Intraarticular lesions in distal fractures of the radius in young adults

INTRAARTICULAR LESIONS IN DISTAL FRACTURES RADIUS IN YOUNG ADULTS A descriptive artllroseopie study in 50 patients

OF THE

T. LINDAU, M. ARNER and L. HAGBERG

From the Hand Unit, Department of Orthopaedic Surgery, Lund University Hospital and the Department of Hand Surgery, Malm6 University Hospital, Sweden We examined the frequency of associated chondral and ligament lesions in distal fractures of the radius in young adults (men 20-60 years, women 20-50 years). Fifty initially displaced fractures were examined arthroscopically. Chondral lesions were found in 16 patients (32%). All patients but one were found to have a ligamentous injury in the wrist. No major instability was found. The most frequent ligament tear was the triangular fibrocartilage complex in 39 cases (78%), with a statistical correlation to ulnar styloid fractures. The scapholunate ligament was partially or totally torn in 27 cases (54%). No correlation was found between specific fracture type and pattern of ligament injury. Chondral and ligamentous lesions were frequent and may explain poor outcomes after seemingly well-healed distal fractures of the radius. The ligament lesions should also be kept in mind when early mobilization of the distal fracture of the radius is considered.

Journal of Hand Surgery (British and European Volume, 1997) 22B: 5:638 643 The distal fracture of the radius is the most common fracture in the upper extremity and its epidemiology, pathomechanics, fracture treatment and long-term outcome are well described. Only a few articles, however, deal with the high energy fracture in the non-osteoporotic young adult (Knirk and Jupiter, 1986; Kopylov et al, 1993). There are problems in demonstrating ligament lesions in the acute injury. In some cases scapholunate ligament tears will be shown on plain radiographs during loading (Biyani and Sharma, 1989), they may be suspected if a broken line is seen in the proximal row (Bellinghausen et al, 1983), or they may even be seen directly on plain radiographs (Mudgal and Jones, 1990). However, many ligament injuries are not diagnosed on plain radiographic films or arthrograms (Hixon et al, 1990; Meade et al, 1990). With MRI, acceptable confidence levels are now attained in detecting tears of the TFCC, but the levels are still unacceptable in the detection of SL and LT tears (Gilula 1994; Rominger et al, 1993). Several authors agree that arthrography, even when done as a triple-injection cinearthrogram, does not rule out pathological findings that may be seen with arthroscopy (Cooney and Berger, 1993; Schers and van Heusden, 1995; Weiss et al, 1996), indicating that arthroscopy may be an important adjunct in detecting ligament lesions primarily. In recent years arthroscopy has been used in treating intraarticular distal radius fractures, and concomitant intra-articular ligament injuries have been found (Cooney, 1993; Geissler, 1995; Leibovitz and Geissler, 1994; Whipple, 1995; Wolfe et al, 1995). In intraarticular distal fractures of the radius with an intraarticular incongruency greater than 2 mm, ligament injuries have been found in the majority (68%) of cases (Geissler et al, 1996). The aim of this study was to examine the frequency and distribution of chondral and ligament injuries, to examine the degree of instability in the interosseous ligaments, and to see if there was any correlation with specific

fracture types in initially displaced distal fractures of the radius in young adults. PATIENTS AND M E T H O D S

Women in the age group 20 to 50 years and men in the age group 20 to 60 years with initially displaced distal fractures of the radius were included in the study. Two centres in the south of Sweden, the University Hospital in Lund (area population 226,000) and the University Hospital in Malm6 (area population 243,000), and two surgeons, were involved. The indication for arthroscopy in Lund was an initially displaced fracture, independent of the result of reduction. In Malm6, arthroscopy was done only if closed reduction was impossible or unsatisfactory. The 37 patients from the Lund region correspond to 37% of the distal fractures of the radius in young adults, and the 13 patients from the Malm6 region correspond to 9% of all distal fractures of the radius in this age group. Fifty patients, 26 women and 24 men, with a mean age of 39 years (range 20-58) were included. Twenty dominant and 30 non-dominant hands were injured. Fortyone cases involved a severe injury, i.e. more than a simple fall in the same plane (Mallmin and Ljunghall, 1992). Fifteen of these were sports injuries, eleven involved a fall from a height, eight a fall on ice, five were traffic accidents a n d two were due to miscellaneous circumstances. The mechanism of injury was hyperextension in 29 cases, unclear in 18 cases, hyperflexion in two cases and rotational trauma in one case. The fractures were treated according to the preference of the surgeon. Radiography

The fractures were classified according to the Association for the Study of Internal Fixation (AO/ASIF) (Mtiller et 638

