- Email: [email protected]
Arthroscopically Assisted Reduction and Percutaneous Fixation of Dorsal Perilunate Dislocations and Fracture-Dislocations
Technical Note
Arthroscopically Assisted Reduction and Percutaneous Fixation of Dorsal Perilunate Dislocations and Fracture-Dislocations Min Jong Park, M.D., and Jin Hwan Ahn, M.D., Ph.D.
Abstract: Perilunate injuries are severe disruptions of the wrist joint that produce variable patterns of injury to the carpal anatomy. Most surgeons advocate an open reduction followed by ligament repair or internal fixation. We tried to reduce and fix the carpal bones under arthroscopic control to minimize surgical trauma and to preserve blood supply. While viewing the articular surface with the arthroscope, the disrupted proximal carpal row was anatomically reduced using Kirschner wires as joysticks, and fixed percutaneously without any repair of the capsuloligamentous tears. Three patients with dorsal perilunate dislocations or fracture-dislocations were treated by this technique. All the patients achieved accurate reduction and stable fixation, and showed successful healing of the carpal fractures with proper alignment after 10 to 12 weeks of immobilization. At 16 to 22 months follow-up, all patients showed normal radiographic findings with no evidence of instability or arthritis. The arthroscopic treatment of acute dorsal perilunate injuries is technically feasible in achieving anatomic reduction and stable fixation. Our preliminary clinical results were encouraging, but the long-term results need to be observed. Key Words: Wrist—Perilunate injury—Arthroscopy.
P
erilunate injuries are highly unstable carpal dissociations that are characterized by a complete loss of contact between the lunate and the head of the capitate at the midcarpal joint. They can be pure ligamentous disruptions or associated with fractures of 1 or more bones around the lunate, creating multiple variations of a basic injury pattern. In the vast majority of cases, the carpus dislocates in a dorsal direction.1-4 An excessive radiocarpal hyperextension and
From the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Address correspondence and reprint requests to Min Jong Park, M.D., Department of Orthopaedic Surgery, Samsung Medical Center, 50 Ilwon-dong, Kangnam-Ku, Seoul 135-710, Korea. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America Cite this article as: Park MJ, Ahn JH. Arthroscopically assisted reduction and percutaneous fixation of dorsal perilunate dislocations and fracture-dislocations. Arthroscopy 2005;21:1153.e11153.e9 [doi:10.1016/j.arthro.2005.06.010]. 0749-8063/05/2109-4360$30.00/0 doi:10.1016/j.arthro.2005.06.010
ulnar deviation coupled with intercarpal supination has proved the principal pathologic force that disrupts the key osseous and ligament components of the wrist.5 Treatment of a perilunate injury is difficult because of the extensive soft tissue and bony damage. A number of studies have noted that the restoration of normal bone and ligament alignment is essential to avoid complications such as nonunion, malunion, avascular necrosis, instability, and ultimately arthritic change.1-3,6 Controversy persists regarding the optimal management of perilunate injuries. In acute injuries, it is usually possible to reduce the overall carpal alignment by closed manipulation, but it is unusual for this to restore anatomic alignment of all injured structures. Because of the uncertain results obtained with closed treatment, most authors now advocate an open reduction and internal fixation particularly if anatomic reduction and adequate stabilization are not achieved by the closed techniques.2,3,7-11 With the advent of arthroscopic surgery of the wrist, many surgeons have attempted to treat ligament inju-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 9 (September), 2005: pp 1153.e1-1153.e9 1153.e1
1153.e2
M. J. PARK AND J. H. AHN
ries and carpal bone fractures by using an arthroscope. The arthroscopic approach allows excellent visualization of the joint surface and the intra-articular ligaments without the additional soft tissue damage that accompanies an open procedure. It can be assumed that an arthroscopically assisted reduction combined with percutaneous fixation provides a more accurate reduction of intercarpal articulations and proper stabilization than with open techniques in acute perilunate injuries, but there have not been any reports to describe on it. In this article, we describe the technique of arthroscopic treatment of perilunate dislocations and fracture-dislocations, and report the clinical results of our three cases. OPERATIVE TECHNIQUE Before the arthroscopic surgery, the capitolunate joint had been reduced by closed manipulation at the emergency room. Arthroscopy was performed under general anesthesia an average of 11 days after the trauma (range, 5 to 28 days). The patient was placed on the operating table in the supine position with the arm on a radiolucent arm table. The wrist was suspended in a Traction Tower (Linvatec, Largo, FL) and 4.5 kg of traction was applied through the finger traps to the index and long fingers. Evaluation of the radiocarpal joint was initially performed through the 3-4 portal. The joint was thoroughly lavaged with a motorized, small-joint shaver through the 4-5 portal to remove fibrin clot and debris. To minimize the fluid extravasation through the capsular rents, a separate outflow was established in the 6U portal throughout the procedure and continuous saline irrigation was instilled by gravity infusion from an elevated bag. The palmar capsular ligaments originating from the radius were evaluated from the radial side in their sequence. Injury to the radioscaphocapitate ligament with a relatively intact long and short radiolunate ligament was the consistent finding, which can be explained anatomically based on the pathology of dorsal perilunate injury. After having evaluated the palmar radiocarpal ligaments, our attention was directed toward the scapholunate and lunotriquetral interosseous ligaments. The arthroscope placed through the 4-5 portal usually provided a more optimal view of these ligaments (Fig 1A). If the ligaments were found to be torn, the frayed edges were thoroughly debrided to help primary healing. The midcarpal space was then evaluated by placing the arthroscope approximately 1 cm distal to the 3-4
