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Arthroscopic assisted internal fixation of volar intraarticular wrist fractures
Arthroscopy: The Journal of Arthroscopic and Related Surgery 9(!):122-124
Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America
Technical Note
Arthroscopic Assisted Internal Fixation of Volar Intraarticular Wrist Fractures Howard J. Levy, M.D., and Steven Z. Glickel, M.D.
Summary: Open reduction internal fixation of displaced volar intraarticular distal radius fractures traditionally require sacrificing the volar ligaments to visualize the articular surface. We present a modification of standard arthroscopy that facilitates visualization of the radiocarpal joint while preserving these ligaments. Key Words: Volar intraarticular fracture--Wrist.
useful with the more common dorsal die-punch fractures. We have used a modification of standard wrist arthroscopy techniques that facilitates visualization of intraarticular fractures of the distal radius requiring internal fixation through a volar approach.
The various treatments of intraarticular distal radius fractures are well documented in the literature (1-4). Scheck (5) first described a die-punch fracture as a dorsomedial fragment separated from the radius through axial compression by the lunate. Melone (6,7) later proposed a classification of these fractures and recommended an open reduction for displaced intraarticular fractures with die-punch fragments. A less common variant of intraarticular distal radius fractures occurs when the major fragment is volar and medial and is referred to as a Smith Type H or a volar Barton's fracture. In cases where the volar fragment is displaced, open reduction and internal fixation through the volar approach may be indicated. To assess the adequacy of reduction through a volar approach, the surgeon must violate the volar wrist ligaments to directly visualize the articular surface. Recently, arthroscopic assisted reduction and internal fixation (ARIF) has been described as a technique to aid the treatment of intraarticular wrist fractures (8,9). The fragments are elevated under direct arthroscopic visualization and internally fixed with K-wires. This technique, however, is
TECHNIQUE The decision to perform surgery should be based on careful analysis of the fracture with plain radiographs supplemented b y tomograms or computed tomographic scans if necessary. If the fracture is unstable with an articular step-off of >2 mm, open reduction and internal fixation should be performed (1,2). A volar Henry approach is used, exposing the interval between the flexor carpiradialis and the brachioradialis tendons. The pronator quadratus is subperiosteally dissected from the distal radius and elevated ulnarly. After reduction, the fracture may be provisionally fixed with Kirchner wires. The first portal is established with a blunt trochar inserted into the radiocarpal joint in the interval ulnar to the radiolunate ligament (Fig. 1). After insertion of a 2.7 mm 30° arthroscope, a second portal in the interval between the radiolunate and the radiocapitate ligaments is established (Fig. 2). The second portal may be used for outflow and for placement of instruments. If necessary, the wrist may be distracted manually by an assistant. A
From the Division of Orthopedic Surgery, Beth Israel Medical Center (H.J.L.), and the Hand Surgery Center, Roosevelt Hospital, New York, New York, U.S.A. Address correspondence and reprint requests to Dr. Howard J. Levy, Division of Orthopedic Surgery, Beth Israel Medical Center, 317 East 17th Street, New York, NY 10003, U.S.A.
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VOLAR I N T R A A R T I C U L A R W R I S T F R A C T U R E
123
FIG, 1. Arthroscopic probe demonstrating radiolunate (RL) and radioscaphocapitate (RS) ligaments (DR, distal radius).
complete routine wrist examination is performed with particular attention directed to the scapholunate ligament and the proximal articular surface of the lunate. The distal radius articular surface is assessed by direct visualization, and any stepoff may
be reduced intraarticularly using an arthroscopic probe or extraarticularly with a bone tap. Large cancellous defects should be bone grafted. Unstable volar fragments are rigidly fixed with a buttress plate.
FIG. 2. Arthroscopic cannula inserted in the interval ulnar to the radiolunate ligament (RL). A second portal between the radiolunate and radioscaphocapitate (RS) ligaments is used for additional instruments (DR, distal radius).