DISTAL FRACTURES OF THE RADIUS IN YOUNG ADULTS

Table 1--The classification system for interosseous scapholunate and lunotriquetral ligament injuries and mobility of the joints, modified from Geissler (1995)

Grade

1 2 3 4

Radiocarpal arthroscopy Ligament appearance

Midcarpal arthroscopy Diastasis Step-ojf ( mm ) (ram)

Haematoma or distension As above and/or partial tear Partial or total tear Total tear

0 0-1 1-2 > 2

0 < 2 <2 > 2

639

AO class

A3

Arthroscopy

C1

The Z2 test, the Mann-Whitney U test and the Wilcoxon rank sum test were used. Statistical significance was accepted as P < 0.05.

Number of patients

]

B1

Statistics

Frykman class

A2

al, 1990) and according to Frykman (1967). The dorsal angulation perpendicular to the axis of the radius was measured as well as the radial length (Solgaard, 1984; 1992) and the axial compression was recorded by the ulnar variance (Palmer et al, 1982; Schuind et al, 1992).

The mean time to arthroscopy was five (1-17) days after injury. Axillary block or general anaesthesia was used. The arthroscopic procedure described by Whipple et al (1986) was used. The radiocarpal and the midcarpal joints were both examined, usually through the 3 4, 4-5, M C R and M C U portals. The distal radioulnar joint was not examined arthroscopically. A thorough examination was done following a standardized protocol. Under direct vision, the different structures were probed with a hook and stress tests were done in order fully to define ligament tears and the degree of mobility. Ligament injuries were classified as haematomas with or without distension (described as lesions), partial or total tears. The SL ligament was examined in its dorsal, membranous and palmar portions, and a total SL ligament tear was recorded only if all portions were totally ruptured. Widened midcarpal joint spaces and step-offs were measured with a probe with a known thickness (1 ram) and tip length (2 ram) as a reference. These indicate the degree of mobility and not necessarily pathological instability in the afflicted intercarpal joint. Thus, the arthroscopic classification of interosseous carpal ligament instability suggested by Geissler (1995) was modified, as shown in Table 1. The traumatic TFCC lesions were classified according to Palmer (1989) as either central perforations (IA), or ulnar (IB), distal (IC), or radial avulsions (ID). Each TFCC-injury was examined and graded as lesions or tears. The relationship of the arthroscopic TFCC injury to the radiographic fracture of the ulnar styloid was examined.

Number of patients

14

C2

7-8

C3 ~ " ~ ~

Fig 1

9

Classification of the fractures by the AO and Frykman classifications: Frykman 1-2 = an extraarticular fracture; Frykman 3-4 = an intraarticular fracture; Frykman 5-6 = an extraarticular fracture extending into the D R U joint; Frykman %8 = an intraarticular fracture involving the DRU joint. Even numbers (Frykman 2, 4, 6, 8) include a fracture of the ulnar styloid.

RESULTS

Radiographicfindings Thirty-five intraarticular and 15 extraarticular fractures were included. Their classification is shown in Figure 1. Twenty-seven cases had fractures of the ulnar styloid. In the primary prereduction radiographs the mean dorsal angulation was 16° (range; minus 2345°), the radial length was 9 (range; 1-17) mm and the mean axial compression as measured by the ulnar variance was + 2 (range; minus 4-10) mm.

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.... Fig 2

:'iiiiiiii,iiii!i

The distribution of 35 chondral injuries in 16 cases shown diagramatically: T T = Trapezium and trapezoid (-- 1); C = Capitate (= 1); H = H a m a t e (= 2); S = Scaphoid (midcarpal = 1, radiocarpal= 4); L = Lunate (midcarpal -- 4, radiocarpal = 6); T R I = Triquetrum (midcarpal = 0, radiocarpal = 1); SF = Scaphoid facet of the radius (-- 10); LF -- Lunate facet of the radius (= 5).

Arthroseopie findings Joint surfaces Thirty-six intraarticular fracture lines, most often in the lunate facet (25/36), were seen in 31 cases. In four cases the fracture lines were not observed through the arthroscope. Thirty-five subchondral haematomas were seen in 16 cases, with one case showing eight lesions in the radioand midcarpal joints (Fig 2). Twelve of these cases had intraarticular fractures and four had extraarticular fractures. Ten localized areas of osteoarthritis were seen in five cases. Eleven areas in one patient with a SLAC-wrist secondary to a previous scaphoid fracture were excluded.

Fig 3

() The distribution of all minor (lesions) and major (partial or total tears) injuries to the palmar extrinsic ligament.