and 4-5 portals. Examination of the midcarpal joint allowed an excellent visualization of the distal articular surface of the proximal carpal row, in which the main disruption had occurred. The injury of the interosseous ligaments between the carpal bones of the proximal carpal row was evaluated by observing the separation of the bones from each other and/or incongruity of their distal articular surfaces (Fig 1B, C). Probing of the scapholunate and lunotriquetral articulations was performed to determine the degree of instability.12 In case of a fracture-dislocation, the fracture site was evaluated and small fragments obstructing the reduction were removed. After the injury pattern was determined, the patient’s arm was removed from the traction tower and was placed under the fluoroscope. Kirschner wires (K-wires) were inserted percutaneously into the scaphoid and triquetrum. For the trans-scaphoid type injury, the wires were driven into the distal scaphoid fragment and not across the fracture site. Attention was paid to select the optimum site of insertion and to place the wires in a proper direction for an accurate fixation of the fracture site or for the intercarpal intervals when these wires were advanced. Two wires were usually used in each carpal bone. After the proper placement of the K-wires into the carpal bones, the wrist was resuspended in the traction tower and the arthroscope was inserted into the midcarpal joint. While viewing the articular surface from the midcarpal portals, the scaphoid and triquetrum were manipulated to reduce the scapholunate and lunotriquetral intervals using percutaneously introduced K-wires as joy sticks. If the lunate needed to be rotated into the neutral position, a K-wire was inserted into the lunate from dorsal to volar and used as a joystick. When the reduction was anatomic, the wires were then driven across the intercarpal intervals into the lunate (Fig 1D, E). The displaced scaphoid fracture was also reduced as seen with the arthroscope in the midcarpal space, using K-wires placed in the distal fragment. Longitudinal traction was released when the scaphoid fracture was reduced and fixed by driving the K-wires across the fracture site into the proximal fragment. When it was determined that the percutaneous insertion of a headless compression screw into the scaphoid was technically feasible and helpful in achieving more secure reduction, we attempted to insert a cannulated Acutrak screw (Acumed, Beaverton, OR) using the dorsal percutaneous approach, as described by Slade et al.13 With the K-wires placed in the scaphoid, the wrist was flexed and a guidewire was driven from dorsal to volar along the central axis of
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
1153.e3
FIGURE 1. Arthroscopic views in a patient with dorsal perilunate dislocation (case 1). (A) Radiocarpal view showing scapholunate interosseous ligament (SLIL) injury. (B, C) Midcarpal views showing the separation of scapholunate and lunotriquetral articulations. (D, E) After reduction and percutaneous fixation under the arthroscopic control, the midcarpal views shows accurate scapholunate and lunotriquetral alignment. (Sc, scaphoid; Lu, lunate; Triq, triquetrum).
the scaphoid under fluoroscopic guidance. The cannulated screw was placed into the scaphoid after measuring the screw length and reaming. The previously inserted K-wires were then removed. After completing the arthroscopic reduction and fixation, fluoroscopic assessment was performed to confirm the adequacy of reduction, carpal alignment, and K-wire placement. Associated radial styloid and ulnar styloid fractures were stabilized using K-wires percutaneously or after open reduction in an anatomic
position. Finally the wires were bent, cut, and buried underneath the skin. POSTOPERATIVE MANAGEMENT The wrist was immobilized in a short arm cast for 10 to 12 weeks. The thumb was incorporated if a scaphoid fracture was present. Following the immobilization period, radiocarpal motion was allowed and physiotherapy was started. In ligamentous injuries, the
1153.e4
M. J. PARK AND J. H. AHN
FIGURE 2. (A, B) Initial radiographs of 37-year-old man (case 1) with trans-styloid dorsal perilunate dislocation. (C, D) This patient was treated by an arthroscopic reduction and percutaneous fixation of the scapholunate and lunotriquetral disruption. (E, F) Radiographs at 18 months showing normal carpal alignment with no evidence of instability or arthritis.
K-wires were removed from the scapholunate interval and lunotriquetral interval at 12 weeks. In scaphoid fractures, the K-wires were left in place until there was definite radiographic evidence of union. CASE 1 A 37-year-old man injured his left wrist in a fall from a 6-m height with his hand outstretched. A closed reduction had been successfully accomplished during his first visit to the local clinic after confirming dorsal perilunate dislocation by radiographs (Fig 2A,
B). The wrist had been kept in a short arm splint and the patient was referred to our hospital 4 weeks after the injury. The preoperative radiographs showed a residual carpal instability in the proximal row and associated fractures of the radial and ulnar styloid processes. Wrist arthroscopy was performed to attempt an accurate reduction of the proximal carpal row followed by adequate fixation. Tears of the both scapholunate and lunotriquetral interosseous ligaments were identified and the view from the midcarpal portal revealed instabilities of the scapholunate and lunotriquetral junctions (Fig 1A-C).
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
1153.e5
FIGURE 3. (A, B) Initial radiograpahs of 40-year-old man (case 2) with trans-scaphoid dorsal perilunate fracture-dislocation. (C, D) The patient was treated by arthroscopically assisted reduction and percutaneous fixation of the scaphoid fracture and lunotriquetral disruption. (E, F) Radiographs at 22 months showing good scaphoid union and restoration of normal carpal alignment.
