in order to perform their job. It is advis-
fracture. able that the physical therapist does an on-site ergonomic
Preoperative and postoperative evaluation of all the evaluation of the patient and quantifies the forces
patients was done using the Mayo Wrist Score [9]. required of the patients entire upper extremity in order
TheDASH Questionnaire was also administered in the to perform their work duties [29].
postop check-up.
2. Group 2: Hyaluronan antiadhesion barrier gel,
Hyaloglide, as adjunct to AWA technique Results
Recently, several authors have published their clinical
experience in AWA with good results in terms of wrist Intraoperative findings (100%) were fibrotic bands
ROM recovery and pain relief. However, for the cases between the radius and the scaphoid bone, the scapho-
in which arthroscopy had demonstrated severe chon- lunate ligament, and the lunate bone depending on the
dral damage, a high recurrence of wrist rigidity has type of previous damage. Osteochondral lesions and
been observed. Hyaloglide, an antiadhesive absorb- articular step-off were recorded on the articular surface
able hyaluronan-based gel, already tested for tendon of the radius and these were in correlation with the
and nerve surgery, has been used (introduced into the residual pain after surgery (worst result). The dorsal rim
wrist joint through a portal) to prevent adhesions and of the distal radius was resected to improve wrist exten-
fibrous band formation in patients after AWA. sion in such cases. No complication were documented
From 2006 to 2007, 6 of 12 patients were included in either group. All group 1 cases were clinically reeval-
in the study. The average age of the patients was 37 uated at a mean follow-up of 32 months (range from 2
years, all affected by wrist rigidity in which arthros- to 140 months). One case failed because the surgical
copy showed severe distal radial cartilage damage. The indications were not correctly evaluated and one patient
same preoperative and postoperative evaluation as in was deceased. In all the 19 cases, pain was significantly
the previous group was carried out. diminished or completely absent and wrist ROM and
grip strength were improved (Table12.3). The average
modified Mayo Clinic Wrist Score improved from 39
(preop) to 87 (postop), and the DASH Questionnaire
Postop Treatment obtained an average of 21 points (Figs.12.35). All the
patients of group 2 were reevaluated at a mean follow-
Rehabilitation is started immediately after surgery [29]. up of one year. Preliminary analysis showed that in all
The same rehabilitation protocol was used in both the the patients, pain diminished, while wrist ROM and
studies. Routine analgesics were used for postoperative grip strength improved. The mean score of modified
pain control. Prono-supination and flexion-extension
exercises were performed for almost 3 months, gradually
improving the passive mobilizing force. Aquatic reha- Table12.3 Clinical results of AWA (group 1)
bilitation is the initial treatment of choice and the patient Preop (mean) Postop (mean)
can gradually progress to exercising in antigravity pos- Pain (VAS) 7 1
tures out of the water. Passive, active, and active-assisted Flexion/extension (degrees) 84 107
exercises are performed by the patient, under the guid-
Radial/ulnar deviation (degrees) 48 49
ance of a physiotherapist.
Return to work is limited up to 3 months as per the Prono/supination (degrees) 132 156
work requirements of the patient. A palmar wrist splint Grip strength (kg) 27 36
is used for protection while performing heavy activities.
Mayo Wrist Score 28 79
Work-hardening and endurance-strengthening exercises
using isokinetic and isotonic rehabilitation equipment DASH Questionnaire 21
166 R. Luchetti

Table12.4 Clinical results of AWA + hyaloglide (group 2) Mayo Wrist Score improved from 45 to 65. Postoperative
Preop (mean) Postop (mean) DASH score was 26 from a preoperative score of 49
Pain (VAS) 6 4 (Table12.4) (Figs12.40).
Flexion/extension (degrees) 92 100

Radial/ulnar deviation (degrees) 38 50

Prono/supination (degrees) 105 135 Discussion

Grip strength (kg) 22 27
Arthroscopic wrist arthrolysis is a difficult and time con-
Mayo Wrist Score 41 68
suming procedure. It must be performed by a surgical
DASH Questionnaire 49 35 specialist skilled in both wrist arthroscopy and wrist

Fig.12.35 Case 1: BA, 24-year-old male, affected by intraar- with reduction and pin fixation and prolonged immobilization
ticular distal radius fracture of the right wrist associated with by cast for 50 days. After intensive rehabilitation the wrist
crush syndrome of the forearm. Forearm and hand fasciotomies showed a painful stiffness (Fig.12.35)
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
12 The Role of Arthroscopy in Postfracture Stiffness 167

Fig. 12.37 Case 1 (cont): Arthroscopic arthrolysis was per-

formed 4 months after unsatisfied rehabilitation, obtaining intra-
operative improvement of flexion-extension of the wrist.
Traditional portals for radiocarpal and midcarpal joint were
used
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

Fig.12.39 Case 1 (cont):

X-ray films showed an evident
improvement of the radiocar-
pal joint space at follow-up,
but also the persistence of
ascapholunate dissociation
and a dorsal radio carpal
abutment due to malunion
ofthe dorsal border of the
radius. Fortunately both were
clinically asymptomatic
168 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, immobili-
zation 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 radiocar-
pal joint with sclerosis of the border
both in radiocarpal and midcarpal
joints

Table12.5 Comparison between previous studies in literature

Authors Cases Follow-up Preop Postop
n (months)

Flex/Ext Flex/Ext
(mean degrees) (mean degrees)
Pederzini etal. [25] 5 10 44/40 54/60
Verhellen and Bain [30] 5 6 17/10 47/50
Osterman etal. [24] 20 32 9/15 42/58
Luchetti etal. [17,21] 19 32 46/38 54/53
Hattori etal. [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 prom-
ising 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 regard-
ing the improvement of wrist ROM after arthroscopic
wrist arthrolysis is reported in Table12.5.
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 169

Fig.12.42 Case 2 (cont): Preop clinical function of the wrist

shows more limitation of flexion-extension than prono-supina-
Fig.12.41 Case 2 (cont): MRI image shows the same result (yel- tion (Fig.12.43)
low arrows) with involvement of the scapho-lunate joint (red
arrows)

selecting surgical candidates is based on the subjects

level of wrist rigidity associated with pain. Wrist
rigidity aloneis not considered to be important enough
to require an arthroscopic arthrolysis, but when asso-
ciated with pain, this surgical technique is strongly
indicated.
An additional arthroscopic arthrolysis can be per-
formed if required (one such case occurred in our study)
based on the clinical results and degree of improvement
in ROM. Fig.12.43 Case 2 (cont): Preop clinical function of the wrist
Arthroscopy can reveal associated soft tissue tears shows more limitation of flexion-extension than prono-supina-
that are considered to be the cause of wrist pain. In our tion (Fig.12.43)
study, we frequently found loose bodies, arthrofibrosis,
radiocarpal septum, chondritis and osteochondritis, in the X-ray and/or MRI. This confirms the validity of
partial tears of the intercarpal ligaments and TFCC, arthroscopy in comparison to other methods of investi-
and/or a minimal articular step, which were not evident gation [8,34]. Moreover, by this procedure it is often
170
Fig. 12.44 Case 2 (cont): Arthroscopic view of the wrist after
arthrolysis
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
R. Luchetti
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
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 immobili-
zation time and the rehabilitation protocol is con-
trary 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
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 rehabilita-
tion 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 intraop-
erative 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
171
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 frequentlyencoun-
tered and it can be isolated or associated with the
radiocarpal joint. When the rigidity of the DRUJ is iso-
lated, 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.
Weencountered 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, 36 months from the time
offracture, does not always demonstrate all the under-
lying problems, and when the surgeon sees a pre-
served 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 evi-
dent 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 rigid-
ity that has been caused by reflex sympathetic dystro-
phy. In these cases, wrist arthrolysis must be associated
with the release of extra-articular soft tissue adhe-
sions. 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 situ-
ations during surgery such as the breakdown of instru-
ments; tweezers, scissors, mini-scalpel or motorized
instruments [20].
When the patient reports that wrist pain has reap-
peared or has never completely disappeared after sur-
gery, 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 liga-
ments tears (SL or LT) that had not been taken into
consideration preoperatively.
Moreover, the use of articular instruments and
motorized instruments can cause unwanted osteo-
articular 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;22:16971
2. Altissimi M, Rinonapoli E. Le rigidit del polso e della mano.
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 Treatment of the Associated
Ulnar-Sided Problems 13
Pier Paolo Borelli and Riccardo Luchetti

Introduction

Ulnar impaction, ulnar styloid impaction (USI), liga-

mentous injury, chondral lesions, associated TFC
tear (triangular fibrocartilage) with or without insta-
bility [1820], 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 patients symptoms with-
out addressing the radius, and a less involved postop-
erative course. Arthroscopic exploration allows the
assessment of the impact that those associated inju-
ries might have on the patients 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 con- Fig.13.1 The ulnar-sided pathology in an extra-articular radius
comitant injuries. malunion (DRM) (marked in red)
The purpose of this chapter is to describe the detec-
tion and treatment of these minor injuries associated Ulnar Carpal Impaction (UCI)
with the main radius deformity that can be a source of
patient dissatisfaction and a poor result.
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,
P. P. Borelli, MD ()
triquetrum, and head of the ulna; and finally osteoar-
Wrist and Hand Surgery Service 1st Division of Orthopaedic
and Trauma Center Spedali Civili of Brescia, Brescia, Italy thritis occur in a progressively unrelenting fashion
e-mail: pborelli@tin.it (Fig. 13.2).Typically, patients complain of subacute
ulnar pain. Tenderness to palpation is observed in the
R. Luchetti ulnocarpal space dorsally, and the fovea sign may be
Rimini Hand Surgery & Rehabilitation Center,
Rimini Multimedica Policlinic, Milano,
positive [31]. The pain usually worsens with prona-
Via Pietro da Rimini 4, 47900 Rimini, Italy tion, and the ulnar deviation and the ulnocarpal stress
e-mail: rluc@adhoc.net test [28] may reproduce symptoms.

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 175
DOI: 10.1007/978-3-642-05354-2_13, Springer-Verlag Berlin Heidelberg 2010
176
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 b
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 cen-
tral perforation of the triangular fibrocartilage (TFC) (arrow),
P. P. Borelli and R. Luchetti
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 sagit-
tal planes, it is less traumatic for the patient to pro-
ceed to an arthroscopic wafer resection of the ulnar
head. Also, an arthroscopic wafer resection can be
useful in those cases when, after the radius osteot-
omy, the ulnar head remains positive and still impacts
against the carpus.
The arthroscopic wafer, however, is not recom-
mended when there is a major radial shortening (more
chondromalacia of the lunate bone and ulnar head with second-
ary 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 b
c d
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 sug-
gests 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-
than 3 or 4mm of ulnar head to be resected). It has to
be stressed that the contact area at the distal radioulnar
joint is only about 79mm [32]. Consequently, a major
177
e
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
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
178 P. P. Borelli and R. Luchetti

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 Pial)

Fig. 13.6 (a, b) In a well aligned, in the sagittal and frontal Instability of the ulna remained after the shortening due to TFC
planes, but shortened radius, an open ulna-shortening osteotomy avulsion from the fovea. Arthroscopic reattachment of the TFC
is the best alternative to restore the anatomy of the DRUJ. (c) at the fovea was carried out. (Courtesy of Dr Pial)

open ulnar shortening will restore the anatomy at the the DRUJ may remain unstable after the shortening,
distal radioulnar joint. However, arthroscopy still plays still needing TFC reattachment (Fig. 13.6), or some
an important role in the decision-making process, as 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 Rubys 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 palpa-
tion 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 tri-
quetrum and subcortical sclerosis on the styloid process, are
illustrated
179
the styloid is longer than 6mm, or in any nonunion of
the tip of the styloid (which relatively lengthens the
styloid itself). MR imaging may show focal subchon-
dral 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 23mm 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 conse-
quence of radius malunion, a radius-corrective osteot-
omy 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 sty-
loid 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 stabi-
lizer [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 tri-
quetrum and the ulnar styloid can be seen. MR imag-
ing may show the status of the distal and proximal part
of the TFCC, the early chondromalacia of the tri-
quetrum 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 asso-
ciated with its avulsion. The following scenarios can
be found:
180 P. P. Borelli and R. Luchetti

a b

c d

e f

Fig.13.8 (a) Insidious onset of ulnar-sided wrist pain 4 months dromalacia of the triquetral bone with secondary subchondral
after a distal radius nascent malunion treatment. (b,c, d) Pain changes (red arrows), indicative of the USI syndrome, and mor-
was severe when the patient attempted dorsiflexion and supina- phological alteration both at the ulnar and radial side of TFCC
tion, but not when she dorsiflexed with the wrist pronated. (e, f) (yellow arrows). The thickness of TFCC opposite to the LT joint
Coronal T1-weighted, coronal STIR MR images show chon- may be predictive of the UCI syndrome
13 Treatment of the Associated Ulnar-Sided Problems 181