Tears to the extrinsic ligaments from the scaphoid facet

Tears to the extrinsic ligament from the lunate facet

Ligaments Ninety-six injuries to the palmar extrinsic radio- and/or ulnocarpal ligaments were seen in 37 cases (74%) (Fig 3). Combinations of partial or total tears in the palmar extrinsic ligaments were seen in 26 cases (Fig 4). Twentythree cases had partial or total tears in the radioscapholunate (RSL) ligament. Nineteen of these showed a grade 2 and 3 mobility in the SL joint, two cases showed a grade 1 mobility and two cases had no mobility. Injuries to the intrinsic ligaments were seen in 46 cases (92%), with partial or total tears in 32 cases (64%) (Fig 5). The LT ligament was injured in 17 cases (34%), with partial or total tears in eight cases (16%) (Fig 5). Mobility of the

Tears to the ulnocarpal extrinsic ligament Fig 4

Distribution of partial or total palmar extrinsic ligament tears in 26 cases.

DISTAL FRACTURES OF THE RADIUS IN YOUNG ADULTS

641

Table 3--Numbers and types of TFCC-tears in 39 patients. Classification according to Palmer (1989). For definitions, see text

LT

TFCC tears

Number of tears

Type IA Type IB Type IC Type ID Total

13 17 5 17 52

.,

Table 4--Relationship between TFCC tear and a fracture of the ulnar styloid

Fracture o f the ulnar styloid Yes No

TFCC Fig 5

TFCC tear

Combination of injuries of the intrinsic ligaments and the TFCC in 49 patients.

Yes No

1 2 3 4 Total number of injuries

SL

LT

6

2

30 7 0 43

12 3 0 17

15 8

Table 5--Isolated or combined, partial or total tears of the major intrinsic ligaments and the TFCC in relation to fracture

Table 2--Ligament injuries and grading of mobility in scapholunate (SL) and lunotriquetral (LT) joints. Gradings according to the modified classification in Table 1

Mobility Grade

24 3

Extraarticular fractures Isolated tears (n = 18) TFCC SL LT Combined injuries (n = 27) SL + TFCC LT + TFCC SL + LT SL + LT + TFCC Total

lntraarticular fractures

6 1 0

7 3 1

5 1 ! 1 15

15 3 0 1 30

SL = scapholunate ligament; LT = lunotriquetral ligament; TFCC = triangular fibrocartilage complex.

interosseous carpal joints was classified according to the modified classification system in Table 1 (Table 2).

Ligament injuries in relation to fracture type TFCC Forty-one cases (82%) had traumatic TFCC injuries with 39 tears (78%) (Fig 5). Thegtistribution of TFCC injuries according to Palmer (1989) are shown in Table 3. The TFCC sometimes showed multiple injuries. Twenty-five patients had a single tear of the TFCC, 11 had two tears and three patients had three tears. In four patients a round, central defect (degenerative central perforation) was found. Two of these patients had acute lesions superimposed. In ten cases a radial avulsion tear was associated with a fracture involving the ulnar edge of the radius. The risk of a TFCC tear was increased if a fracture of the ulnar styloid was present [odds ratio = 5.1 (exact 95% confidence interval 1.2-24.7) (the Baptista-Pike algorithm)] (Table 4).

No correlation was found between ligament tear and fracture type (Table 5). No correlation was found between ligament tear and degree of initial displacement of the fracture.

Complications of arthroscopy No patients had any complications secondary to the arthroscopy itself. DISCUSSION In the present study, 49 of 50 patients (98%) had ligament injuries of various degrees of severity and onethird of the patients had chondral lesions. However, no