Under arthroscopic control, the proximal row was reduced anatomically and fixed using percutaneously inserted K-wires (Fig 1D, E). The radial and ulnar styloids were fixed with K-wires after a small incision was made (Fig 2C, D). The wrist was immobilized in a short arm cast for 10 weeks. Radiocarpal motion was initiated thereafter and the K-wires were removed at 12 weeks. At 18 months after surgery, the patient had moderate pain with the strenuous use of the involved wrist but not at rest. He was able to return to his work with modified duties. The flexion-extension arc of the in-
jured wrist was 90°, which was 70% of the uninjured wrist. Grip strength was 36.3 kg or 75% of the normal, dominant hand. Neither instability nor the arthritic changes were observed in the final radiographs (Fig 2E, F). CASE 2 A 40-year-old man fell onto his outstretched left hand from a standing position. The radiographs revealed a trans-scaphoid dorsal perilunate fracture-dislocation (Fig 3A, B). The midcarpal joint was imme-
1153.e6
M. J. PARK AND J. H. AHN
diately reduced by closed manipulation in the emergency room. Wrist arthroscopy was performed 5 days after the injury. The displaced scaphoid fracture and separated lunotriquetral space was identified through the midcarpal portals. These were reduced and fixed using percutaneously inserted K-wires while viewing the articular surface from the midcarpal portals (Fig 3C, D). The wrist was immobilized in a thumb spica short arm cast. At 12 weeks, the radiographs showed a union of the scaphoid and the Kwires were removed. At 22 months’ follow-up, the patient was pain free and had returned to his previous occupation with full duties. The flexion-extension arc of the injured wrist was 110°, which was 85% of the uninjured wrist. Grip strength was 41.2 kg or 85% of the normal, dominant hand. The final radiographs revealed good scaphoid union and normal carpal alignment with no evidence of arthritis (Fig 3E, F).
CASE 3 A 28-year-old man sustained a hyperextension injury to his left wrist in a football game. He visited the emergency room 3 days after the injury and radiographs showed a trans-scaphoid dorsal perilunate fracture-dislocation with an avulsion of the triquetral insertion of the lunotriquetral interosseous ligament (Fig 4A, B). The closed reduction was successful in restoring gross alignment of the wrist, but malalignment of the fracture lines persisted. Wrist arthroscopy was performed 7 days after the injury. The displaced scaphoid fracture and unstable lunotriquetral joint were reduced and percutaneously fixed using K-wires under arthroscopic control. An adequate repositioning of the avulsed triquetral fragment could be observed with the fluoroscope. A cannulated Acutrak screw (Acumed) was implanted into the scaphoid using the dorsal percutaneous approach to achieve a more stable fixation instead of K-wires (Fig 4C, D). At 10 weeks, radiographs showed good bony union and the K-wires were removed. At 16 months’ follow-up, the patient was pain free and had returned to his previous occupation with full duties. The flexion-extension arc of the injured wrist was 120° or 90% of the uninjured wrist. Grip strength was 45.5 kg or 95% of the uninjured, dominant hand. Final radiographs revealed an adequate bony union and intercarpal alignment with no evidence of arthritis (Fig 4E, F).
DISCUSSION The key to a good clinical result in the treatment of perilunate dislocation or fracture-dislocation is the restoration of proper alignment of the carpal bones. Although a gross reduction by closed manipulation is possible in a high percentage of cases, most clinicians agree that closed reduction cannot reliably restore the complex anatomic intercarpal relationships sufficiently to prevent carpal instability, nonunion, or malunion.2,3,6,7,14 Open reduction gives the best opportunity for the primary repair of ligaments and fixation of fractures. But the techniques for open reduction always require extensive dissection. Recent studies recommend a dorsal incision for fracture reduction and fixation, and a palmar incision for the release of the carpal tunnel and direct palmar ligament repair.3,15-18 It is clear that the open technique introduces additional surgical trauma with the incision of important capsular and ligamentous structures. It can be associated with a high rate of complications, such as the development of joint stiffness resulting from capsular fibrosis and the delay or failure of proper bone healing because of damage to the blood supply. Additionally, carpal alignment is difficult to visualize even with volar and dorsal approaches because of the limited joint space. Percutaneous pinning under fluoroscopic guidance has been suggested as a reasonable alternative for stabilizing the carpus, if an anatomic reduction can be precisely achieved.14,19,20 Although it can minimize the surgical trauma, its superiority has not been definitely proven. The main disadvantage of this technique is that the assessment of an accurate reduction of the intercarpal alignment is always insufficient when it depends on a radiological aid.3 With the advent of arthroscopic surgery, wrist arthroscopy has become increasingly useful in treating wrist injury and instability. Arthroscopy has excellent illumination and magnification, which provides a substantial advantage over fluoroscopy in visualizing the reduction of intercarpal articulations. For scapholunate ligament injury, Whipple21 described arthroscopic reduction and pinning using multiple K-wires across the scapholunate interval, in an effort to produce a controlled ankylosis of the scapholunate articulation. Satisfactory results were obtained if the procedure was performed within 3 months of the injury. Whether the healing occurs by arthrofibrosis from disruption of the articulation by pins or by the primary healing of the ligament following accurate reduction and immobilization remains controversial. However, it can be assumed that the
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
1153.e7
FIGURE 4. (A, B) Initial radiographs of 28-year-old man (case 3) with trans-scaphoid transtriquetral dorsal perilunate fracture-dislocation. (C, D) The patient was treated by arthroscopically assisted reduction and fixation of scaphoid and triquetral fractures. The scaphoid fracture was fixed using an Acutrak screw with the dorsal percutaneous approach. (E, F) Radiographs at 16 months showing satisfactory union of fractures and normal carpal alignment.