Fig. 13.9 (a, b) Combined USI and UCI syndromes were ing osteotomy which restored the congruency at the sigmoid
treated in this patient with a congenital long styloid (10mm), fossa and widened the styloid-triquetral space (dotted line) (c)
after ruling out other causes of pain by a simpler ulnar shorten- (Case courtesy of Dr Pial)

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 superfi-
cial 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
Fig.13.10 Possible styloid nonunion sites are shown
as the ulna is positive [30].
Two treatment options are suggested depending on the
size of the ulnar styloid itself.
(a) If only the tip of the ulnar styloid process is avulsed If the fragment is small, excision through a mini-open
(Fig.13.11) and there are no clinical signs of DRUJ subcutaneous ulnar approach is recommended.
instability, wrist arthroscopy can help to define the Through the same approach, the fovea may be
presence of USI. If marked synovitis is noted in the inspected and, if needed, refreshened and finally the
dorsal ulnar recess, arthroscopic synovectomy TFCC be reinserted with a mini anchor into the fovea.
182 P. P. Borelli and R. Luchetti

Fig.13.11 Pure USI syndrome caused by a fleck of the tip of Fig.13.13 Partial tear of the deep part of TFCC (see text)
the styloid

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 ben-
efit 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 impor-
tant 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 oc-
curred (Fig.13.14). This will be confirmed during
arthroscopy by a positive hook test. Reattachment
Fig.13.12 The ulnar styloid fragment is minimally displaced.
ofthe TFCC at the fovea is mandatory. Alternative-
DRUJ is often pretty stable. In longstanding conditions, signs of ly, if the styloid is large enough direct fixation will
USI and UCI syndromes may be associated solve the problem [2, 3] (see also Chap. 6).
13 Treatment of the Associated Ulnar-Sided Problems
Fig. 13.14 Complete ulnar detachment. The ulnar styloid is
highly displaced and the DRUJ is unstable. In longstanding con-
ditions, signs of the UCI syndrome may be associated
(e)In rare instances, the ulnar styloid is totally dis-
connected (floating styloid) (Fig.13.15). Typically
the ulnar styloid does not show a remarkable dis-
placement, 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 arthros-
copy 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).
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].
183
Fig.13.15 Floating styloid causing styloid impaction and distal
radioulnar instability
Radiocarpal arthroscopy helps in evaluating the dis-
tal component of the TFCC, represented by the cen-
trally 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 associ-
ated one another. In order to avoid oversights, the sur-
geon has to do a thorough exploration of the ulnar part
of the joint, rather than stopping with the first diagno-
sis. Three different conditions may be found when
dealing with tears: a peripheral detachment with a sta-
ble DRUJ clinically (ballotment negative) (Fig.13.19);
an unstable DRUJ with complete TFC detachment (bal-
lotment positive, peripheral tear evident, and hook test
184 P. P. Borelli and R. Luchetti

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 hypertro-
phic 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 c d
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
patients symptoms.
(i)Arthroscopic view of the
sutured TFC. (Courtesy
of Dr Pial)

e f
13 Treatment of the Associated Ulnar-Sided Problems 185

g h i

Fig.13.16 (continued)

Fig.13.18 Coronal aspect of the ulnar wrist. The TFCC is com-

posed of the distal component, formed by the UCL and the
distal hammock structure, and the proximal component, which
Fig.13.17 Tridimensional anatomy of the ulnar aspect of the originates from the ulnar fovea and the basistyloid
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
etal. [26]), the distal part of palmar and dorsal radioulnar liga-
ments and the ulnolunate and ulnotriquetral ligaments
186 P. P. Borelli and R. Luchetti

positive) (Fig.13.20); and finally, a distal component

intact but a proximal detachment from the fovea (bal-
lotment test positive, hook test positive) (Fig.13.21).
The repair of each condition has been explained in
Chaps. 57, 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 prob-
Fig. 13.20 The DRUJ is clearly unstable. In case of a long-
lem the cause of the pain, and this is paramount in standing UCI syndrome, the superficial part of TFCC can be
identifying and treating all causes of pain for a good damaged or perforated
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 Fig.13.21 The DRUJ is more or less unstable The untightened
frayed or perforated TFCC may have resulted, with time, in the UCI syndrome
13 Treatment of the Associated Ulnar-Sided Problems
b c
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) associ-
ated 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 evalu-
ated after distal radius fixation, thus resulting unstable. TFCC
187
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
188
e f
Fig.13.22 (continued)
a b
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
P. P. Borelli and R. Luchetti
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 189

Fig.13.23 (continued)
d

f g
190
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4238
 Arthroscopic-Assisted Osteotomy
for Intraarticular Malunion 14
of the Distal Radius

Francisco del Pial

Introduction 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
Classically, the management of the young patient with
is a fracture line in the coronal plane. Secondly, in volar
a step-off in the distal radius has been panarthrodesis.
shearing malunions, one has to cut the bone in a rela-
Several pioneer surgeons such as Saffar, Fernndez,
tively blind fashion as the volar ligaments need to be
and others [1, 12, 14, 1821, 23] opened the door to
kept intact. The direction of the osteotome is a matter of
the possibility of cutting the displaced fragments again
guesswork, and any rough maneuver can create new
and reducing them in an anatomical position. The gold
cartilage fracture lines (Fig. 14.2). In some cases, the
standard for the most common sagittal step-off (antero-
configuration of the fracture may not allow a straight cut
posterior) is to carry out the osteotomy through a dor-
from outside-in preoperatively (Fig.14.3).
sal route partly under fluoroscopic guidance [1, 14, 19,
Finally, I have found that another limitation of the
20]. For the volar shearing-type malunions, the joint is
outside-in techniques is that the joint space is small
approached volarly, the external callus removed, and
before the osteotomy, and becomes inexistent after the
with an osteotome directed toward the joint, the frag-
fragment is reduced. As a result, one is left to control
ment is slowly cut away with the hope that the osteot-
the reduction in the tight joint space by palpation with
ome follows the original fracture line [19, 20, 23]. All
a Freer elevator, and fluoroscopy, both methods being
these procedures and others can be grouped under
most unreliable [11, 17] (Fig.14.4).
outside-in osteotomy techniques, and although good
Bearing in mind these limitations, we sought a way
results have been reported, fears of devascularization
for assessing the status of the articular cartilage in the
and inaccurate reduction exist. Fernndez [12] consid-
area of malunion, which at the same time allowed us to
ers the technique appropriate only for single line frac-
accurately identify the fracture(s) line(s), and in this
tures, Gonzlez del Pino and others [14, 20] used it for
way we could cut exactly where the malunion was
the more complex four-part fracture configurations.
located at the cartilage level [6]. Our initial attempts
The outside-in techniques have had several draw-
with the classic arthroscopic technique were frustrated
backs in my hands: first, I have found after a CT scan
by constant vision losses due to water escaping through
that some malunions have quite odd configurations far
the large portals. We later moved on to carry out the
from a simple fracture line (Fig.14.1). For these cases,
arthroscopy without the infusion of water, which
unless one creates a very large capsular window to
solved most of the visibility problems [7]. The dry
obtain visual control of the osteotomy (with the subse-
technique has two further advantages: there is no risk
quent risk of devascularization and stiffness), there is no
of massive fluid extravasation causing compartment
syndrome, and secondly, the open part of the operation
is carried out without the tissues being infiltrated with
F. del Pial water. Conversely, not infusing water engenders a new
Head of Hand and Plastic Surgery, Private practice and
set of difficulties secondary to vision loss due to
Hospital Mutua Montaesa, Caldern de la Barca 16-entlo,
39002-Santander, Spain splashes and blood staining. I have presented in detail
e-mail: drpinal@drpinal.com and pacopinal@gmail.com how to deal with these inconveniences in Chap. 4.

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 191
DOI: 10.1007/978-3-642-05354-2_14, Springer-Verlag Berlin Heidelberg 2010
192 F. del Pial

Fig.14.1 (ac) 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
14 Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 193

a c d

Fig. 14.3 (a, b) This C31 fracture was simplified (see blocked a direct osteotomy line. A secondary iatrogenic carti-
Preoperative Planning) and only the major volar-ulnar frag- lage fracture would have resulted if an outside-in osteotomy
ment was to be mobilized (V.U.). (c) The articular line has been technique had been used in this case
highlighted with red dots. (d) Notice that the metaphyseal cortex

Fig.14.4 Outside-in osteotomy in a case of depression of the mobilized distally, blocking any visual control of the reduction.
lunate fossa. (a) The step-off is clearly seen prior to the planned (c) The limitations of exposure can be seen at the end of the
osteotomy that will consist of the mobilization of the lunate operation (notice the capsular dissection required in this type of
fossa as a dice (in dots). (b) The osteochondral dice has been osteotomy)
194
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 2mm or more
is an absolute indication whether symptomatic or not.
Some authors [10, 24] believe that step-offs of just a mil-
limeter 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 oper-
ation. On the other hand, low demand patients or rela-
tively 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 situ-
ation is more urgent for intrafacet malunions as the car-
tilage 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 defi-
nitely 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 Pial
as to assess the condition of the cartilage of the carpal
bones prior to proceeding to theosteotomy, as another
option may be selected when the cartilage is damaged.
But time, in itself, should not be considered a contrain-
dication, 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 68 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, over-
zealous resection of tissue in the gap may cause nar-
rowing 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 osteochon-
dral 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 195

Fig.14.6 (a, b) A large

a c
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 vascular-
ized osteochondral graft or a
partial arthrodesis b

a c d

Fig.14.7 (a) A free osteochondral fragment of about 3mm was ment in the joint has been sketched but not to scale. Notice cor-
found to be devoid of cartilage and removed from the joint (b). rection of the step-off radially and ulnarly (arrow). (d) Fourteen
(c) Intraoperative view. The contour of the fragments is outlined months later the mirror carpal bone does not show any worn
with dots. For orientation purposes, only the position of the frag- cartilage (same patient as in Fig.14.3)
196 F. del Pial

Fig.14.8 Massive bone loss

(left) or major distortion of
the anatomy (right) contrain-
dicates the procedure (both
patients were treated with a
vascularized osteochondral
grafting)

Fig.14.9 Authors decision-

making process when dealing
with an intraarticular step-off
on the radius (modified from
Pial in [3])

Preoperative Planning the number of fragments that need to be mobilized

A good quality CT scan is paramount in order to under-
stand 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 frag-
ment), is not easy, and becomes all the more difficult as
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 tolera-
ble, with the latter being unavoidable in old malunions.
Keeping this in mind, and although each case is dif-
ferent, four patterns of deformity can be identified in
14 Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 197

order of difficulty (Fig.14.10). Single-fragment straight-
line 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,
where only one articular fragment is markedly displaced,
the operation can be simplified, acting only on this mal-
positioned fragment. A concomitant open ulna shorten-
ing 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).