642

major instability was seen and no correlation with any specific fracture type or degree of primary dislocation was found. A fracture of the ulnar styloid was related to an increased frequency of a TFCC lesion. The role of arthroscopy, both in the treatment of intraarticular fractures of the distal radius and in diagnosing concomitant ligament injuries, is gaining acceptance (Cooney and Berger, 1993; Geissler, 1995; Geissler et al, 1996; Leibovitz and Geissler, 1994; Whipple, 1995; Wolfe et al, 1995). In their arthroscopic study of ligament lesions associated with distal fractures of the radius, Geissler et al (1996) included only intraarticular fractures with more than 2 mm displacement. Forty-one of their 60 patients (68%) were found to have ligament injuries in the wrist joint. This is a lower frequency than in the present study which may be because we recorded minor lesions of ligaments and the TFCC. Another possible explanation is that the intraarticular fractures with severe displacement and incongruity may be associated with fewer ligament injuries, the intraarticular fracture occurring instead of ligament injuries. We found chondral lesions in approximately one-third of the cases. These types of lesions have not previously been described. Vener et al (1992) used an in vitro canine joint model to investigate subchondral damage after transarticular loading and found that the subchondral bone and cartilage were damaged before a fracture developed. They suggested that these lesions could lead to the development of osteoarthritis. Mankin (1982) claimed that single or even multiple cartilage lacerations would heal, but that the joint would undergo consistent changes if a critical threshold was passed. MRI studies in the knee joint have shown that cartilage and osteochondral lesions can lead to osteochondral sequelae (Speer et al, 1991; Vellet et al, 1991). Adalberth et al (1997) showed that subchondral bone "bruises" were seen on MRI and scintigraphy in patients with haemarthrosis of the knee, but that arthroscopy detected additional cases of cartilage injuries not seen with MRI and scintigraphy. They suggested that these lesions could develop into post-traumatic osteoarthritis. In a study of 43 young adults with intraarticular distal radius fractures, Knirk and Jupiter (1986) reported post-traumatic osteoarthritis in all fractures with a joint incongruency of more than 2 ram, as well as osteoarthritis in 11% of the congruent fractures. The natural course of chondral lesions of different severity is still not fully known. Geissler et al (1996) did not describe any extrinsic palmar ligament injury in conjunction with distal fractures of the radius. We found frequent injuries to these ligaments. All partial or total tears originated from the scaphoid facet of the radius. A high incidence of partial and total tears of the radioscapholunate extrinsic ligament (48%) was found, combined with grade 2 and 3 mobility of the SL joint in as many as 79% of cases. It is difficult to evaluate the importance of these lesions, but in agreement with Mudgal and Hastings (1993) we suspect that they may destabilize the scapholunate complex

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and thereby possibly cause later dynamic or static instability. In a retrospective, radiographic study 2 years after distal fractures of the radius in young adults (unpublished results), scapholunate dissociation on stress radiographs was seen in 18% of cases, although the primary plain radiographs did not show any sign of ligament injury. The SL dissociation in these cases may be the result of progressive stretching of partially damaged ligaments eventually leading to a total rupture. Geissler et al (1996) found 32% isolated SL ligament tears, 15% isolated LT ligament tears and 22% combined tears. Even when considering the intraarticular fracture group only in the present study, more frequent injuries to the SL and the LT ligaments were found. However, no major instability was found, and since there is no clear definition of the difference between laxity and pathological intercarpal mobility, all ligament injuries were treated conservatively. We found tears in the TFCC in 78% of the patients. In an arthrographic study of 58 distal fractures of the radius in patients with a mean age less than 50 years, Fontes et al (1992) found that the TFCC was torn in 66%. In another arthrographic study of 60 patients, Mohanti and Kar (1980) found 45% with TFCC tears. Geissler et al (1996), in their arthroscopic series of 60 intraarticular fractures, found 26 (43%) had TFCC tears. Like Mohanti and Kar (1980) and Geissler et al (1996) we found more TFCC lesions in patients with fractures of the ulnar styloid. According to Fontes (1992) the incidence of degenerative TFCC tears in younger age groups is low, but degenerative changes were found in 8% in the present study, and in half of these there were acute tears superimposed. In spite of the difference in indications for arthroscopy, no differences were found in the distribution of fracture types or the frequency of findings between the two centres in our study. Many alternative treatments have been described for distal fractures of the radius. With the finding of frequent intraarticular ligament lesions, the various operative treatments should be reconsidered once again. External fixation both as uniplanar and multiplanar ligamentotaxis (Agee, 1993) is a widely used method for achieving fracture alignment. However, with the additional strain, this may further damage or displace the ligament lesions and impair anatomical ligament healing. Thus an instability could develop even from a stable partial tear. In contrast, open reduction and internal fixation give a stable osteosynthesis, thus decreasing the tension within the ligaments and optimizing ligament healing. Open reduction and internal fixation of the distal fractures of the radius allow early mobilization. This leads to discussion about whether a partial ligament injury can tolerate or even benefit from early mobilization, or if it should be protected by immobilization, perhaps in combination with percutaneous pinning. There may also be a difference between the extrinsic and intrinsic ligaments in the need for postoperative protection, analogous to the collateral and cruciate ligaments of the knee joint.

DISTAL FRACTURES OF THE RADIUS IN YOUNG ADULTS

Acknowledgements This study was supported by Stiftelsen f6r bist~.nd 5t vanf6ra i Sk~ne. We thank Carl-G6ran Hagert, MD, PhD for constructive criticism, Jonas Ranstam, PhD for statistical advice and analysis, and Jane Wigertz for linguistic analysis.

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