adequate stabilization of an acute scapholunate or lunotriquetral ligament injury can be obtained by an accurate reduction and pinning with no effort to repair the torn ligaments. Recently, several authors have described arthroscopic treatment of distal radius fractures, and they also used this approach for associated scapholunate and lunotriquetral injuries.22-24 Using an arthroscopic technique to treat acute carpal bone fractures has been introduced in the management of acute scaphoid fractures.25-27 An attempt to perform percutaneous fixation of scaphoid fractures
under the guide of a fluoroscope was more popularized in reports,13,28,29 but visualization of the fracture reduction by arthroscope is definitely superior to that with radiological aid. We attempted to place the cannulated headless compression screw into the scaphoid in 1 patient with trans-scaphoid perilunate dislocation, once the scaphoid fracture was secured with the Kwires driven under the arthroscopic control. It is clear that the quality of fixation with the compression screw is superior to that with the K-wire only. Percutaneous insertion of the screw from the dorsal side is techni-
1153.e8
M. J. PARK AND J. H. AHN
cally easier than that from the volar distal side, where the previously inserted K-wires were present outside the skin. Considering later fixation with a headless screw, we intentionally placed the K-wires away from the central axis of the scaphoid and thus they did not interfere with the screw insertion. Because the reduction was already confirmed arthroscopically and secured with the K-wires, reassessment of scaphoid reduction was not necessary during percutaneous placement of a headless screw. We believe that accurate reduction and percutaneous fixation under arthroscopic control is a feasible technique in treating perilunate injury, which is a combination of carpal fractures and ligament injuries. Compared with the open technique, arthroscopy minimizes capsular and adjacent soft tissue scarring, reducing postoperative contracture. It has the great advantage of providing preservation of an already tenuous blood supply and facilitating healing of fractures and torn ligaments. In our clinical trials, the patients who had the adequate management using arthroscopy within 1 week after the injury showed excellent final wrist motions that were greater than 85% of the normal side at the time of the final followup. One of our initial concerns was the relatively high risk of extravasation due to the massive disruption of capsular structures, which is always present in perilunate injuries. To decrease fluid extravasation, we maintained a separate outflow and instilled saline irrigation by gravity infusion instead of using a mechanical pump. Severe swelling or any evidence of compartment syndrome was never observed in the postoperative period. Despite the many advantages of the arthroscopically assisted reduction and fixation, direct repair of the torn capsule or ligaments is not possible by this method. Many surgeons have invariably reported a transverse rent in the palmar capsule at the level of the midcarpal joint with the palmar surgical approach.7,9,18 Adkison and Chapman7 suggested that the maintenance of anatomic position is sufficient to restore perilunate ligamentous integrity without individual ligament repair. But others have emphasized the need for repair of the palmar ligaments to stabilize the carpal bones.2,17 It is generally known that the ligament structures of the joint, particularly the capsular ligaments, are believed to heal adequately when they are properly approximated and protected for some period, and we believe that this concept also applies to perilunate injuries. The development of traumatic arthritis is always a major concern following the severe articular disrup-
tion resulting from perilunate injury. Many reports of perilunate injuries have indicated a considerable incidence of post-traumatic arthritis.2-4 Although our clinical cases did not show evidence of arthritis after approximately 2 years of follow-up, we need to observe more patients with long-term follow-up to prove that the arthroscopically assisted technique is a reliable option in the treatment of perilunate injuries. REFERENCES 1. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop 1980;149:55-72. 2. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop 1987;214:136-147. 3. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations. A multicenter study. J Hand Surg [Am] 1993;18:768779. 4. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations. Questionnaire, clinical, and radiographic evaluation. J Hand Surg [Am] 2000;25:1069-1079. 5. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations. Pathomechanics and progressive perilunar instability. J Hand Surg 1980;5:226-241. 6. Minami A, Ogino T, Ohshio I, Minami M. Correlation between clinical results and carpal instabilities in patients after reduction of lunate and perilunar dislocations. J Hand Surg [Br] 1986;11:213-220. 7. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop 1982;164:199-207. 8. Viegas SF, Bean JW, Schram RA. Transscaphoid fracture/ dislocations treated with open reduction and Herbert screw internal fixation. J Hand Surg [Am] 1987;12:992-999. 9. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations. J Hand Surg [Am] 1993;18:1099-1106. 10. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracture-dislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl 1997;275:55-59. 11. Inoue G, Imaeda T. Management of trans-scaphoid perilunate dislocations. Herbert screw fixation, ligamentous repair and early wrist mobilization. Arch Orthop Trauma Surg 1997;116: 338-340. 12. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78:357-364. 13. Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous fixation of scaphoid fractures with a novel dorsal technique. Orthop Clin North Am 2001;32:247-261. 14. Green DP, O’Brien ET. Open reduction of carpal dislocations. Indications and operative techniques. J Hand Surg 1978;3: 250-265. 15. Moneim MS, Hofammann KE, Omer GE. Transscaphoid perilunate fracture-dislocation. Result of open reduction and pin fixation. Clin Orthop 1984;190:227-235. 16. Inoue G, Tanaka Y, Nakamura R. Treatment of trans-scaphoid perilunate dislocations by internal fixation with the Herbert screw. J Hand Surg [Am] 1990;15:449-454. 17. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture disloca-
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
18. 19. 20. 21. 22.
23.
tion. A critical analysis of the volar-dorsal approach. J Hand Surg [Am] 1997;22:49-56. Melone CP Jr, Murphy MS, Raskin KB. Perilunate injuries. Repair by dual dorsal and volar approaches. Hand Clin 2000; 16:439-448. Rabb DJ, Fischer DA, Quick DC. Lunate and perilunate dislocations in professional football players. A five-year retrospective analysis. Am J Sports Med 1994;22:841-845. Kozin SH. Perilunate injuries. Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:114-120. Whipple TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin 1995;11:37-40. 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;81:1093-1110. Geissler WB, Freeland AE. Arthroscopic management of intraarticular distal radius fractures. Hand Clin 1999;15:455-465.
1153.e9
24. Peicha G, Seibert F, Fellinger M, Grechenig W. Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures. Knee Surg Sports Traumatol Arthrosc 1999;7:327-333. 25. Whipple TL. The role of arthroscopy in the treatment of intra-articular wrist fractures. Hand Clin 1995;11:13-18. 26. Geissler WB, Hammit MD. Arthroscopic aided fixation of scaphoid fractures. Hand Clin 2001;17:575-588. 27. Sommerkamp TG. Arthroscopically assisted reduction and internal fixation of scaphoid fractures. J Am Soc Surg Hand 2001;1:192-210. 28. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83:483-488. 29. Yip HSF, Wu WC, Chang RYP, So TYC. Percutaneous cannulated screw fixation of acute scaphoid wrist fracture. J Hand Surg [Br] 2002;27:42-46.