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
198
Surgical Technique
Logistics
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 invalu-
able 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 instru-
ments extraordinarily awkward (Copyright by Dr. Pial, 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 Pial, 2009)
F. del Pial
review of the preoperative X-rays, the original fracture
films, where possible, and a good quality CT scan.
Instruments and Osteotomy Technique
The setup I use for an arthroscopic-guided osteotomy is
identical to the one presented in Chap. 4. The instru-
ments are quite different, however. As there is no spe-
cific 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 4mm 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 Pial etal, [2])
14 Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 199

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. Pial, 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 ame-
nable 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 intro-
duced 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 alter-
native (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 (412 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,
200 F. del Pial

Fig.14.16 (a) As a rule, malunited dorsal fragments are better such instances, an angulated osteotome and a tear line osteot-
approached from the palmar. (b) When the fragment is depressed, omy may solve the problem
however, the ridge of the step-off may block this approach. (c) In

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 hypertro-
phy that responds well to silicone patches (Fig.14.19).
Ihave several times used combined approaches and pro-
vided 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
14 Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 201

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 ducing an osteotome 34mm parallel to the volar cortex (b). It
the volar plate and the arthroscopy itself, I recommend remov- is also crucial to remove the most exuberant callus in relation to
ing the volar callus, and weaken the anterior junction by intro- the malunited styloid fragment
202
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 710 kg of
traction applied to all fingers, but one has to expect
joint tightness, and the counterweight can be increased.
The standard dorsal 34 and 6R portals are developed,
but they are made larger, to approximately 0.5cm, 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 2.7mm scope is introduced through the
34 portal and a shaver in the 6R portal. It is indis-
pensable 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 Pial
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 carti-
lage 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
14 Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 203

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 lacera-
tions 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 (4mm 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 frag-
ments 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 frac-
tures (Chap. 4). Oftentimes, scar and new bone forma-
tion between the fragments impede perfect reduction.
This early granulation tissue should be resected with
the help of small curettes, and the shaver or burrs intro-
duced 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
204 F. del Pial

Fig.14.24 Simple straight line malunion involving the scaphoid fossa (2mm 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 frag-
ments/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 (48h). One should protect
the joint for 34 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 explor-
atory 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 dis-
tal radius 15 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 frag-
ment (up to 3) was osteotomized. In one patient with a
14 Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 205

a b c d

e g

f h

Fig.14.26 (ad) This C31fracture resulted in a relatively well- original surgeon, the axial shortening was approximately 3mm
aligned, albeit incongruent, radius at the lunate and sigmoid in comparison to the healthy side. A Sauve-Kapandji has been
fossae. The patient had scant ROM and 10 supination when offered elsewhere. Only the antero-ulnar fragment was osteoto-
first seen 12 weeks after the injury. Despite the confusing mark- mized with the technique presented in Fig.14.17. (eh) Result
ings in (b, d) concerning the ulnar variance depicted by her at 4 years (Copyright by Dr. Pial, 2009)
206
shortened radius by more than 2mm (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
e g
f h
Fig.14.27 (a, b) This four-part fracture resulted in a relatively
well aligned but shortened (by 5mm) radius. The antero-
ulnar fragment was 3mm more depressed than the rest. (c) Only
this fragment was mobilized and fixed with a volar buttress plate
F. del Pial
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 d
inserted from a volar-ulnar approach. In the same operation, the
ulna was shortened (by 2mm) 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 207

patients and good for seven patients with a mean score
of 2.8. The Modified Green and OBrien 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 frag-
ments did not fit as in an acute fracture (<2mm). Step-
offs, however, were reduced in most cases to zero (from
a maximum of 5mm). One patient was considered a
radiological failure, because the fragment redisplaced
due to poor fixation, although so far no additional sur-
gery has been required, and the patient has no com-
plaints. Another asked for hardware removal.

a b

c d

Fig.14.28 Complex
malunion (multiple-fragment
multi-directional osteoto-
mies). (a, b) Radiograms of a
patient who had been treated
with an external fixator
elsewhere (the CT scan is
shown in Fig.14.1). (c, d)
Result at 2 years. (e, h)
Clinical result at 2 years
208 F. del Pial

Fig.14.28 (continued)
e g

f h

Discussion Conclusions
The inside-out osteotomy technique allows full evalu-
It may be argued that fragments may be more easily
ation of the articular deformity, more precise osteot-
defined early on by simply breaking the external cal-
omy, and mobilization of the displaced fracture
lus as some of our patients were treated early (around
fragments. Even irregular fragments, not amenable to
the 4th5th week). On the basis of the experience of
other techniques, can be dealt with by this procedure.
our group and others, however, impacted bony frag-
Correction of step-offs was achieved in every case with
ments that contain cartilage are heal soundly as early
an accuracy of 0 mm. Residual gaps of about 1 mm
as 34 weeks and need to be redefined with the use of
were common due to cartilage loss, interposition of
an osteotome [4, 18]. Piecemeal fragmentation can
newly formed bone, and presumably cartilage destruc-
occur if the mobilization is not done carefully as
tion from the original injury. Understanding of the dry
shown in Fig.14.2. Herein lies the main advantage of
technique intricacies is needed to carry out the proce-
the procedure: the arthroscope allows us to follow the
dure in a safe and efficient manner. Any accomplished
exact line of chondral fracture under magnification,
arthroscopist should not have any undue difficulty to
and to restore the anatomy of the cartilaginous sur-
incorporate the dry technique.
face. Additionally, the risk of avascular necrosis of
the mobilized fragments is minimized as there is
minimal interference between the soft tissues (cap- References
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 The Role of Arthroscopic Arthrodesis and
Minimal Invasive Surgery in the Salvage 15
of the Arthritic Wrist: Midcarpal Joint

Joseph F. Slade

Introduction Background

Wrist arthritis results in chronic pain and limited hand Partial wrist fusion or limited carpal fusion is consid-
function. While the etiologies for wrist arthritis are ered as a motion-preserving salvage procedure for
numerous, the most common causes are SLAC/SNAC multiple painful wrist conditions. It is a good alterna-
wrist injuries and malunion after distal radius fractures tive particularly for those patients who would prefer a
[1, 8, 34]. These injuries result in an incongruent artic- mobile functional wrist rather than solid total wrist
ular gliding surface which leads to progressive degen- fusion [15].
erative arthritis (Fig. 15.1). The process of joint
degeneration results in increasing decline in wrist
function and increased wrist pain. The goal of treat-
ment is to arrest the process of cartilage degeneration,
reduce pain, and preserve the remaining wrist func-
tion. Treatment strategies are twofold. The first is the
removal of arthritis, and the second is restoration of a
normal synchronous gliding surface. Numerous partial
wrist fusions have been described, some with signifi-
cant complications [1, 12, 14, 24]. If these strategies
can be accomplished using minimal invasive tech-
niques, then normal uninjured structures can be pre-
served allowing for faster recovery of hand function
while limiting the risk of complications [26]. The tools
for percutaneous surgery include arthroscopy, minif-
luoroscopy, arthroscopic instruments, and guide-wire
introduced fixation such as headless cannulated screws.
These instruments permit reduction of carpal align-
ment, restoration of wrist motion, joint debridement,
reduction of carpus, and limited wrist fusion.

J. F. Slade Fig.15.1 This a photomicrograph of a rabbit model. The top

Department of Orthopaedics and Rehabilitation, plate is a displaced articular surface of a simulated injury in a
Yale University School of Medicine, New Haven, 06519, rabbit knee model. The plate below demonstrates degeneration
CT, USA of the articular surface which occurs over time with fractures of
e-mail: joseph.slade@yale.edu the cartilage

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 211
DOI: 10.1007/978-3-642-05354-2_15, Springer-Verlag Berlin Heidelberg 2010
212
The wrist consists of multiple bony linkages from
the forearm to the metacarpus via the carpal bones, and
this anatomic peculiarity offers an opportunity to allow
fusion of the painful segments of the wrist while pre-
serving motion in other unaffected segments. It also
helps to halt any predictable mechanical collapse of
the carpal column and maintain carpal height in carpal
instability conditions due to the failure of ligament
constraint or the loss of bony integrity such as scaphoid
nonunion and Kienbcks disease.
A variety of partial wrist fusions have been designed
in the past to address the problems arising from vari-
ous parts of the wrist and each with its own modifica-
tion with increasing experience [5, 10, 13, 16, 17, 18].
Any of the carpal bones and intervals can be fused
selectively, depending on the location of the symptoms
and arthritis. The resulting motion loss and the biome-
chanical effects have been studied extensively in labo-
ratory and clinical settings.
The following joints can be fused:
1. Between the radius and the proximal carpal row
(a) Radiolunate (RL) fusion [24, 30]
(b) Radioscapholunate (RSL) fusion [8, 25]
2. Between the two carpal rows
(a)Scaphotrapeziotrapezoid (STT) fusion [6, 36]
(b) Scaphocapitate (SC) fusion [18, 20, 23, 31]
(c) CL fusion [3, 12, 26]
(d) Triquetrohamate fusion [21]
(e)Four-corner fusion (involving the medial carpal
bones) [1]
3. Within the proximal carpal row
(a) Scapholunate (SL) fusion [38]
(b) Lunotriquetral (LT) fusion [9]
Commonly described operations in the literature and
considered as standard practice in todays care of the
arthritic wrist include open surgery requiring much soft
tissue dissection, including capsular and ligament inci-
sions around the wrist to expose the carpal intervals.
This may lead to iatrogenic stiffness of the joint on top
of the mechanical constraint rendered by selected car-
pal fusion. The expected loss of motion can be pre-
dicted theoretically from the biomechanical models,
although in practice, the final range of motion retained
clinically will also rely on the degree of soft tissue con-
tracture and the amount of compensatory hypermobil-
ity of the adjacent joints. It is therefore desirable to
minimize the surgical insult to soft tissue so as to maxi-
mize the motion preservation that is always the interest
of both the patients and the surgeons.
J. F. Slade
Arthroscopic intervention in partial wrist fusion
[11, 26] has potential advantages over these open
procedures, mainly the minimal surgical damage to the
supporting ligaments and capsular structures of the
wrist while allowing an unimpeded view to most artic-
ular surfaces of the joints and important soft tissue
elements. This ensures a more accurate staging of the
arthritis and facilitates clinical decision-making on the
most appropriate choice of fusion. The remaining car-
pal motion can be maximized and the postoperative
pain can be reduced, optimizing the rehabilitation
potential. Finally, there is also a cosmetic benefit with
the minimal surgical scar.
The goal of treatment is to arrest the process of
cartilage degeneration, reduce pain, and preserve the
remaining wrist function. The purpose of this chapter
is to describe arthroscopic and minimal surgical tech-
niques, which preserve wrist function, limit compli-
cations, and lead to an early recovery of hand
function.
Overview of Surgical Approach
Treatment strategies are twofold. The first is
removal of arthritis and the second is restoration
of a normal synchronous gliding surface. The tools
for percutaneous surgery include arthroscopy, mini-
fluoroscopy, arthroscopic instruments, and guide-
wire introduced fixation such as headless cannulated
screws.
To accomplish these steps, first, the pathology must
be correctly diagnosed. This is done with advanced
imaging including CT, MRI, fluoroscopy, and
arthroscopy.
Next, carpal alignment must be correctly restored,
capturing the remaining wrist motion. This often
requires the need for percutaneous surgical release
of the joint capsular.
Arthritis is removed by arthroscopic debridement
with aggressive shavers and arthroscopic debriders
[2]. Minimal incisions using additional arthroscopic
portals are also used with miniosteotomes and small
rongeurs for larger osteophytes.
Fusion surfaces are identified and debrided with
arthroscopic shavers and osteotomes under fluoro-
scopic guidance.
Percutaneous bone is inserted as needed.
Provisional fixation with Kirschner wires K-wires.
15 The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist
Rigid fixation is performed with headless cannu-
lated screws.
Arthroscopic and percutaneous limited wrist arthr-
odesis is suitable for the following surgical tech-
niques with caveats and pearls:
CL arthrodesis
Treatment for stage II/III SLAC/SNAC
Headless Acutrak screws placed between the
second or third web-space through the cen-
tral axis of capitate into the lunate provides
for the most rigid biomechanical fixation of
fusion surface. Also there is no violation
of radiocarpal joint to accomplish this arthr-
odesis [25, 31, 36]
Four-corner arthrodesis
Treatment for Stage II/III SLAC/SNAC
Reduction of lunate to capitate reduces
impingement [1]
Scaphoid excision increases radial-ulna devi-
ation [7]
Radio-scaphoid lunate (RSL) arthrodesis
Treatment for radiocarpal arthritis (intraar-
ticular malunion of distal radius) with normal
midcarpal joint
Excision of distal scaphoid increases motion
and decreases stress at Midcarpal joint result-
ing in degeneration [4, 8, 16]
Radio-Lunate (R-L) arthrodesis.
Very limited motion
Unsatisfactory for the treatment of keinbcks
disease [22]
Lunate-triquetral arthrodesis
Requires strong compression screw and tie-
rod blocking K-wires or mini-screw for a
solid union to be achieved
Requires bone graft [9]
Treatment for chronic LTIO ligament tear
Fifty-five percent failure rate for union [33]
STT arthrodesis
Treatment for Keinbocks disease
Requires correct reduction for successful out
come
Little tolerance for failure. Complication rate
as high as 52% [14]
213
Surgical Technique in Detail
Diagnosis of Pathology Using Imaging,
Fluoroscopy, and Arthroscopy
Standard radiographs can identify arthritis, but often
will underestimate the extent of joint involvement.
Not uncommonly, radiographs may fail to identify
early arthritis and correctly identify chondromalacia.
MRI is best used to identify avascular necrosis of the
carpal bones including proximal scaphoid fractures or
lunate AVN. MRI has been effective in the early iden-
tification of occult fractures including scaphoid frac-
ture, local impaction zones of the lunate as seen with
ulna impaction, TFCC tears, and on some occasions,
SLIO or LTIO carpal ligament injuries. CT scans are
best used to review the wrist bone architecture. CT
scans are commonly used to identify bone fractures,
displacement, and confirm fracture healing.
Radiographic imaging targets the potential pathol-
ogy which can now be confirmed and graded using
arthroscopy (Fig.15.2).
Arthroscopy requires longitudinal traction through
four fingers permitting maximum safe traction and
wrist joint penetration with minimum chance of
additional cartilage injury. Five to ten kilograms can
safely be applied, to stretch the wrist capsule for the
safe introduction of surgical instruments. Injection
of the wrist joint does little to distend the joint like
it does with other joint arthroscopic examination
such as the elbow. We use a standard arthroscopic
infusion pump. Outflow is established using multi-
ple 19-gauge needles or a second arthroscopic can-
nula when an arthroscopic shaver is not in use.
A minifluoroscopy unit is placed perpendicular to
the wrist and arthroscopic joint portals are identi-
fied. 19-gauge needles are inserted under fluoro-
scopic guidance to label the portal entry sites. The
portal site is incised no deeper than the skin level. A
small curved hemostat is used to bluntly dissect the
soft tissue to the level of the joint capsule. This per-
mits extensor tendons and dorsal nerves to be safely
retracted away from the portal site, preventing iat-
rogenic injury.
Using imaging, with wrist under traction, the small
curved hemostat is introduced into the wrist joint
with the clamp closed. After entry, slight spreading
of the hemostat establishes a portal site for the
introduction of arthroscopic instruments.
214
Fig. 15.2 Arthroscopy requires longitudinal traction through
four fingers permitting maximum safe traction-5-10 kg. A mini-
fluoroscopy unit is placed perpendicular to the wrist. The
arthroscopic joint portals 34; 45; 6R and radial and ulna mid-
carpal portals are identified using imaging. 19-gauge needles are
inserted under fluoroscopic guidance to label the portal entry
sites. This technique prevents iatrogenic cartilage injury and
correct portal placement. A small curved hemostat is used to
bluntly dissect the soft tissue to the level of the joint capsule.
This permits extensor tendons and dorsal nerves to be safely
retracted away from the portal site
Wrist and Carpal Arthrofibrosis
(Fig.15.3ae)
Joint arthritis is commonly associated with carpal
mal-alignment and joint arthrofibrosis. Arthroscopic
capsular release for the contracture of the wrist was
first described by Verhellen [34]. The addition of
fluoroscopy provides valuable guidance when used
in tandem with arthroscopy. Wrist and carpal joint
release is accomplished under fluoroscopic guid-
ance using traction and small curved hemostat.
Radiocarpal arthrofibrosis is released by implanting
a small curved hemostat through the 34 arthroscopic
portal using fluoroscopic guidance. Under maxi-
mum traction and image guidance, the curved
hemostat is gently swept radially and dorsally to
release capsular fibrosis. The small curved hemo-
stat is reintroduced through the 34 portal and now
swept ulnarly and dorsally, freeing the remaining
articular scar tissue and dorsal capsule. It is manda-
tory that these maneuvers are performed under fluo-
roscopic guidance to prevent iatrogenic injury to
the remaining healthy joint cartilage. These same
maneuvers can be performed on the midcarpal,
J. F. Slade
thumb CMC, and small joints of the hand to release
joint capsule arthrofibrosis [28].
Next, a small joint arthroscopic instrument can
safely be introduced to complete capsular release
and joint fibrosis excision.
With SLAC/SNAC wrist pathology, a DISI deformity
is commonly present with a dorsiflexed lunate. After
joint capsule release, the wrist can be hyperflexed and
the lunate corrected to a neutral position. A 1.5 mm
K-wires is placed through the distal radius into the
lunate in corrected neutral position. This provisional
fixation permits the lunate to be held in position while
the surgical treatment plan is executed.
Surgical Technique for Capitate-Lunate
Arthrodesis in Detail [26]
The patient is placed in a supine position with the arm
outstretched on a hand table with a tourniquet applied
to the arm. The arm is flexed and placed in a traction
tower, after the operative extremity is prepped and
draped in a standard surgical fashion. A minifluoro-
scopic imaging unit is placed perpendicular to the
wrist (Fig. 15.4a). The radiocarpal, midcarpal, and
DRU joints are visualized. Standard arthroscopic por-
tals are identified and established using a small curved
hemostat and these include the 34; the 45; the 6R,
and 6U. The radio and ulna midcarpal portals are also
identified. Longitudinal traction is applied and a small
joint-angled arthroscope with an aggressive shaver is
introduced into the joint and a complete synovectomy
and dorsal capsular release is performed. After a com-
plete exam of the carpus, the pathology is recorded.
All superficial chondromalacia is treated with chondro-
plastic shaving.
The first key step is the reduction of the lunate from
its current extended position (DISI deformity) to a
neutral position. This is done by flexing the wrist and
manually reducing the lunate to its neutral anatomic
location. Elimination of the DISI deformity (extended
lunate) is confirmed on lateral fluoroscopic imaging.
A 1.5 mm K-wires is now placed through the dorsal
aspect of the distal radius and advanced into the
reduced lunate (Fig.15.4b). The K-wires should not
be directly in the center of the lunate but rather in a
more ulnar position to permit the later placement of
a compression screw in the center of the lunate. This
effectively secures the lunate in its zero degree (neu-
tral) lateral position.
15 The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist 215

