Arthroscopic Management of Distal Radius Fractures (eBook)

184609_1_En_BookFrontmatter_OnlinePDF.pdf 2
184609_1_En_1_Chapter_OnlinePDF.pdf 14
1 14
Pre-Operative Assessment in Distal Radius Fractures 14
Introduction 14
History 14
Examination 15
Investigations 15
X-Ray 15
Normal Parameters 15
Fracture Characteristics 16
Fracture Stability 19
CT Imaging 20
MRI and Arthroscopy 22
Fracture Classification 22
Summary 23
References 23
184609_1_En_2_Chapter_OnlinePDF.pdf 26
2 26
Portals and Methodology 26
Introduction 26
Relevant Anatomy 26
Dorsal Portals 27
Dorsal Radiocarpal Portals 27
Dorsal Midcarpal Portals 28
Triquetro-Hamate (TH) Portal 28
Dorsal Radioulnar Portals 28
Volar Portals 28
Volar Radial Portal 28
Volar Radial Midcarpal (VRM) Portal 29
Volar Ulnar Portal 29
Volar Distal Radioulnar (VDRU) Portal .[21] 30
Field of View 30
Radial Midcarpal Portal 31
Ulnar Midcarpal Portal 31
Dorsal DRUJ Portals: Proximal and Distal 31
Volar DRUJ Portal 31
Methodology: Diagnostic Survey 31
3–4 Portal 32
4–5 Portal 32
6R, 6U Portals 32
Midcarpal Portals 32
Volar Portals 33
DRUJ Portals 33
Arthroscopic-Assisted Fixation: Distal Radius 34
Indications 34
Contraindications 34
Equipment and Implants 34
Required 34
Optional 35
Surgical Technique 35
Radial Styloid Fractures 35
Three-Part Fractures 35
Four-Part Fractures 37
Ulnar Styloid Fractures 38
Summary 38
References 38
184609_1_En_3_Chapter_OnlinePDF.pdf 40
3 40
Management of Simple Articular Fractures 40
Introduction 40
Fracture Classification 40
Indications and Contraindications 43
Surgical Technique 43
Reduction of the Fracture 44
Two-Part Fractures 44
Three-Part Fractures 47
Four-Part Fractures 49
Associated Injuries 50
Complications 50
Results 51
Clinical Experience and Personal Results 51
Conclusion 51
References 52
184609_1_En_4_Chapter_OnlinePDF.pdf 53
4 53
Treatment of Explosion-Type Distal Radius Fractures 53
The Dry Technique 54
Management of the Fracture 55
Classic Part 57
Arthroscopic Part 58
1. Joint Acceptably Reduced 60
2. One or Two Fragments Displaced 60
Many Fragments Remain Unreduced 63
Aftercare 65
Special Situations 66
Severe Metaphyseal Comminution 66
The Small Volar-Ulnar Fragment 67
Scaphoid Fossa Comminution 69
Osteochondral Fragments with Attached Ligaments 73
Preventive Opening of the Carpal Tunnel 73
Clinical Experience 75
References 76
184609_1_En_5_Chapter_OnlinePDF.pdf 78
5 78
Management of Distal Radius Fracture-Associated TFCC Lesions Without DRUJ Instability 78
Introduction 78
Indications for TFCC Repair 78
Contraindications for TFCC Repair 79
Surgical Technique 80
Management of a TFCC Tear 80
Discussion 82
References 82
184609_1_En_6_Chapter_OnlinePDF.pdf 84
6 84
Arthroscopic Management of DRUJ Instability Following TFCC Ulnar Tears 84
Introduction 84
Clinical Assessment and Arthroscopic Findings 87
Indications 89
Technique 91
Operative Setup and Diagnostic Arthroscopy 91
Direct Foveal Portal 91
Technique of Suture Anchor Foveal Repair 92
Technique of Styloid Fixation 96
Aftercare 96
References 98
184609_1_En_7_Chapter_OnlinePDF.pdf 100
7 100
Radial Side Tear of the Triangular Fibrocartilage Complex 100
Introduction 100
Anatomy of the TFCC 100
Classification of the Radial Tear of the TFCC 101
Mechanism of the Radial Side of the TFCC 102
Diagnosis and Evaluation with Physical Examination 102
Treatment 104
Fibrocartilage-Radius Interface Tear 104
Avulsion Fracture of the Dorsal Sigmoid Notch of the Radius Including the Dorsal Radioulnar Ligament 104
Avulsion Fracture of the Palmar Sigmoid Notch of the Radius Including Palmar Portion of the Radioulnar Ligament 105
Combination Injury of the Fibrocartilage Tear and either the Dorsal or Palmar Rim Avulsion of the TFCC Including Avulsion Frac 105
Total Avulsion of the TFCC at its Radial Insertion 105
Postoperative Care 108
References 109
184609_1_En_8_Chapter_OnlinePDF.pdf 110
8 110
Arthroscopic Management of Scapholunate Dissociation 110
Introduction 110
Anatomy and Biomechanics 111
Scapholunate Pathology 113
Clinical Assessment 113
Radiographs 114
CT and MRI Imaging 114
Arthroscopy 114
Indications for Arthroscopy 114
Technique 114
SL Grading 115
Management of Scapholunate Injury 116
Acute Injuries 116
Grade I Injuries 116
Grade II Injuries 116
Grade III and Grade IV Injuries 117
Post-Operative Rehabilitation 117
Late Presentation (> 6 Weeks)
Conclusions 118
References 119
184609_1_En_9_Chapter_OnlinePDF.pdf 120
9 120