Arthroscopically Assisted Reduction and Percutaneous Fixation of Dorsal Perilunate Dislocations and Fracture-Dislocations Min Jong Park, M.D., and Jin Hwan Ahn, M.D., Ph.D.
Abstract: Perilunate injuries are severe disruptions of the wrist joint that produce variable patterns of injury to the carpal anatomy. Most surgeons advocate an open reduction followed by ligament repair or internal fixation. We tried to reduce and fix the carpal bones under arthroscopic control to minimize surgical trauma and to preserve blood supply. While viewing the articular surface with the arthroscope, the disrupted proximal carpal row was anatomically reduced using Kirschner wires as joysticks, and fixed percutaneously without any repair of the capsuloligamentous tears. Three patients with dorsal perilunate dislocations or fracture-dislocations were treated by this technique. All the patients achieved accurate reduction and stable fixation, and showed successful healing of the carpal fractures with proper alignment after 10 to 12 weeks of immobilization. At 16 to 22 months follow-up, all patients showed normal radiographic findings with no evidence of instability or arthritis. The arthroscopic treatment of acute dorsal perilunate injuries is technically feasible in achieving anatomic reduction and stable fixation. Our preliminary clinical results were encouraging, but the long-term results need to be observed. Key Words: Wrist—Perilunate injury—Arthroscopy.
P
erilunate injuries are highly unstable carpal dissociations that are characterized by a complete loss of contact between the lunate and the head of the capitate at the midcarpal joint. They can be pure ligamentous disruptions or associated with fractures of 1 or more bones around the lunate, creating multiple variations of a basic injury pattern. In the vast majority of cases, the carpus dislocates in a dorsal direction.1-4 An excessive radiocarpal hyperextension and
From the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Address correspondence and reprint requests to Min Jong Park, M.D., Department of Orthopaedic Surgery, Samsung Medical Center, 50 Ilwon-dong, Kangnam-Ku, Seoul 135-710, Korea. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America Cite this article as: Park MJ, Ahn JH. Arthroscopically assisted reduction and percutaneous fixation of dorsal perilunate dislocations and fracture-dislocations. Arthroscopy 2005;21:1153.e11153.e9 [doi:10.1016/j.arthro.2005.06.010]. 0749-8063/05/2109-4360$30.00/0 doi:10.1016/j.arthro.2005.06.010
ulnar deviation coupled with intercarpal supination has proved the principal pathologic force that disrupts the key osseous and ligament components of the wrist.5 Treatment of a perilunate injury is difficult because of the extensive soft tissue and bony damage. A number of studies have noted that the restoration of normal bone and ligament alignment is essential to avoid complications such as nonunion, malunion, avascular necrosis, instability, and ultimately arthritic change.1-3,6 Controversy persists regarding the optimal management of perilunate injuries. In acute injuries, it is usually possible to reduce the overall carpal alignment by closed manipulation, but it is unusual for this to restore anatomic alignment of all injured structures. Because of the uncertain results obtained with closed treatment, most authors now advocate an open reduction and internal fixation particularly if anatomic reduction and adequate stabilization are not achieved by the closed techniques.2,3,7-11 With the advent of arthroscopic surgery of the wrist, many surgeons have attempted to treat ligament inju-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 9 (September), 2005: pp 1153.e1-1153.e9 1153.e1
1153.e2
M. J. PARK AND J. H. AHN
ries and carpal bone fractures by using an arthroscope. The arthroscopic approach allows excellent visualization of the joint surface and the intra-articular ligaments without the additional soft tissue damage that accompanies an open procedure. It can be assumed that an arthroscopically assisted reduction combined with percutaneous fixation provides a more accurate reduction of intercarpal articulations and proper stabilization than with open techniques in acute perilunate injuries, but there have not been any reports to describe on it. In this article, we describe the technique of arthroscopic treatment of perilunate dislocations and fracture-dislocations, and report the clinical results of our three cases. OPERATIVE TECHNIQUE Before the arthroscopic surgery, the capitolunate joint had been reduced by closed manipulation at the emergency room. Arthroscopy was performed under general anesthesia an average of 11 days after the trauma (range, 5 to 28 days). The patient was placed on the operating table in the supine position with the arm on a radiolucent arm table. The wrist was suspended in a Traction Tower (Linvatec, Largo, FL) and 4.5 kg of traction was applied through the finger traps to the index and long fingers. Evaluation of the radiocarpal joint was initially performed through the 3-4 portal. The joint was thoroughly lavaged with a motorized, small-joint shaver through the 4-5 portal to remove fibrin clot and debris. To minimize the fluid extravasation through the capsular rents, a separate outflow was established in the 6U portal throughout the procedure and continuous saline irrigation was instilled by gravity infusion from an elevated bag. The palmar capsular ligaments originating from the radius were evaluated from the radial side in their sequence. Injury to the radioscaphocapitate ligament with a relatively intact long and short radiolunate ligament was the consistent finding, which can be explained anatomically based on the pathology of dorsal perilunate injury. After having evaluated the palmar radiocarpal ligaments, our attention was directed toward the scapholunate and lunotriquetral interosseous ligaments. The arthroscope placed through the 4-5 portal usually provided a more optimal view of these ligaments (Fig 1A). If the ligaments were found to be torn, the frayed edges were thoroughly debrided to help primary healing. The midcarpal space was then evaluated by placing the arthroscope approximately 1 cm distal to the 3-4