Fig.15.3 Wrist capsular

a
release for contracture can
be accomplished using
arthroscopy and fluoroscopy.
(a) Demonstrate wrist
arthrofibrosis and capsular
contracture after distal radius
fracture repair with volar
locking plate. The wrist is
placed perpendicular to the
imaging units and a 19-gauge
needle placed into the 34
portal (b). A small curved
hemostat is introduced
through the 3,4 arthroscopic
portal using fluoroscopic
guidance under maximum
traction (c). The curved
hemostat is gently swept
radially, ulnarly, and dorsally
to release the capsular
fibrosis (d). After the
capsular release, the
arthroscope can now be b
inserted into the wrist joint
to complete the joint
debridement. After the joint
release, significant mobility
is obtained (e)

c
216 J. F. Slade

Fig.15.3 (continued)
d

e
15 The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist
Fig.15.4 Surgical technique for arthroscopic/percutaneous cap-
itate-lunate arthrodesis in detail. The arm is placed in a traction
tower, a minifluoroscopic imaging unit is placed perpendicular to
the wrist, and the radiocarpal, midcarpal, and DRU joints are
identified. A small joint arthroscope is introduced into the wrist
joint and the joint is debrided (a fluro unit). After arthroscopy,
the DISI deformity must be corrected. The lunate is reduced to a
neutral position by flexing the wrist. The corrected lunate position
is confirmed on lateral fluoroscopic imaging. A Kirschner wire is
placed through the distal radius and advanced into the reduced
lunate (b). Imaging is used to identify the ulna midcarpal and the
34 radiocarpal portal (c). An oblique incision is made between
these portals. The tendons of the fourth dorsal extensor compart-
ment are exposed and retracted. The capitolunate (CL) joint inter-
val is identified just deep to the retracted tendons (d). A transverse
incision is made through the dorsal capsule exposing the CL joint
(e). Next the CL joint is resected. The resection of the CL joint
now provides for easy access to the scaphoid for resection (f).
This is accomplished using a small rongeur, 1 & 2-mm osteot-
omes, a small curved hemostat, and a bone cutting burr. After the
scaphoid excision, a radial styloidectomy is performed as needed.
Care must be taken not to remove more than 5mm of the radial
styloid to preserve the attachment of radio-scaphoid capitate
(RSC) ligament to the carpus. After joint debridement, a guide-
wire is percutaneously introduced along the long axis of the capi-
tate, the wrist is flexed, a wire is driven proximal to distal through
217
the exposed proximal pole of the capitate and driven through the
base of the metacarpal into the second and/or third web-space (g).
Using fluoroscopy, the capitate is now reduced on the lunate into
a neutral position. The guide-wire is then advanced from the capi-
tate into the lunate securing the reduction. (h). A cannulated, stan-
dard Acutrak drill is used to prepare the capitate and lunate for
screw placement and driven from distal to proximal (i). The screw
selected will be 4mm shorter than the length of carpal fusion. A
headless cannulated compression screw is implanted in a retro-
grade fashion over the guide-wire between the web-space (j).
Fluoroscopy confirms proper screw placement along the long axis
of the capitate and lunate fusion mass. The central axis radiolu-
nate (RL) capitate K-wires is then removed. The wounds are irri-
gated and closed with 5-0 nylon sutures. As an alternative to the
limited incision technique described above, an arthroscopic tech-
nique can also be successful. A radiocarpal portal is used to con-
firm preservation of the RL joint. Midcarpal and radiocarpal
arthroscopy portals are utilized for the CL, scaphoid, and radial
styloid resections (k). The remainder of the procedure is identical
to that described above. The hand incision and portals are closed
(l). CT scanning is used to confirm solid fusion commonly seen at
46 weeks (m). The patients are then released to full, unrestricted
duties including sports and heavy labor. This is a 55-year male 1
year after a partial scaphoid excision and capitate-lunate arthrod-
esis. He is pain-free and has resumed both his work and avocation
without difficulties (n)
218 J. F. Slade