Arthroscopy, Vol. 9, No. 1, 1993
124
H. J. L E V Y A N D S. Z. GLICKEL DISCUSSION
REFERENCES
The importance of anatomic reduction of intraarticular distal radius fractures, especially in younger patients, is well documented (1,2). A step-off of >2 mm frequently leads to posttraumatic arthritis. Traditionally, when performing open reduction and internal fixation of volar and intraarticular wrist fractures, the surgeon must rely on intraoperative radiographs or sacrifice part of the volar ligaments to visualize the articular surface. The anatomy and function of the volar ligaments have been studied extensively and have been shown to contribute significantly to the stability of the wrist (10). Sacrificing these structures prohibits early motion of the wrist and risks future radiocarpal instability. We have presented a technique for arthroscopic assisted internal fixation of volar intraarticular wrist fractures that allows direct visualization of the radiocarpal joint and eliminates the need to transect the volar carpal ligaments. In addition to being a safe and simple procedure, arthroscopy allows inspection of the wrist joint for any other associated pathology.
1. Bradway JK, Amadio PL, Cooney WP. Open reduction and internal fixation of displaced comminuted intra-articular fractures of the distal end of the radius. J Bone Joint Surg 1989;71A:839-47. 2. Knirk J, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;58A: 647-59. 3. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long term results of conservative treatment of fractures of the distal radius. Clin Orthop 1986;206:202-10. 4. Cooney WP, Agee JM, Hastings H, Melone CP, Rayhack JM. Symposium: Management of intra-articular fractures of the distal radius. Contemp Orthop 1990;21:71-104. 5. Scheck M. Long term follow up of treatment of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg 1962;44A:33751. 6. Melone CP. Articular fractures of the distal radius. Orthop Clin 1984;15:2t7-36. 7. Melone CP. Open treatment for displaced intra-articular fractures of the distal radius. Clin Orthop 1986;202:103-11. 8. Bora WF, Osterman AL, Maitin E, Bednar J. The role of arthroscopy in the treatment of disorders of the wrist. Contemp Orthop 1986;12:28-36. 9. Taleisnik J. Current concepts review: carpal instability. J Bone Joint Surg 1988;70A:1262-8. 10. Mayfield JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin 1984;15:209-15.
Arthroscopy, Vol. 9, No. 1, 1993
Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America
Technical Note
Arthroscopic Assisted Internal Fixation of Volar Intraarticular Wrist Fractures Howard J. Levy, M.D., and Steven Z. Glickel, M.D.
Summary: Open reduction internal fixation of displaced volar intraarticular distal radius fractures traditionally require sacrificing the volar ligaments to visualize the articular surface. We present a modification of standard arthroscopy that facilitates visualization of the radiocarpal joint while preserving these ligaments. Key Words: Volar intraarticular fracture--Wrist.
useful with the more common dorsal die-punch fractures. We have used a modification of standard wrist arthroscopy techniques that facilitates visualization of intraarticular fractures of the distal radius requiring internal fixation through a volar approach.
The various treatments of intraarticular distal radius fractures are well documented in the literature (1-4). Scheck (5) first described a die-punch fracture as a dorsomedial fragment separated from the radius through axial compression by the lunate. Melone (6,7) later proposed a classification of these fractures and recommended an open reduction for displaced intraarticular fractures with die-punch fragments. A less common variant of intraarticular distal radius fractures occurs when the major fragment is volar and medial and is referred to as a Smith Type H or a volar Barton's fracture. In cases where the volar fragment is displaced, open reduction and internal fixation through the volar approach may be indicated. To assess the adequacy of reduction through a volar approach, the surgeon must violate the volar wrist ligaments to directly visualize the articular surface. Recently, arthroscopic assisted reduction and internal fixation (ARIF) has been described as a technique to aid the treatment of intraarticular wrist fractures (8,9). The fragments are elevated under direct arthroscopic visualization and internally fixed with K-wires. This technique, however, is
TECHNIQUE The decision to perform surgery should be based on careful analysis of the fracture with plain radiographs supplemented b y tomograms or computed tomographic scans if necessary. If the fracture is unstable with an articular step-off of >2 mm, open reduction and internal fixation should be performed (1,2). A volar Henry approach is used, exposing the interval between the flexor carpiradialis and the brachioradialis tendons. The pronator quadratus is subperiosteally dissected from the distal radius and elevated ulnarly. After reduction, the fracture may be provisionally fixed with Kirchner wires. The first portal is established with a blunt trochar inserted into the radiocarpal joint in the interval ulnar to the radiolunate ligament (Fig. 1). After insertion of a 2.7 mm 30° arthroscope, a second portal in the interval between the radiolunate and the radiocapitate ligaments is established (Fig. 2). The second portal may be used for outflow and for placement of instruments. If necessary, the wrist may be distracted manually by an assistant. A
From the Division of Orthopedic Surgery, Beth Israel Medical Center (H.J.L.), and the Hand Surgery Center, Roosevelt Hospital, New York, New York, U.S.A. Address correspondence and reprint requests to Dr. Howard J. Levy, Division of Orthopedic Surgery, Beth Israel Medical Center, 317 East 17th Street, New York, NY 10003, U.S.A.