and 4-5 portals. Examination of the midcarpal joint allowed an excellent visualization of the distal articular surface of the proximal carpal row, in which the main disruption had occurred. The injury of the interosseous ligaments between the carpal bones of the proximal carpal row was evaluated by observing the separation of the bones from each other and/or incongruity of their distal articular surfaces (Fig 1B, C). Probing of the scapholunate and lunotriquetral articulations was performed to determine the degree of instability.12 In case of a fracture-dislocation, the fracture site was evaluated and small fragments obstructing the reduction were removed. After the injury pattern was determined, the patient’s arm was removed from the traction tower and was placed under the fluoroscope. Kirschner wires (K-wires) were inserted percutaneously into the scaphoid and triquetrum. For the trans-scaphoid type injury, the wires were driven into the distal scaphoid fragment and not across the fracture site. Attention was paid to select the optimum site of insertion and to place the wires in a proper direction for an accurate fixation of the fracture site or for the intercarpal intervals when these wires were advanced. Two wires were usually used in each carpal bone. After the proper placement of the K-wires into the carpal bones, the wrist was resuspended in the traction tower and the arthroscope was inserted into the midcarpal joint. While viewing the articular surface from the midcarpal portals, the scaphoid and triquetrum were manipulated to reduce the scapholunate and lunotriquetral intervals using percutaneously introduced K-wires as joy sticks. If the lunate needed to be rotated into the neutral position, a K-wire was inserted into the lunate from dorsal to volar and used as a joystick. When the reduction was anatomic, the wires were then driven across the intercarpal intervals into the lunate (Fig 1D, E). The displaced scaphoid fracture was also reduced as seen with the arthroscope in the midcarpal space, using K-wires placed in the distal fragment. Longitudinal traction was released when the scaphoid fracture was reduced and fixed by driving the K-wires across the fracture site into the proximal fragment. When it was determined that the percutaneous insertion of a headless compression screw into the scaphoid was technically feasible and helpful in achieving more secure reduction, we attempted to insert a cannulated Acutrak screw (Acumed, Beaverton, OR) using the dorsal percutaneous approach, as described by Slade et al.13 With the K-wires placed in the scaphoid, the wrist was flexed and a guidewire was driven from dorsal to volar along the central axis of
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
1153.e3
FIGURE 1. Arthroscopic views in a patient with dorsal perilunate dislocation (case 1). (A) Radiocarpal view showing scapholunate interosseous ligament (SLIL) injury. (B, C) Midcarpal views showing the separation of scapholunate and lunotriquetral articulations. (D, E) After reduction and percutaneous fixation under the arthroscopic control, the midcarpal views shows accurate scapholunate and lunotriquetral alignment. (Sc, scaphoid; Lu, lunate; Triq, triquetrum).
the scaphoid under fluoroscopic guidance. The cannulated screw was placed into the scaphoid after measuring the screw length and reaming. The previously inserted K-wires were then removed. After completing the arthroscopic reduction and fixation, fluoroscopic assessment was performed to confirm the adequacy of reduction, carpal alignment, and K-wire placement. Associated radial styloid and ulnar styloid fractures were stabilized using K-wires percutaneously or after open reduction in an anatomic
position. Finally the wires were bent, cut, and buried underneath the skin. POSTOPERATIVE MANAGEMENT The wrist was immobilized in a short arm cast for 10 to 12 weeks. The thumb was incorporated if a scaphoid fracture was present. Following the immobilization period, radiocarpal motion was allowed and physiotherapy was started. In ligamentous injuries, the
1153.e4
M. J. PARK AND J. H. AHN
FIGURE 2. (A, B) Initial radiographs of 37-year-old man (case 1) with trans-styloid dorsal perilunate dislocation. (C, D) This patient was treated by an arthroscopic reduction and percutaneous fixation of the scapholunate and lunotriquetral disruption. (E, F) Radiographs at 18 months showing normal carpal alignment with no evidence of instability or arthritis.
K-wires were removed from the scapholunate interval and lunotriquetral interval at 12 weeks. In scaphoid fractures, the K-wires were left in place until there was definite radiographic evidence of union. CASE 1 A 37-year-old man injured his left wrist in a fall from a 6-m height with his hand outstretched. A closed reduction had been successfully accomplished during his first visit to the local clinic after confirming dorsal perilunate dislocation by radiographs (Fig 2A,
B). The wrist had been kept in a short arm splint and the patient was referred to our hospital 4 weeks after the injury. The preoperative radiographs showed a residual carpal instability in the proximal row and associated fractures of the radial and ulnar styloid processes. Wrist arthroscopy was performed to attempt an accurate reduction of the proximal carpal row followed by adequate fixation. Tears of the both scapholunate and lunotriquetral interosseous ligaments were identified and the view from the midcarpal portal revealed instabilities of the scapholunate and lunotriquetral junctions (Fig 1A-C).
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
1153.e5
FIGURE 3. (A, B) Initial radiograpahs of 40-year-old man (case 2) with trans-scaphoid dorsal perilunate fracture-dislocation. (C, D) The patient was treated by arthroscopically assisted reduction and percutaneous fixation of the scaphoid fracture and lunotriquetral disruption. (E, F) Radiographs at 22 months showing good scaphoid union and restoration of normal carpal alignment.
Under arthroscopic control, the proximal row was reduced anatomically and fixed using percutaneously inserted K-wires (Fig 1D, E). The radial and ulnar styloids were fixed with K-wires after a small incision was made (Fig 2C, D). The wrist was immobilized in a short arm cast for 10 weeks. Radiocarpal motion was initiated thereafter and the K-wires were removed at 12 weeks. At 18 months after surgery, the patient had moderate pain with the strenuous use of the involved wrist but not at rest. He was able to return to his work with modified duties. The flexion-extension arc of the in-
jured wrist was 90°, which was 70% of the uninjured wrist. Grip strength was 36.3 kg or 75% of the normal, dominant hand. Neither instability nor the arthritic changes were observed in the final radiographs (Fig 2E, F). CASE 2 A 40-year-old man fell onto his outstretched left hand from a standing position. The radiographs revealed a trans-scaphoid dorsal perilunate fracture-dislocation (Fig 3A, B). The midcarpal joint was imme-
1153.e6
M. J. PARK AND J. H. AHN
diately reduced by closed manipulation in the emergency room. Wrist arthroscopy was performed 5 days after the injury. The displaced scaphoid fracture and separated lunotriquetral space was identified through the midcarpal portals. These were reduced and fixed using percutaneously inserted K-wires while viewing the articular surface from the midcarpal portals (Fig 3C, D). The wrist was immobilized in a thumb spica short arm cast. At 12 weeks, the radiographs showed a union of the scaphoid and the Kwires were removed. At 22 months’ follow-up, the patient was pain free and had returned to his previous occupation with full duties. The flexion-extension arc of the injured wrist was 110°, which was 85% of the uninjured wrist. Grip strength was 41.2 kg or 85% of the normal, dominant hand. The final radiographs revealed good scaphoid union and normal carpal alignment with no evidence of arthritis (Fig 3E, F).