Fig.15.4 (continued)
d

e
15 The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist 219

Fig.15.4 (continued)
220 J. F. Slade

Fig.15.4 (continued)
15 The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist
Fig.15.4 (continued)
A line is then drawn between the ulna midcarpal
and the 34 portal, delineating the intended surgical
incision (Fig.15.4c).
This oblique incision (approximately two cm in
length) is made, and the tendons of the fourth dorsal
extensor compartment are exposed and retracted.
The CL joint interval is identified just deep to the
retracted tendons (Fig. 15.4d). A transverse inci-
sion is made through the dorsal capsule exposing
the CL joint (Fig.15.4e).
The next step consists of the resection of the CL
joint. This increases the surgeons working space and
permits easy access to the scaphoid and radial sty-
loid. Joint resection provides two beds of bleeding
subchondral bone in anticipation for arthrodesis. The
decortication of the distal lunate articular surface and
proximal capitate articulation is performed using an
aggressive cutting burr or small osteotomes. The
resection of the CL joint now provides for easy access
to the dysfunctional scaphoid for partial or full resec-
tion (Fig.15.4f). This is accomplished using a small
rongeur (such as a sinus surgery rongeur), 1 & 2-mm
osteotomes, a small curved hemostat, and a bone cut-
ting burr. All of these instruments can be introduced
through an enlarged arthroscopic portal to perform
carpal excision. After the scaphoid excision, these
same instruments are used for radial styloidectomy.
221
Care must be taken not to remove more than 5mm of
the radial styloid in order to preserve the attachment
of radio-scaphoid capitate (RSC) ligament to the car-
pus. Failure to preserve this ligament will result in
ulnar translation of the carpus.
The goal of arthritic debridement is the removal of
diseased ossific overgrowths (radial styloid and sca-
phoid), which can be impacted during radiocarpal
motion. This is critical for pain relief.
Next, a guide-wire is percutaneously introduced
along the long axis of the capitate, in between the
second and third web-space. The guide-wire can be
introduced distal to proximal through the CMC
joint into the capitate or with the wrist flexed, proxi-
mal to distal through the exposed proximal pole of
the capitate (Fig. 15.4g). The guide-wire is intro-
duced into the capitate and driven through the base
of the metacarpal into the second and/or third web-
space. Using fluoroscopy, the capitate is now
reduced on the lunate into a neutral position. Care
must be taken to ensure that both the capitate and
lunate are aligned in the same plane on the P.A. &
lateral images. The guide-wire is then advanced
from the capitate into the lunate securing the reduc-
tion (Fig. 15.4h). A cannulated, standard Acutrak
drill is used to prepare the capitate and lunate for
screw placement and driven from distal to proximal
222
(Fig. 15.4i). It is critical not to drill closer than
2mm to the proximal lunate cortex. If bone graft
is needed, it is percutaneously inserted into the
capitate-lunate joint. Occasionally, an Acutrak plus
drill is used to ream the CMC base to permit driver
introduction. Prior to reaming, the combined length
of the lunate and capitate is measured using a sec-
ond guide-wire. Once the length is determined, the
guide-wire is driven through the lunate into the
radius. This prevents the wire from dislodging when
the cannulated drill is removed. The screw selected
will be 4 mm shorter than the length of carpal
fusion. Finally, a headless cannulated compression
screw is implanted in a retrograde fashion over the
guide-wire between the web-space (Fig.15.4j). We
prefer a standard-sized Acutrak screw. The screw is
advanced from the capitate into the lunate taking
care to stop 2mm from the lunate proximal surface.
To prevent possible distraction or push-off at the
arthrodesis, a 1.5 mm K-wires can be inserted into
the lunate. Fluoroscopy confirms proper screw
placement along the long axis of the capitate and
lunate fusion mass. The central axis RL capitate
K-wires is then removed. The wounds are irrigated
and closed with 5-0 nylon sutures. As an alternative
to the limited incision technique described above,
an arthroscopic technique can also be successful. A
Fig. 15.5 Bone is percutaneously harvested from the distal
radius. An imaging unit is placed perpendicular to the wrist and
a 1.25 mm K-wires is driven into the distal radius (a). A cannu-
lated reamer is used to penetrate the bone cortex (b). After the
bone cortex is penetrated, an 8-gauge, 4in. Baxter bone biopsy
J. F. Slade
radiocarpal portal is used to confirm the preserva-
tion of the RL joint. Midcarpal and radiocarpal
arthroscopy portals are utilized for the CL, sca-
phoid, and radial styloid resections (Fig. 15.4k).
The remainder of the procedure is identical to that
described above. The hand incision and portals are
closed (Fig.15.4l).
Postoperative care: postoperatively, patients are
immobilized in a volar wrist splint, which is then
changed to a removable canvas wrist splint after
suture removal. Hand therapy is then started to
recover finger motion. A strengthening program is
started to axially load the fusion mass. This aids in
rapid recovery of hand function and stimulates bone
healing. CT scanning is used to confirm solid fusion
commonly seen at 46 weeks (Fig. 15.4m). The
patients are then released to full, unrestricted duties
including sports and heavy labor (Fig.15.4n).
Percutaneous Bone Graft
The bone is percutaneously harvested from the distal
radius along the ulna border. An imaging unit is placed
perpendicular to the wrist and a 1.25 mm K-wires is
driven into the distal radius (Fig.15.5). Asmall stab
cannula is placed over the guide-wire. The guide-wire is
removed, and multiple bone plugs are harvested using the can-
nula. This same cannula will later be used to percutaneously
introduce bone plugs at the arthrodesis site
15 The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist
incision is made next to the K-wires. A small curved
hemostat is used to bluntly dissect the soft tissue away
from the K-wires down to the bone. A cannulated
reamer is used to penetrate the bone cortex. After the
bone cortex is penetrated, an 18-gauge, 4 in. Baxter
bone biopsy cannula is placed over the guide-wire.
The guide-wire is removed and multiple bone plugs
are harvested using the cannula. These will later be
introduced percutaneously at the arthrodesis site using
the same cannula and a plunger [29].
Clinical Experience
Twelve cases were treated with percutaneous CL arthr-
odesis. At 38-month follow-up, 12 patients had solid
fusions confirmed by CT scan. There was one compli-
cation. This complication was a technical error, which
was a result of underresection of the radial styloid pro-
cess. This patient had mild occasional pain at the radial
styloid, but declined further treatment as she had no
limitation in her activities The remaining patients were
pain-free. All had a functional range of motion with a
70% flexion-extension arc, 68% radial-ulnar deviation
arc, and 92% supination-pronation arc. Grip strength
was 90% of the opposite normal uninjured wrist. All
the patients returned to their prior work and avoca-
tions, including weight training, tennis, baseball, and
recreational golf.
Conclusion
Arthroscopic-assisted fluoroscopic percutaneous sur-
gery to treat wrist arthritis can restore function and
reduce pain with minimal complications. We report
our experience on CL arthrodesis using minimally
invasive surgical techniques including arthroscopy and
minifluroscopy. Adjunct procedures including capsu-
lar release and percutaneous bone-grafting are often
required. These cases yielded a 100% union rate with
high satisfaction. These advanced techniques require
training to avoid complications, as the learning curve
is steep.
Acknowledgments I thank Peter C. Yeh, MD for his assis-
tance during the preparation of this manuscript.
223
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 Arthroscopic Radiocarpal Fusion
for Post-Traumatic Radiocarpal Arthrosis 16
Pak-cheong HO

Introduction Specific type of dorsal loading of the wrist joint can

lead to localized damage to the radiolunate articulation,
resulting in the so-called die-punch fracture [14].
Post-traumatic radiocarpal arthrosis occurs mainly
Another common form of injury involves the volar
after fracture with major intra-articular component,
ulnar lunate facet fragment with subluxation [4]. Under
without adequate articular reduction and optimal fixa-
such circumstance, the scaphoid fossa is frequently
tion. It has been well shown that intra-articular fracture
spared, and severe damage to the articulation between
of the distal radius with more than 2mm residual artic-
lunate and lunate fossa can be resulted. Isolated osteo-
ular step particularly in young patient can lead to radio-
chondral fracture can also occur at the radiolunate joint
logical degenerative arthritis in 91% of cases [8].
in the absence of radiological fracture, and cause pro-
Catalano etal. found that 76% of patients with residual
longed joint pain and dysfunction. Diagnosis is diffi-
gap over the articular surface developed radiological
cult and is frequently revealed only after arthroscopic
arthrosis [1]. Fernandez also noted a direct correlation
intervention. Recent improvement in MRI technique
with subjective complaint and functional result with
helps to depict this type of lesion.
the articular alignment on follow-up radiographs [2].
Post-traumatic wrist arthrosis can cause protracted
Post-traumatic arthrosis of the radiocarpal joint can
wrist pain, loss of motion and impairment of limb
happen even in cases when articular reduction is opti-
function. The aim of surgical treatment is to abolish
mal [10, 13, 16]. Radiocarpal fracture dislocation, both
pain by removing the source of pain, stabilize the wrist
in dorsal and palmar direction, has been associated
segments to halt progressive arthritis and to preserve
with radiocarpal arthritis, particularly if there is resid-
useful wrist motion and function. Radiocarpal fusion
ual ulnar translocation of carpus or recurrent instability
is indicated whenever there is irreversible damage to
[11]. Patient with unsatisfactory reduction of extra-
the radiocarpal joint articulation after distal radius
articular fracture has a higher incidence of accelerated
fracture, while the mid-carpal joint is relatively pre-
degeneration of the radiocarpal joint. Experimental
served. Conventional radiocarpal fusion is performed
study showed that excessive dorsal tilt of the articular
by open approach, almost exclusively from dorsal
surface of more than 20 can decrease the contact area
approach. Potential disadvantages include extensive
between scaphoid and lunate with the articular surface
surgical dissection upon exposure which may lead to
of distal radius, and this leads to excessive and eccen-
unnecessary extensor tendon adhesion and undesirable
tric loading of the dorso-radial aspect of the distal
loss of finger and wrist motion due to post surgical
radius articular surface [15].
capsular contracture. Assessment of mid-carpal joint
cannot be completed without unnecessary surgical
Pak-Cheng HO, MBBS, FRCS(Edinburgh), FHKCOS, insult. Remaining motion after radioscapholunate
FHKAM(Orthopaedics) fusion can be marked limited, based on obligate inter-
Department of Orthopaedics & Traumatology, ference of mid-carpal motion due to loss of scaphoid
Division of Hand and Microsurgery,
motion. Nagy and Bchler reported that flexion aver-
Chinese University of Hong Kong, Prince of Wales Hospital,
Shatin, Hong Kong SAR, China aged 18, extension 32, radial deviation 3 and ulnar
e-mail: pcho@ort.cuhk.edu.hk deviation 25 [12]. Kilgus reported that the active