Lunotriquetral and Extrinsic Ligaments Lesions Associated with Distal Radius Fractures 120
Incidence of Associated LTIO and Extrinsic Ligaments Lesions with Distal Radius Fractures 120
Management of LTIO and Extrinsic Ligaments-Associated Lesions 121
Lunotriquetral Ligament Lesions 121
Extrinsic Ligaments Lesions 123
Volar Extrinsic Ligament Injury 123
Dorsal Extrinsic Ligament Injury 124
Conclusion 126
References 127
184609_1_En_10_Chapter_OnlinePDF.pdf 128
10 128
Management of Concomitant Scaphoid Fractures 128
Introduction 128
Indications 128
Logistics 129
Technique 129
Discussion 135
Conclusion 136
Acknowledgments 137
References 137
184609_1_En_11_Chapter_OnlinePDF.pdf 138
11 138
Perilunate Dislocations and Fracture Dislocations/Radiocarpal Dislocations and Fracture Dislocations 138
Introduction 138
Indications 139
Technique 140
Marginal Fragments from the Distal Radius 141
Extrinsic Ligament Midsubstance Disruption (or Marginal Fragment of Inconsequential Size) 144
Carpal Fractures in a Perilunate Fracture Dislocation Pattern 145
Intrinsic Ligament Ruptures in a Perilunate Dislocation Pattern 148
Combined Injuries 150
Combining Arthroscopic Management of Radiocarpal and Perilunate Injuries with Open Radius Surgery 153
Rehabilitation 155
Discussion 157
Conclusion 160
References 160
184609_1_En_12_Chapter_OnlinePDF.pdf 161
12 161
The Role of Arthroscopy in Postfracture Stiffness 161
Introduction 161
Technique 162
Radiocarpal Joint 163
First Step [Fibrosis and Fibrotic Band Resection] 164
Second Step [Volar and Dorsal Capsule Resection] 168
Ancillary Procedures 171
Midcarpal Joint 172
Distal Radioulnar Joint 172
Clinical Experience 174
Postop Treatment 175
Results 175
Discussion 176
Failures and Complications 181
References 182
184609_1_En_13_Chapter_OnlinePDF.pdf 184
13 184
Treatment of the Associated Ulnar-Sided Problems 184
Introduction 184
Ulnar Carpal Impaction (UCI) 184
Ulnar Styloid Impaction 188
TFC Traumatic Tears 192
Conclusion 195
References 199
184609_1_En_14_Chapter_OnlinePDF.pdf 200
14 200
Arthroscopic-Assisted Osteotomy for Intraarticular Malunion of the Distal Radius 200
Introduction 200
Indications and Contraindications 203
Preoperative Planning 205
Surgical Technique 207
Logistics 207
Instruments and Osteotomy Technique 207
The Operation 208
Results 213
Discussion 217
Conclusions 217
References 217
184609_1_En_15_Chapter_OnlinePDF.pdf 219
15 219
The Role of Arthroscopic Arthrodesis and Minimal Invasive Surgery in the Salvage of the Arthritic Wrist: Midcarpal Joint 219
Introduction 219
Background 219
Overview of Surgical Approach 220
Surgical Technique in Detail 221
Diagnosis of Pathology Using Imaging, Fluoroscopy, and Arthroscopy 221
Wrist and Carpal Arthrofibrosis (Fig. .15.3a–e.) 222
Surgical Technique for Capitate-Lunate Arthrodesis in Detail .[26] 222
Percutaneous Bone Graft 230
Clinical Experience 231
Conclusion 231
References 231
184609_1_En_16_Chapter_OnlinePDF.pdf 233
16 233
Arthroscopic Radiocarpal Fusion for Post-Traumatic Radiocarpal Arthrosis 233
Introduction 233
Indications and Contra-Indications 234
Surgical Approach 234
Set Up and Instrumentation 234
Radioscapholunate Fusion 235
Radiolunate Fusion 240
Results and Complication 243
Conclusion 246
References 249
184609_1_En_BookBackmatter_OnlinePDF.pdf 251

"1 Pre-Operative Assessment in Distal Radius Fractures (p. 1-2)

Introduction

The determinants of clinical outcome following distal radial fracture are multi-factorial and may provide several 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 characteristics, 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 planning, 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, compliance and functional demands should all be considered.

Details of the mode of injury should be sought as 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 tissue 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 position 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 dorsal angulation of the distal fragment. A fall from a height of greater than two metres, sporting injuries and motor vehicle accidents are highenergy injuries. The soft tissue envelope may be significantly 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 critical in the older patient who, for example, requires the use of a walking aid to maintain independence, or suffers 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 Pre-Operative Assessment in Distal Radius Fractures"