CASE 3 A 28-year-old man sustained a hyperextension injury to his left wrist in a football game. He visited the emergency room 3 days after the injury and radiographs showed a trans-scaphoid dorsal perilunate fracture-dislocation with an avulsion of the triquetral insertion of the lunotriquetral interosseous ligament (Fig 4A, B). The closed reduction was successful in restoring gross alignment of the wrist, but malalignment of the fracture lines persisted. Wrist arthroscopy was performed 7 days after the injury. The displaced scaphoid fracture and unstable lunotriquetral joint were reduced and percutaneously fixed using K-wires under arthroscopic control. An adequate repositioning of the avulsed triquetral fragment could be observed with the fluoroscope. A cannulated Acutrak screw (Acumed) was implanted into the scaphoid using the dorsal percutaneous approach to achieve a more stable fixation instead of K-wires (Fig 4C, D). At 10 weeks, radiographs showed good bony union and the K-wires were removed. At 16 months’ follow-up, the patient was pain free and had returned to his previous occupation with full duties. The flexion-extension arc of the injured wrist was 120° or 90% of the uninjured wrist. Grip strength was 45.5 kg or 95% of the uninjured, dominant hand. Final radiographs revealed an adequate bony union and intercarpal alignment with no evidence of arthritis (Fig 4E, F).
DISCUSSION The key to a good clinical result in the treatment of perilunate dislocation or fracture-dislocation is the restoration of proper alignment of the carpal bones. Although a gross reduction by closed manipulation is possible in a high percentage of cases, most clinicians agree that closed reduction cannot reliably restore the complex anatomic intercarpal relationships sufficiently to prevent carpal instability, nonunion, or malunion.2,3,6,7,14 Open reduction gives the best opportunity for the primary repair of ligaments and fixation of fractures. But the techniques for open reduction always require extensive dissection. Recent studies recommend a dorsal incision for fracture reduction and fixation, and a palmar incision for the release of the carpal tunnel and direct palmar ligament repair.3,15-18 It is clear that the open technique introduces additional surgical trauma with the incision of important capsular and ligamentous structures. It can be associated with a high rate of complications, such as the development of joint stiffness resulting from capsular fibrosis and the delay or failure of proper bone healing because of damage to the blood supply. Additionally, carpal alignment is difficult to visualize even with volar and dorsal approaches because of the limited joint space. Percutaneous pinning under fluoroscopic guidance has been suggested as a reasonable alternative for stabilizing the carpus, if an anatomic reduction can be precisely achieved.14,19,20 Although it can minimize the surgical trauma, its superiority has not been definitely proven. The main disadvantage of this technique is that the assessment of an accurate reduction of the intercarpal alignment is always insufficient when it depends on a radiological aid.3 With the advent of arthroscopic surgery, wrist arthroscopy has become increasingly useful in treating wrist injury and instability. Arthroscopy has excellent illumination and magnification, which provides a substantial advantage over fluoroscopy in visualizing the reduction of intercarpal articulations. For scapholunate ligament injury, Whipple21 described arthroscopic reduction and pinning using multiple K-wires across the scapholunate interval, in an effort to produce a controlled ankylosis of the scapholunate articulation. Satisfactory results were obtained if the procedure was performed within 3 months of the injury. Whether the healing occurs by arthrofibrosis from disruption of the articulation by pins or by the primary healing of the ligament following accurate reduction and immobilization remains controversial. However, it can be assumed that the
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
1153.e7
FIGURE 4. (A, B) Initial radiographs of 28-year-old man (case 3) with trans-scaphoid transtriquetral dorsal perilunate fracture-dislocation. (C, D) The patient was treated by arthroscopically assisted reduction and fixation of scaphoid and triquetral fractures. The scaphoid fracture was fixed using an Acutrak screw with the dorsal percutaneous approach. (E, F) Radiographs at 16 months showing satisfactory union of fractures and normal carpal alignment.