F. del Pial et al. (eds.), Arthroscopic Management of Distal Radius Fractures, 225
DOI: 10.1007/978-3-642-05354-2_16, Springer-Verlag Berlin Heidelberg 2010
226
range of motion in the operated joint remained con-
stant over 10 years of follow-up, with mean 60 dorso-
palmar and 30 ulnoradial [7]. Motion is expected to
improve to averaged 71 flexion-extension arc after
simultaneous distal scaphoidectomy which unlocks
the mid-carpal joint [12]. In radiolunate fusion, loss of
motion can be at least 50%. By simulated fusion in the
laboratory, Myerdierks etal. found a 47% loss of flex-
ion/extension and a 37% loss of radio-ulnar deviation
[9]. In clinical situation, remaining motion of the wrist
can further be jeopardized by accompanying soft tis-
sue contracture.
Arthroscopic approach in principle can help to min-
imize unnecessary surgical trauma to the ligamentous
capsular and tendon structures and hence maximize
motion preservation. Simultaneous evaluation of the
mid-carpal joint condition can be performed without
added trauma to ensure the correct indication. Post-
operative pain is minimal and overall rehabilitation can
be facilitated. There is also a cosmetic merit with the
small and inconspicuous surgical scars. Arthroscopic
debridement of the radiocarpal joint is technically rela-
tively straight forward. Recent advance in percutane-
ous cannulated screw system simplifies the surgical
technique and enhances rigidity of the bony fixation to
allow earlier mobilization of the wrist.
Indications and Contra-Indications
Selective radiocarpal fusion is an attractive option for
young patients suffering from painful post-traumatic
arthrosis of the radiocarpal joint who would like to pre-
serve useful motion of the wrist and are reluctant to
consider total wrist fusion. An average of 50% of the
physiological motion of the wrist can be preserved after
fusing the proximal carpal row to the radius. Absence
of significant mid-carpal pathology is essential to pre-
dict successful outcome of the surgery. Arthroscopic
examination of the mid-carpal joint is the most reliable
method to rule out mid-carpal joint arthrosis. The pres-
ence of carpal dissociation such as scapholunate liga-
ment injury does not preclude the consideration of
radiocarpal fusion, as long as there is no associated
degenerative change in the mid-carpal joint.
Partial wrist fusion is absolutely contraindicated
when there is active ongoing sepsis over the wrist joint.
Partial wrist fusion is also not a guarantee for pain
Pak-Cheng HO
relief. The potential advantage of partial wrist fusion in
preserving a useful arc of motion may be offset by risks
of non-union or by continuing pain despite successful
fusion [5]. Nagy and Bchler reviewed a cohort of 15
cases of radioscapholunate fusion and reported a non-
union rate of 27% [12]. Nearly half of them showed
secondary degenerative changes of the mid-carpal joint,
two of which were progressive. Four patients had con-
tinuing symptoms despite sound radiological union of
the partial wrist fusion. Revision total wrist fusion was
required in 33% of cases ultimately. Thus those patients
who prefer more guaranteed outcome on pain control,
do not want multiple surgical procedure and do not
bother loss of wrist motion may be better candidates for
total wrist fusion. Chronic smoker has higher incidence
of non-union after partial wrist fusion and required
more revision surgery to achieve union. An alternative
for pain control treatment such as wrist denervation can
be considered. Interposition arthroplasty using fascial
or dermo structures have been reported in rheumatoid
wrist but is seldom indicated in post-traumatic lesion.
Total wrist arthroplasty can be considered in older
patients with limited functional demand. Wrist pain
constituted by ulnar sided pathology such as TFCC
injury, DRUJ instability and luno-triquetral dissocia-
tion which may be associated with the distal radius
fracture cannot be adequately dealt with by radiocarpal
fusion alone and requires specific treatment such as
TFCC reconstruction, Darrach procedure, Sauve-
Kapandji operation etc to control the source of pain.
Surgical Approach
Set Up and Instrumentation
Operation is performed under general or regional
anaesthesia. C-arm fluoroscopy should be available in
all cases for intra-operative assessment. List of essen-
tial instrumentation includes motorized full-radius
shaver and burr system of diameters ranging from 2.0
to 2.9, 2.5mm suction punch, radiofrequency thermal
ablation system and small cannulated screw system.
Patient is put in supine position while the operated
arm is supported on a hand table. Arm tourniquet is
applied but need not be inflated routinely. Most of the
procedures can be done without the use of tourniquet.
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis
Vertical traction of 46 kg force is applied through
plastic finger trap devices to the middle three fingers
for joint distraction via wrist traction tower. We
employ continuous saline irrigation to maintain clear
arthroscopic view by using 3L bag of normal saline
solution hung up at about 1.5 m above the patient
level. Infusion pump is not necessary as excessive
pressure may cause harmful extravasation of fluid.
We perform routine inspection of both radiocarpal
joint through 3/4 portal and mid-carpal joint through
RMC portal using 2.7 or 1.9 mm video arthroscope.
Adrenaline solution of 1 in 200,000 dilution is injected
to the portal site skin and capsule to reduce the bleed-
ing associated with incision (Fig. 16.1) [6]. Outflow
portal is established at 6U portal just volar to the ECU
tendon using 18-guage needle. In general, all portals
should be marked after careful palpation with thumb
tip and the wrist being distracted on the traction device
before saline was injected intra-articularly.
When the arthroscope is being placed inside the
joint, particular attention is paid to note the status of
interosseous ligament, triangular fibrocartilage com-
plex, degree of synovitis and articular cartilage condi-
tion of the radiocarpal joint. Frequently associated
localized post-traumatic synovitis may obscure the
observation of cartilage condition and needs to be
eliminated by using 2.0mm shavers or radiofrequency
probe inserted from 4/5 portal. It may be necessary to
Fig.16.1 Lignocaine (1%) with adrenaline solution in 1:200,000
dilution is injected into the portal sites for haemostasis effect
227
swap the portal of the arthroscope and instrument in
order to obtain a better attacking angle of the instru-
ment for more efficient synovectomy. The ulno-carpal
joint should also be routinely inspected and the status
of TFCC ascertained. Any central perforation of the
TFCC without peripheral involvement should be deb-
rided of any unstable flap tear at the same operation to
avoid possible new source of pain after the definite
index procedure.
The mid-carpal joint is approached through the
RMC portal. Routinely, the STT joint, scaphocapitate
joint, capitolunate joint and triquetrohamate joint are
inspected for cartilage lesion and synovitis. The
scapho-lunate and luno-triquetral joint are assessed for
stability with 2mm probe introduced from the UMC
portal. Synovial overgrowth should be debrided by
using shaver or radiofrequency probe to adequately
expose the underlying cartilage area for the assessment
of the true extent of chondral damage and subchondral
bone exposure. A prerequisite for successful radiocar-
pal fusion is a relatively intact articular surface at the
mid-carpal and STT joints. If significant arthritis
change is present, one may need to abandon the
planned procedure and consider other salvage option
such as total wrist fusion.
Radioscapholunate Fusion
Radioscapholunate fusion is indicated for severe pain-
ful post-traumatic arthritis involving the whole radio-
carpal joint while the mid-carpal joint is relatively
preserved [17]. It has been shown that an accompany-
ing distal scaphoidectomy procedure can help to
improve mid-carpal motion especially on ulnar radial
deviation [3].
A general surveillance of the mid-carpal joint to
confirm its relative integrity is a prerequisite for suc-
cessful radioscapholunate fusion. Arthroscopic distal
scaphoidectomy can also be performed at the same
time. With the arthroscope placed at UMC portal, a
2.9 mm burr is inserted into the RMC portal and
directed towards the distal scaphoid portion articulat-
ing with the trapezoid. Burring of the scaphoid is
started at this point towards the distal pole from dorso-
ulnar to volar-radial direction. Caution has to be taken
to avoid iatrogenic damage to the articular cartilage of
trapezoid, trapezium and capitate. The junction between
228
capitate, scaphoid and trapezoid forms the landmark of
the proximal extent of resection (Fig.16.2). A shell of
cartilage can be left intact until majority of the cancel-
lous bone of the distal scaphoid pole is removed
(Fig.16.3). This shell of cartilage can help to separate
the burr from the adjacent carpal bones during the
burring process. This can be removed piece-meal at the
end of the distal scaphoidectomy procedure by using a
small pituitary rongeur or arthroscopic punch. The
STT portal can also be employed to facilitate burring
of the most distal part of the scaphoid. At the end of
the procedure, there should be a void opposing the tra-
pezium and trapezoid bone, while the waist of sca-
phoid is preserved and is articulating with capitate.
The precise extent of distal scaphoid resection can be
checked with intra-operative fluoroscopy (Fig.16.4).
Fig.16.2 Arthroscopic view at mid-carpal joint showing the
junction between capitate, trapezoid and scaphoid, which forms
the proximal limit of arthroscopic distal scaphoid resection
Fig.16.3 Shell of cartilage left intact during burring of sca-
phoid to protect other uninvolved articular surface
Pak-Cheng HO
After distal scaphoidectomy is complete, the arthro-
scope can be directed to the radiocarpal joint. The
remaining articular cartilage of the radiocarpal joint is
denuded. With the arthroscope in 3/4 portal, a 2.9mm
burr is inserted into 4/5 portal and both lunate fossa
and proximal surface of the lunate are debrided of
articular cartilage. The degree of cartilage denudation
should be well controlled so that no excessive sub-
chondral cancellous bone is being removed. Burring is
completed when subchondral cancellous bone with
healthy punctate bleeding is reached (Fig.16.5). This
phenomenon can be easily observed if tourniquet is
not used during this process. Usually bleeding is lim-
ited and can easily be controlled with hydrostatic pres-
sure applied through the irrigation system. If bleeding
is profuse, one may use the coagulatory role of radiof-
requency apparatus. Use of tourniquet is optional
depending on the degree of bleeding. During the burr-
ing process, suction can be switched on and off inter-
mittently to remove any accumulated bone debris
which may block the visual field. If suction is applied
continuously during the burring process, excessive air
bubbles drawn in will severely compromise the visibil-
ity of the operating site. The portals are then switched
so that the burr is introduced from the 3/4 portal to
have a better clearance of the articular cartilage of the
proximal scaphoid and the scaphoid fossa including
the radial styloid area.
After completion of the burring process, the hand is
taken off the wrist traction tower and placed horizon-
tally on the operating hand table. An image intensifier
is moved in. Percutaneous K-wire is inserted from the
distal radius to transfix the radiolunate and radio-
scaphoid joint (Fig. 16.6). A small longitudinal inci-
sion is made at the distal radius about 2cm proximal to
the midpoint between the 3/4 and 4/5 portal. This is
corresponding to the direct articulation between radius
and lunate. The extensor tendons are bluntly dissected
off from the potential wire insertion point using a fine
pointed stitch scissor. With the wrist placed in neutral
position both in flexion-extension plane and radio-ulnar
deviation plane, two 1.1mm K-wires are inserted using
a protective sheath one after the other from the distal
radius to fix the lunate. If small cannulated screw is
being used, the guide pin is inserted in the same man-
ner. One or two guide pins are used according to the
size of the carpal bone. The two wires should aim at the
radial and ulnar border of the lunate so as to have even
purchase on the bone. The radiolunate angle should be
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis
Fig.16.4 Post-op
radiograph showing the extent
of distal scaphoidectomy in a
patient receiving arthroscopic
radioscapholunate fusion
(circle of dotted line)
Fig.16.5 Burring of the lunate fossa with 2.9mm arthroscopic burr
maintained at zero degree. This requires confirmation
using both AP and lateral view of X-ray. On the lateral
projection, the wire should target on the anterior horn
of the lunate bone. To optimize the bone purchase, the
angle of insertion of the K-wires should be quite acute
at 2030 with reference to the long axis of the fore-
arm. Another incision is made over the radial styloid at
the bare area between the first and second extensor
compartment. After careful blunt dissection of the
superficial branches of the radial nerve, two K-wires or
guide wires are inserted in sequence to transfix the dis-
tal radius to the scaphoid. After verification of the wire
229
position, they can be back out from the carpal bones
while attaching to the distal radius. The protruded ends
of the K-wires are capped to avoid injury to the sur-
geon. The wrist is then put back to the wrist traction
tower for the arthroscopic grafting procedure.
With the arthroscope introduced at 4/5 portal, the
arthroscopic cannula is inserted through 3/4 portal to
reach the radial side of the scaphoid fossa using a tro-
car. The trocar should have a flat end and the size of
the trocar selected should be in such way that it does
not snug fit the cannula. There should be some free
space between the inner wall of the canula and the tro-
car so that granules of bone substitute will not be
trapped and hinder the passage of the trocar. Bone sub-
stitute is inserted to fill up the radial side of the radio-
scaphoid joint (Fig.16.7). Granule or injectable form
can be used. As the fusion surfaces are usually well
vascularized, there is generally no need to use autog-
enous bone graft to avoid donor site morbidity. This
process requires two assistants to execute smoothly.
One assistant helps to maintain the position of the
arthroscope to provide optimal vision of the fusion
site. The operating surgeon controls the arthroscopic
cannula and trocar while a second assistant is respon-
sible to deliver the bone substitutes into the cannula in
small volume every time (Fig.16.8). The speed of the
230
Fig.16.6 Arthroscope being
inserted into the radiocarpal
joint after the two percutane-
ous K-wires were back out
from the joint
Fig.16.7 Cannulated drill was inserted through percutaneous
pins fixing the radiolunate interval. Note the acute angle of
insertion with reference to the forearm
process can be enhanced by using a cannula of wider
bore such as 4.5 or 5mm, so that each time more bone
substitute can be accommodated. The granule inside
the joint should be compressed with a small impactor
(Fig.16.9). If injectable bone substitute is to be used,
joint irrigation should be ceased and all joint fluid
evacuated with suction. A wide bore needle connect-
ing the syringe containing the bone substitute is
inserted through appropriate portal to reach the fusion
Pak-Cheng HO
Fig.16.8 Insertion of the granule form of bone substitute into
the radiocarpal joint at the fusion site through the arthroscopic
cannula
site. Injection of the bone substitute can then be per-
formed under direct vision till the cavity is filled up
completely. When the radio-scaphoid joint is half filled
with bone substitute, the arthroscope is switched to 3/4
portal and the cannula is inserted at the 4/5 portal.
Grafting process is continued at the radiolunate joint.
If necessary, intra-operative fluoroscopy can help to
confirm the completeness of the filling process
(Fig.16.10). In order to prevent spillage of graft inside
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis
the joint to the ulno-carpal joint area, special Foley
balloon blocking technique has been developed
(Fig.16.11). A French size 6 or 8 Foley catheter with
stylet is introduced through 6R portal. Advancement
of the catheter into the joint can be facilitated by grasp-
ing the tip of the catheter using a small arthroscopic
grasper introduced from the 4/5 portal if necessary.
Once the balloon portion of the catheter is completely
inside the joint as monitored through the arthroscope,
it can be inflated with saline solution until the joint
Fig. 16.9 Arthroscopic view showing impaction of the bone
substitute granules with small impactor
Fig.16.10 Intra-op
fluoroscopy confirms the
filling of radiocarpal joint
with bone substitute while the
ulno-carpal is spared
231
compartment is largely obliterated by the balloon. The
balloon remains inflated during the arthroscopic graft-
ing process. Reducing fluid inflow is also a useful trick
to avoid graft spillage.
When the grafting procedure is complete, the hand
is again taken off the tower and the tourniquet deflated.
Under image guide, the K-wires are driven back into
the carpal bones just short of the articulating surface at
the mid-carpal joint. For post-traumatic arthritis in
younger patient, I prefer using percutaneous compres-
sion screw to enhance fusion rate. After measuring the
length of the inserted portion of the K-wires, the wire
Fig.16.11 Foley catheter blocking technique: size 6 Foley cath-
eter was placed at 6R portal to obliterate the ulno-carpal joint
232
tracks are drilled with cannulated drill bit. Definitive
fixation is performed with 3.0mm cannulated screws
with the head firmly anchored over the dorsal cortex of
the distal radius. Alternatively, headless cannulated
screw system can also be used (Fig.16.12a, b). X-ray
is required to confirm that the thread of the screws
does not perforate the mid-carpal joint surface to
impinge on the distal carpal row. In osteopenic bone,
where screw purchase can be sub-optimal, the 4
K-wires can serve as the definitive fixation means
(Fig.16.13ad). They are cut short and buried under-
neath the skin. The wrist should be moved gently to
confirm the smooth articulation at the mid-carpal joint
and stable fixation at the radiocarpal joint. The inci-
sion wounds are then opposed with steri-strips or sim-
ple stitches. Comfortable compression dressing with
short arm plaster slab is applied. It is changed to remov-
able wrist splint at 12 weeks of time. For K-wires
fixation, active mobilization of the wrist is initially
after fusion is united radiologically and clinically. The
K-wires can be removed under local anaesthesia
through the original skin incision. For compression
screw fixation, gentle active wrist mobilization can be
performed at 2 weeks post-op under supervision. More
vigorous mobilization can be performed when radio-
logical and clinical union is achieved.
Fig.16.12 (a) Intra-op
X-ray shows the final fixation
of radioscapholunate intervals
with two percutaneous
headless screws. Note that the
ulnar shortening was
performed before the indexed
procedure. (b) Solid union of
radioscapholunate fusion site
at 39 months post-op.
Surgical scar was minimal
Pak-Cheng HO
Radiolunate Fusion
Radiolunate fusion is most commonly utilized in rheu-
matoid arthritis where there is painful ulnar transloca-
tion of the carpus at the radiocarpal joint. In post-traumatic
situation, it is indicated when the articular cartilage
destruction is confined to the radiolunate joint, such as
in die-punch fracture of distal radius (Fig.16.14).
The operation is essentially similar to radioscaphol-
unate fusion, except that the radio-scaphoid joint is
spared. In addition, distal scaphoidectomy is not nec-
essary. Thus during the burring procedure, the articular
surface of the proximal scaphoid and scaphoid fossa
should be well protected. Also during the graft inser-
tion procedure, a second Foley catheter can be inserted
at the 1/2 portal to obliterate the space at the radio-
scaphoid articulation so as to isolate the space at the
RL joint (Fig.16.15). Arthroscope is placed at the 3/4
portal while bone substitute is delivered to the radiolu-
nate joint through a cannula at the 4/5 portal
(Fig. 16.16). Fixation can be accomplished by 2
K-wires or two compression cannulated screws inserted
percutaneously from the distal radius as described
above (Fig. 16.17a, b). In a patient with significant
ulnar positive variance, an accompanying ulnar short-
ening osteotomy is performed to unload the ulno-carpal
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis 233