122
VOLAR I N T R A A R T I C U L A R W R I S T F R A C T U R E
123
FIG, 1. Arthroscopic probe demonstrating radiolunate (RL) and radioscaphocapitate (RS) ligaments (DR, distal radius).
complete routine wrist examination is performed with particular attention directed to the scapholunate ligament and the proximal articular surface of the lunate. The distal radius articular surface is assessed by direct visualization, and any stepoff may
be reduced intraarticularly using an arthroscopic probe or extraarticularly with a bone tap. Large cancellous defects should be bone grafted. Unstable volar fragments are rigidly fixed with a buttress plate.
FIG. 2. Arthroscopic cannula inserted in the interval ulnar to the radiolunate ligament (RL). A second portal between the radiolunate and radioscaphocapitate (RS) ligaments is used for additional instruments (DR, distal radius).
Arthroscopy, Vol. 9, No. 1, 1993
124
H. J. L E V Y A N D S. Z. GLICKEL DISCUSSION
REFERENCES
The importance of anatomic reduction of intraarticular distal radius fractures, especially in younger patients, is well documented (1,2). A step-off of >2 mm frequently leads to posttraumatic arthritis. Traditionally, when performing open reduction and internal fixation of volar and intraarticular wrist fractures, the surgeon must rely on intraoperative radiographs or sacrifice part of the volar ligaments to visualize the articular surface. The anatomy and function of the volar ligaments have been studied extensively and have been shown to contribute significantly to the stability of the wrist (10). Sacrificing these structures prohibits early motion of the wrist and risks future radiocarpal instability. We have presented a technique for arthroscopic assisted internal fixation of volar intraarticular wrist fractures that allows direct visualization of the radiocarpal joint and eliminates the need to transect the volar carpal ligaments. In addition to being a safe and simple procedure, arthroscopy allows inspection of the wrist joint for any other associated pathology.
1. Bradway JK, Amadio PL, Cooney WP. Open reduction and internal fixation of displaced comminuted intra-articular fractures of the distal end of the radius. J Bone Joint Surg 1989;71A:839-47. 2. Knirk J, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;58A: 647-59. 3. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long term results of conservative treatment of fractures of the distal radius. Clin Orthop 1986;206:202-10. 4. Cooney WP, Agee JM, Hastings H, Melone CP, Rayhack JM. Symposium: Management of intra-articular fractures of the distal radius. Contemp Orthop 1990;21:71-104. 5. Scheck M. Long term follow up of treatment of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg 1962;44A:33751. 6. Melone CP. Articular fractures of the distal radius. Orthop Clin 1984;15:2t7-36. 7. Melone CP. Open treatment for displaced intra-articular fractures of the distal radius. Clin Orthop 1986;202:103-11. 8. Bora WF, Osterman AL, Maitin E, Bednar J. The role of arthroscopy in the treatment of disorders of the wrist. Contemp Orthop 1986;12:28-36. 9. Taleisnik J. Current concepts review: carpal instability. J Bone Joint Surg 1988;70A:1262-8. 10. Mayfield JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin 1984;15:209-15.
Arthroscopy, Vol. 9, No. 1, 1993