adequate stabilization of an acute scapholunate or lunotriquetral ligament injury can be obtained by an accurate reduction and pinning with no effort to repair the torn ligaments. Recently, several authors have described arthroscopic treatment of distal radius fractures, and they also used this approach for associated scapholunate and lunotriquetral injuries.22-24 Using an arthroscopic technique to treat acute carpal bone fractures has been introduced in the management of acute scaphoid fractures.25-27 An attempt to perform percutaneous fixation of scaphoid fractures
under the guide of a fluoroscope was more popularized in reports,13,28,29 but visualization of the fracture reduction by arthroscope is definitely superior to that with radiological aid. We attempted to place the cannulated headless compression screw into the scaphoid in 1 patient with trans-scaphoid perilunate dislocation, once the scaphoid fracture was secured with the Kwires driven under the arthroscopic control. It is clear that the quality of fixation with the compression screw is superior to that with the K-wire only. Percutaneous insertion of the screw from the dorsal side is techni-
1153.e8
M. J. PARK AND J. H. AHN
cally easier than that from the volar distal side, where the previously inserted K-wires were present outside the skin. Considering later fixation with a headless screw, we intentionally placed the K-wires away from the central axis of the scaphoid and thus they did not interfere with the screw insertion. Because the reduction was already confirmed arthroscopically and secured with the K-wires, reassessment of scaphoid reduction was not necessary during percutaneous placement of a headless screw. We believe that accurate reduction and percutaneous fixation under arthroscopic control is a feasible technique in treating perilunate injury, which is a combination of carpal fractures and ligament injuries. Compared with the open technique, arthroscopy minimizes capsular and adjacent soft tissue scarring, reducing postoperative contracture. It has the great advantage of providing preservation of an already tenuous blood supply and facilitating healing of fractures and torn ligaments. In our clinical trials, the patients who had the adequate management using arthroscopy within 1 week after the injury showed excellent final wrist motions that were greater than 85% of the normal side at the time of the final followup. One of our initial concerns was the relatively high risk of extravasation due to the massive disruption of capsular structures, which is always present in perilunate injuries. To decrease fluid extravasation, we maintained a separate outflow and instilled saline irrigation by gravity infusion instead of using a mechanical pump. Severe swelling or any evidence of compartment syndrome was never observed in the postoperative period. Despite the many advantages of the arthroscopically assisted reduction and fixation, direct repair of the torn capsule or ligaments is not possible by this method. Many surgeons have invariably reported a transverse rent in the palmar capsule at the level of the midcarpal joint with the palmar surgical approach.7,9,18 Adkison and Chapman7 suggested that the maintenance of anatomic position is sufficient to restore perilunate ligamentous integrity without individual ligament repair. But others have emphasized the need for repair of the palmar ligaments to stabilize the carpal bones.2,17 It is generally known that the ligament structures of the joint, particularly the capsular ligaments, are believed to heal adequately when they are properly approximated and protected for some period, and we believe that this concept also applies to perilunate injuries. The development of traumatic arthritis is always a major concern following the severe articular disrup-
tion resulting from perilunate injury. Many reports of perilunate injuries have indicated a considerable incidence of post-traumatic arthritis.2-4 Although our clinical cases did not show evidence of arthritis after approximately 2 years of follow-up, we need to observe more patients with long-term follow-up to prove that the arthroscopically assisted technique is a reliable option in the treatment of perilunate injuries. REFERENCES 1. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop 1980;149:55-72. 2. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop 1987;214:136-147. 3. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations. A multicenter study. J Hand Surg [Am] 1993;18:768779. 4. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations. Questionnaire, clinical, and radiographic evaluation. J Hand Surg [Am] 2000;25:1069-1079. 5. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations. Pathomechanics and progressive perilunar instability. J Hand Surg 1980;5:226-241. 6. Minami A, Ogino T, Ohshio I, Minami M. Correlation between clinical results and carpal instabilities in patients after reduction of lunate and perilunar dislocations. J Hand Surg [Br] 1986;11:213-220. 7. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop 1982;164:199-207. 8. Viegas SF, Bean JW, Schram RA. Transscaphoid fracture/ dislocations treated with open reduction and Herbert screw internal fixation. J Hand Surg [Am] 1987;12:992-999. 9. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations. J Hand Surg [Am] 1993;18:1099-1106. 10. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracture-dislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl 1997;275:55-59. 11. Inoue G, Imaeda T. Management of trans-scaphoid perilunate dislocations. Herbert screw fixation, ligamentous repair and early wrist mobilization. Arch Orthop Trauma Surg 1997;116: 338-340. 12. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78:357-364. 13. Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous fixation of scaphoid fractures with a novel dorsal technique. Orthop Clin North Am 2001;32:247-261. 14. Green DP, O’Brien ET. Open reduction of carpal dislocations. Indications and operative techniques. J Hand Surg 1978;3: 250-265. 15. Moneim MS, Hofammann KE, Omer GE. Transscaphoid perilunate fracture-dislocation. Result of open reduction and pin fixation. Clin Orthop 1984;190:227-235. 16. Inoue G, Tanaka Y, Nakamura R. Treatment of trans-scaphoid perilunate dislocations by internal fixation with the Herbert screw. J Hand Surg [Am] 1990;15:449-454. 17. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture disloca-
ARTHROSCOPIC MANAGEMENT OF PERILUNATE INJURIES
18. 19. 20. 21. 22.
23.
tion. A critical analysis of the volar-dorsal approach. J Hand Surg [Am] 1997;22:49-56. Melone CP Jr, Murphy MS, Raskin KB. Perilunate injuries. Repair by dual dorsal and volar approaches. Hand Clin 2000; 16:439-448. Rabb DJ, Fischer DA, Quick DC. Lunate and perilunate dislocations in professional football players. A five-year retrospective analysis. Am J Sports Med 1994;22:841-845. Kozin SH. Perilunate injuries. Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:114-120. Whipple TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin 1995;11:37-40. 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;81:1093-1110. Geissler WB, Freeland AE. Arthroscopic management of intraarticular distal radius fractures. Hand Clin 1999;15:455-465.
1153.e9
24. Peicha G, Seibert F, Fellinger M, Grechenig W. Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures. Knee Surg Sports Traumatol Arthrosc 1999;7:327-333. 25. Whipple TL. The role of arthroscopy in the treatment of intra-articular wrist fractures. Hand Clin 1995;11:13-18. 26. Geissler WB, Hammit MD. Arthroscopic aided fixation of scaphoid fractures. Hand Clin 2001;17:575-588. 27. Sommerkamp TG. Arthroscopically assisted reduction and internal fixation of scaphoid fractures. J Am Soc Surg Hand 2001;1:192-210. 28. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83:483-488. 29. Yip HSF, Wu WC, Chang RYP, So TYC. Percutaneous cannulated screw fixation of acute scaphoid wrist fracture. J Hand Surg [Br] 2002;27:42-46.