Fig.16.12 (continued)

Fig.16.13 (a) Post-distal

radius fracture arthrosis of
the radiocarpal joint with
complete eburnation of the
scaphoid and lunate fossa
confirmed with arthroscopy.
The mid-carpal joint was
preserved. (b) Fixation of
radioscapholunate fusion
with 4 K-wires and bone
substitutes. Position of
K-wires could be verified
through arthroscopy at
radiocarpal joint. (c) X-ray at
7 months post-op showed
good fusion. Scars on
patients were minimal. (d)
Solid radiocarpal fusion at 40
months post-op
234 Pak-Cheng HO

Fig.16.13 (continued)
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis 235

d joint as well as to avoid potential ulno-carpal impac-

tion after the radiolunate fusion which may shorten the
proximal carpal row. The post-op care and rehabilita-
tion is the same as radioscapholunate fusion as
described above. However, the period of immobiliza-
tion may need to be extended due to the limited contact
area between the lunate fossa and proximal lunate.
Post-operatively, close radiological monitoring is
essential to determine the pacing of rehabilitation. The
authors limited experience favours granule form of
bone substitute rather than injectable form, though the
latter is very convenient for administration through
arthroscopic cannula.

Results and Complication

From Mar 2005 to Aug 2008, we have performed four
cases of arthroscopic radioscapholunate fusion and
two cases of radiolunate fusion. There were 3 male and
3 female patients of average age of 42 (range 1953).
All the patients were manual workers. The average
duration of symptom before surgery was 33 months
(range 1250). The indications for surgery include:
post-distal radius fracture radiocarpal joint arthrosis 4,
Fig.16.13 (continued) post scaphoid non-union radiocarpal joint arthrosis 1

Fig.16.14 Thirty-four-year-
old man with severe painful
post-distal radius fracture
arthrosis at radiolunate joint
236 Pak-Cheng HO

Fig.16.15 Percutaneous
pinning of the radiolunate
joint under X-ray and
arthroscopic guidance. A
Foley catheter had been
placed to obliterate the space
at the radio-scaphoid joint

Fig.16.16 Filling of
radiolunate joint space with
injectable bone substitute.
Spilling of bone substitutes to
adjacent space was blocked
with inflated Foley catheter

and rheumatoid arthritis 1. Multiple K-wires fixation
was used in two cases, cannulated bold screw in one
case and 3.0mm cannulated AO screws in the remain-
ing three cases. In all the cases, bone substitute was
being used to augment the fusion, granule form in four
cases and injectable form in two cases. In one patient,
simultaneous arthroscopic wafer procedure was per-
formed to unload the ulno-carpal joint. In another case
of radioscapholunate fusion, simultaneous arthroscopic
distal scaphoidectomy was performed. Radiological
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis 237

Fig.16.17 (a) Definitive

a
fixation with two percutane-
ous AO screws at radiolunate
joint. (b) Post-op X-ray
appearance of the radiolunate
fusion with good capitolunate
alignment. Note that the bone
substitutes were well
contained at the radiolunate
joint

union was obtained in five cases at a median interval of
9 weeks (range 650 weeks). The average follow-up
period was 28.7 months (range: 852 months). All the
patients were pain-free and could resume their original
duty. The average arc of motion was 64 flexion/exten-
sion and 42 radio-ulnar deviation. Pronation and
supination was full in all the patients. Grip strength
averaged 84% of the opposite unaffected side. Cosmetic
appearance of the surgical scar was excellent and
patient satisfaction was high (Fig.16.18ah).
We have a case of radiolunate fusion using double
percutaneous screw fixation, and injectable bone
238
substitute failed to heal in 9 months despite optimal
internal fixation and was revised successfully with
open radiolunate fusion using iliac crest block bone
graft and plating. Intra-operatively marked osteolysis
was noted at the fusion site though no evidence of
infection was obtained. The final outcome was excel-
lent (Fig.16.19ac).
Other complication included one case of delayed
union of radioscapholunate fusion using injectable
bone substitute and screw fixation with complete
radiological union apparent at 50 weeks post-op. There
was one case of skin irritation by pin with minor pin
tract infection requiring early removal of pin.
Fig.16.18 (a) Fifty-three-year-old lady developed severe radi-
olunate arthrosis without a history of trauma. (b) Wrist arthros-
copy showed complete eburnation of lunate fossa and proximal
lunate, tear of TFCC with preserved ulnar head cartilage. (c)
Operative diagram depicted the extent of joint pathology. There
was associated small osteochondral lesion over the scaphoid
fossa. The mid-carpal joint was normal. (d) Without the tourni-
quet on, burring of proximal lunate revealed good subchondral
punctate bleeding. (e) Intra-operative fluoroscopy showed the
Pak-Cheng HO
Conclusion
Post-traumatic arthrosis of the radiocarpal joint is not
uncommon following distal radius fracture. Symp
tomatic patients can be successfully treated with radio-
carpal fusion, provided the mid-carpal joint is relatively
preserved. Arthroscopic fusion is a viable, technically
straight forward and safe procedure. Combined with
percutaneous fixation technique, arthroscopic radiocar-
pal fusion potentially can generate the best possible
functional outcome by minimizing trauma to soft tissue
and favouring motion preservation. Our preliminary
experience geared towards the use of granule form of
position of guide pins across radiolunate joint. (f) Arthroscopic
view showing the position of Foley catheter at the scaphoid
fossa and granule form of bone substitute at radiolunate joint
space. (g) Final definitive fixation of radiolunate joint with two
percutaneous bold screws. Note that both radio-scaphoid and
ulno-carpal joint were free of bone substitute due to the block-
age by Foley catheter. (h) Solid bone union at 6 months post-op
and clinical range of motion of the left wrist. Patient was pain
free and returned to normal duty as office assistant
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis 239

b c

f g

Fig.16.18 (continued)
240 Pak-Cheng HO

Fig.16.19 (a) Evidence of early osteolysis of fusion site at 14 non-union confirmed at revision operation with fusion converted
weeks post-op in the 34-year-old man with radiolunate fusion to open iliac crest block bone grafting and plating. Final radio-
for post-traumatic radiolunate arthrosis. (b) Definite non-union logical union attained
at 9 months post-op as shown by X-ray and CT scan. (c) Aseptic
16 Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis
Fig.16.19 (continued)
bone substitute rather than the injectable one to aug-
ment bone healing.
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 Index

A distal radioulnar joint, 162164

AO classification, 9 evaluation, 159
Arthritic wrist, arthrodesis extraarticular and intraarticular wrist fractures, 152
background, 211212 failures and complications, 171172
surgical approach overview, 212213 flexion-extension, 162
surgical technique instruments, 153
capitate-lunate, 214, 217222 limitation, 151
carpal arthrofibrosis, 214 midcarpal joint, 162
diagnosis of pathology, 213216 postop treatment, 165
percutaneous bone graft, 222223 radiocarpal joint
Arthroscopic arthrodesis. See Arthritic wrist, arthrodesis ancillary procedures, 161162
Arthroscopic-assisted osteotomy fibrosis and fibrotic band resection, 154159
cartilage fracture lines, 191, 192 volar and dorsal capsule resection, 158161
discussion, 207208 radiocarpal portals, 152
indications and contraindications results, 165168
free osteochondral fragment, 195 Whipple traction tower, 152, 154
massive bone loss, 196 Arthroscopic wafer resection, 176, 178
perfect restoration, 194 Arthroscopic wrist arthrolysis (AWA), 164166
radius step-off, 196 Avulsion fracture, sigmoid notch
scaphoid fossa, 195 arthroscopic repair, 9396
instruments, 198200 open repair, 9394, 97
logistics, 198
operation B
intraoperative view, 203 Ballottement test, 7679
scaphoid fossa, 204 Borelli traction tower, 154
volar-radial approach, 201 Buttressing plates, 58, 63, 200
preoperative planning, 196197 Buttressing principle, 5863
results, 204207
Arthroscopic-assisted reduction, 13, 3638, 41 C
Arthroscopic-assisted reduction and internal fixation (AARIF), 41 Carpal arthrofibrosis, 214
Arthroscopic radiocarpal fusion Carpal interosseous ligament tears, 105
complication and results, 235241 Carpal tunnel, 2, 6163, 69, 94
partial wrist fusion, 226 Class 3-A lesion, 85
radiolunate fusion Concomitant scaphoid fractures
Foley catheter, 232, 236 fracture compression, 124
post-distal radius fracture, 235 indications, 117118
radioscapholunate fusion intraarticular screw exposure, 125
Foley catheter blocking technique, 231 percutaneous screw fixation, 117, 124
intra-operative fluoroscopy, 228, 229 surgical armementarium, 125
K-wires, 232235 technique
shell of cartilage, 228 arthroscopic radiocarpal control, 118119
set up and instrumentation, 226227 cannulated Herbert double-threaded screw, 120, 122
Arthroscopic role compressive effect, 121
Borelli traction tower, 154 Finochietto interdigital traction device, 118
clinical experience, 164165 fracture fixation and localization, 119120
discussion, 166, 168171 K-wire retraction, 119

243
244 Index

open reduction and internal fixation, 118119 fragment displacement, 4850

operative aspects, 123 stabilizing fractures, 48
perioperative complications, 124 unreduced fragments, 51, 5356
reduction quality, 121, 123 carpal tunnel, 6163
risk factors, 124 classic part
tapping, scaphoid poles, 120, 122 flexor carpi radialis sheath, 45
volar percutaneous technique, 124 volar locking plate, 45
clinical experience, 6364
D dry technique
Direct foveal (DF) portal repair, 8081 arthrosponge, 44
Distal hammock-like structure, 89, 90, 185 aspiration procedure, 42
Distal radioulnar joint (DRUJ) moist arthroscopy, 43
arthroscopic role, 162164 soft tissue extravasation, 42
hypermobility, 76 osteochondral fragments, 63
laxity, 76, 78 figure-of-eight wire suture, 61
TFC traumatic tears, 183, 186 short radio-lunate ligament, 64
ulnar styloid impaction, 181183 postoperative care, 53, 56
Distal radioulnar joint (DRUJ) instability scaphoid fossa comminution
classification system, 7475 buttressing principle, 58, 63
clinical assessment and arthroscopic findings external fixator and K-wires, 61
ballottement test, 76 styloid fractures, 57, 60
hook test, 7778 severe metaphyseal comminution
intraoperative parameters, 78 extra-articular reduction, 57
soft end-point resistance, 76, 78 volar radiocarpal dislocation, 55
TFCC laceration, 7677 volar-ulnar fragment, 5559
trampoline test, 77
type 1-B injury, 77 F
clinical implications, 74 Fernandez classification, 10
DRF pathomechanics, 7374 Fibrocartilage-radius interface tear, 93
Galeazzi fracture-subluxation, 75 Fibrosis resection, 154159
hyperextension injury, 73 Fibrotic band resection, 154159
indications, 7880 Finochietto interdigital traction device, 118
ligamentum subcruentum, 73 Floating styloid, 79, 85, 183, 184
long arm cast immobilization, 73 Foley catheter blocking technique, 231
postoperative care, 8587 Fracture dislocations
risk factors, 76 arthroscopic management, 142, 144147
technique carpal
direct foveal portal, 8081 antegrade screw, 136
styloid fixation, 85 greater arc injury, 134, 136
surgical treatment and diagnostic arthroscopy, 80 Kleinert elevator, 137
suture anchor foveal repair, 8184 circumferential access, 129, 130
ulnar styloid fracture, 7475 combined injuries
Doi classification, 29 disruption pathway, 143, 144
Dorsal capsule resection. See Volar and dorsal scaphoid volar dislocation, 141
capsule resection discussion, 146, 148
Dorsal extrinsic ligament injury extrinsic ligament midsubstance disruption, 133135
Slutskys procedure, 113114 final evaluation, 130
thermal shrinkage, 115 indications
Dorsal extrinsic ligaments, 127, 131 magnetic resonance imaging, 129
Dorsal radiocarpal (DRC), 128 physical examination, 128
Dorsal radiocarpal ligament (DRCL), 1720, 113115 intrinsic ligament ruptures, 137141
Dry technique marginal fragments
arthrosponge, 44 Kleinert elevator, 132
aspiration procedure, 42 lunate facet, 133
moist arthroscopy, 43 lunate fossa, 131
soft tissue extravasation, 42 multiple planes, 132
radioscaphocapitate, 131, 132
E scaphoid fossa, 132
European Wrist Arthroscopy Society (EWAS), 105 volar rim, 131
Explosion-type distal radius fractures rehabilitation, 144145
arthroscopic part small bone manipulation, 130
Index 245

Free osteochondral fragments (FOFs), M

48, 50, 53, 64 Magnetic resonance imaging (MRI)
Frykman classifiation, 10 and arthroscopy, 9
CT and, 103
G diagnosis of pathology, 213
Geisslers classification, 104105 fracture dislocations, 129
Greater arch perilunate dislocation, 99100 hypertrophic styloid nonunion, 184
intraarticular step-off, 188
H Midcarpal joint, 13, 15, 16, 19, 20, 48, 123, 137, 152, 162, 168.
Hook test, 25, 79, 83, 84, 181184, 186 See also Arthritic wrist, arthrodesis
DRUJ laxity, 78 Moist arthroscopy, 43
partial detachment, foveal insertion, 181, 182 Mller AO classification, 27, 29
TFCC foveal avulsion, 7778
TFCC peripheral tear, 80
O
ulnar styloid, 183, 184
Open plate fixation (ORIF), 13
Hyaloglide, 158, 165, 166, 170
Open radius surgery, 142, 144147
Osteochondral fragment, 41, 48, 63, 195
I
Osteotomy
Intraarticular distal radial fractures classification, 2830
discussion, 207208
Intraarticular fibrosis, 154, 155
free osteochondral fragment, 195
Intraarticular malunion
instruments, 198200
discussion, 207208
logistics, 198
fracture dislocation, 188
massive bone loss, 196
indications and contraindications
operation, 199204
free osteochondral fragment, 195
perfect restoration, 194
massive bone loss, 196
preoperative planning, 196197
perfect restoration, 194
radius step-off, 196
radius step-off, 196
results, 204207
scaphoid fossa, 195
scaphoid fossa, 195
macroscopic defects, 151
ulnar carpal impaction, 176
preoperative planning, 196197
results, 204207
surgical technique P
instruments, 198200 Percutaneous screw fixation, 117, 124125
logistics, 198 Perilunate dislocations
operation, 199204 arthroscopic management, 142, 144147
Intraoperative fluoroscopy, 22, 228, 229 carpal fractures
Irrigation-suction cycle, 43 antegrade screw, 136
greater arc injury, 134, 136
L Kleinert elevator, 137
Ligamentum subcruentum, 73 discussion, 146, 148
Long radiolunate (LRL), 15, 113, 128, 130, 142, 202 lunotriquetral interosseous
Lunate fossa (LF), 131 interface, 138, 139
Lunotriquetral and extrinsic ligaments lesions marginal avulsion, 137
incidence, 109110 rehabilitation, 145
lnotriquetral interosseous ligament scapholunate interosseous
(LTIO) management interface, 138
arthroscopic debridement, 109 pin fixation, 140
chronic ulnar side pain, 111 scaphoid fracture, 137
electrothermal shrinkage, 110 Portals, wrist arthroscopy
Geissler classification system, 109 anatomy, 1314
joy stick maneuver, 111 arthroscopic-assisted fixation, 21
lunotriquetral arthrodesis, 112 diagnostic survey
management 3-/,4 and 4-/,5 portals, 19
dorsal extrinsic ligament injury, 113115 DRUJ portals, 2021
volar extrinsic ligament injury, 112113 midcarpal portals, 1920
Lunotriquetral interosseous (LTIL) 6R, 6U Portals, 19
carpal fracture, 135 volar portals, 20
indications, 129 dorsal and volar DRUJ, 18
interface, 138, 139 dorsal portals
marginal avulsion, 137 midcarpal, 15
246 Index

radiocarpal, 1415 combination injury, 94

Triquetro-Hamate and radioulnar, 15 fibrocartilage-radius interface tear, 93
equipment and implants palmar sigmoid notch, avulsion fracture, 94
four-part fractures, 2425 postoperative care, 97
radial styloid fractures and surgical technique, 22 total radial avulsion, 94, 98
requirements, 2122 Radiocarpal dislocations
TFC repair kit and ligament repairs, 22 arthroscopic management, 142, 144147
three-part fractures, 2224 discussion, 146, 148
ulnar styloid fractures, 25 indications, 128
ulnar and radial midcarpal portal, 18 marginal avulsion, 133
volar portals marginal fragments
radial, 1516 Kleinert elevator, 132
ulnar, 1617 lunate facet, 133
volar distal radioulnar (VDRU), 17 lunate fossa, 131
volar radial midcarpal (VRM), 16 multiple planes, 132
Posterior ulnar (PU) fragment, 51, 95 radioscaphocapitate, 131, 132
Postfracture stiffness, arthroscopy scaphoid fossa, 132
arthroscopic wrist arthrolysis, 164166 volar rim, 131
discussion, 166, 168171 Radiocarpal joint, arthroscopic role
distal radioulnar joint, 162164 ancillary procedures, 161162
failures and complications, 171172 fibrosis and fibrotic band resection, 154159
postop treatment, 165 volar and dorsal capsule resection, 158161
radiocarpal joint Radiocarpal (RC) portals, 152
ancillary procedures, 161162 Radiolunate (RL) fusion
fibrosis and fibrotic band resection, 154159 Foley catheter, 232, 236
volar and dorsal capsule resection, 158161 post-distal radius fracture, 235
Postop treatment, 165 Radioscaphocapitate (RSC)
Post-traumatic radiocarpal arthrosis free margins, 134
indications and contra-indications, 226 reduction and stabilization, 132
results and complication, 235241 Radioscapholunate (RSL) fusion
surgical approach Foley catheter blocking technique, 231
radiolunate fusion, 232, 235237 intra-operative fluoroscopy, 228, 229
radioscapholunate fusion, 227235 K wires, 232235
set up and instrumentation, 226227 shell of cartilage, 228
Pre-operative assessment Range of motion (ROM)
classification, 910 evaluation, 159
examination, 2 flexion-extension, 162
investigations limitation, 151
CT imaging, 79 Rehabilitation
fracture characteristics, 36 fracture dislocations, 144145
fracture stability, 67 postop treatment, 165
MRI and arthroscopy, 9
parameters, 23 S
X-ray, 2 Scaphoid fossa (SF), 132
patient history, 12 Scaphoid fossa comminution
Preoperative planning buttressing principle, 58, 63
intraarticular malunion, 196197 external fixator and K-wires, 61
simple articular fractures, 30 styloid fractures, 57, 60
Pull-out wiring method, 94, 97 Scaphoid fractures, classification, 125
Scapholunate dissociation
R anatomy and biomechanics, 100102
Radial midcarpal portal, 13, 18, 118, 119, 124 arthroscopic indications, 103
Radial tear, TFCC Geissler grading, 104105
anatomy, 8990 management
classification, 9091 acute injuries, 105106
diagnosis and evaluation, 9193 late presentation, 106107
DRUJ instability, 89, 91, 92, 94, 98 non-osteoporotic patients, 99100
mechanism, 91 pathology
treatment arthroscopy and radiographs, 103
arthroscopic partial resection, 93 clinical assessment, 102
avulsion fracture, dorsal sigmoid notch, 9394 CT and MRI imaging, 103
Index 247

radiocarpal visualization and mid-carpal arthroscopy, 104 Triangular fibrocartilage complex (TFCC), 31, 37, 6771,
SL ligament injury detection, 99 7387, 8998, 100, 109, 110, 115, 125, 154, 158,
Scapholunate instability, 71, 99, 102, 103 160, 169, 170, 177, 213, 226
Scapholunate interosseous (SLIL) arthroscopic role, 162164
carpal fracture, 135 perforation, 227
indications, 129 traumatic tears, 183, 185187
interface, 138 ulnar styloid impaction, 179, 181183
pin fixation, 140 Triangular fibrocartilage complex lesions
scaphoid fracture, 137 contraindications
Scapholunate ligament tears, 9 debridement, central tears, 68
Scapho-trapezial ligamentous complex, 101102 peripheral lesions, 6869
Scaphotrapeziotrapezoid (STT), 18, 19, 121, 125, 162, 212, unstable DRUJ, 68
213, 228 indications, 6768
Severe metaphyseal comminution, 5455 management, 6971
Sharpeys fibers, 90 intraoperative sugar-tong plaster splint, 70
Short radio-lunate ligament (SRL), 17, 64, 128, 130, 131, 139 perforation and suture passing, 6970
Simple articular fractures pronation/supination restriction, 71
advantages, arthroscopic technique, 27 small and large central tears, 69
associated injuries, 37, 38 suture welding technique, 70
classification repair zone, 67
AO type C3 fractures, 28, 30 surgical technique, 69
Mller AO classification, 27, 29 Triquetro-Hamate (TH) portal, 15
clinical experience and personal results, 38
complications, 37 U
four-part fractures, 3637 Ulnar carpal impaction (UCI)
indications and contraindications, 30 arthroscopic wafer resection, 176, 178
surgical technique, 3031 clinical signs, 177
three-part fractures radius osteotomy, 176
arthroscopic fine-tuning, 36, 37 TFC reattachment, 178
depressed lunate facet fragments, 34, 36 triangular fibrocartilage, 176
open standard volar technique, 3536 Ulnar styloid impaction (USI)
treatment effects and outcomes, 38 diagnosis, 179
two-part fractures distal radioulnar joint, 181, 182
joystick technique, 34, 35 floating styloid, 183, 184
Kirschner wire and cannulated screw, 3132 partial detachment, foveal insertion, 181, 182
volar fragment, 3233 pathologic conditions, 179
SMC flip knot, 82, 83 Ulnocapitate (UC), 128, 130
Styloid fixation, 85 Ulnolunate (UL), 128, 134
Suture anchor foveal repair, 8185 Ulnotriquetral (UT), 128, 134
Suture welding technique, 70
V
T Volar and dorsal capsule resection, 158161
TFCC. See Triangular fibrocartilage complex Volar Barton fractures, 58
TFCC ulnar tears. See Distal radioulnar joint (DRUJ) instability Volar extrinsic ligament injury, 112113
Trampoline test, 77, 78, 80 Volar extrinsic ligaments, 127, 131, 133135
Trans-styloid perilunate injury, 103, 107 Volar rim (VR), 131
Traumatic tears, 183, 185187 Volar-ulnar fragment, 50, 55, 59, 197, 199200
Triangular fibrocartilage (TFC)
traumatic tears W
distal radioulnar joint, 183, 186 Whipple traction tower, 152, 154
triangular fibrocartilaginous complex, 185, 187 Wrist arthroscopy, 13, 25. See also Portals,
ulnar carpal impaction, 176178 wrist arthroscopy