Arthroscopically Assisted Distal Radius Fixation_TFCC management

Nickolaos A. Darlis, MD, PhD

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“Thorough knowledge and facility with classic techniques of distal radius fracture treatment is essential for a good result”

Del Piñal F, MD

Arthroscopy cannotReduce

Immobilize orPromote healing

…however Arthroscopy can optimize results

Indications in Distal Radius Fractures

• Intrarticular (≈ 5-10% of all fx)

• Some extrarticular (DRUJ or interosseous lig. injuries)

The “Miami Revolution”

Prognosis of distal radius fractures

• Shortening

• Angulation

• Step-off

• Ligamentous injuries

3mm

>100 Dorsal

2mm

AAOS 2010 WORKGROUP RECOMENDATIONS

Prognosis of distal radius fractures

• Shortening

• Angulation

• Step-off

• Ligamentous injuries

3mm

>100 Dorsal

2mm

AAOS 2010 WORKGROUP RECOMENDATIONS

BEST CONTROLED WITH

WRIST ARTHROSCOPY

Articular Reduction

• Fluroscopic assessment of step-off, gap and rotation is difficult, arthroscopy is more accurate

Catalano et al., 2004, Lutsky et al., 2008

• Accuracy of reduction does not predict final functional outcome or satisfaction in elderly, low demand patients

Young & Rayan, 2000

Concomitant lesions

• ΤFCC ≈60% (43-78%)

• SL lig.≈ 40% (32-75%)

• LT lig. ≈20% (15-61%)

• Chondral lesions ≈20% (19-32%)

Concomitant lesions

• “Most will heal by immobilization alone” but…• We know some will not• We aim at early mobilization

Set-up

Set-up

• Alternative– Ex –fix first– Plate first

Arthroscopically assisted reduction

• Currently indicated in selected injuries– Radial styloid Fx– Die Punch Fx– Three & Four part Fx– DRUJ instability or interosseous lig tear

• No metaphyseal comminution

• Especially in young, high demand patients

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

2. die punch

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

SL management

L S L S SL

C

L S

I II III IV

I II III IV

GEISSLER-DAUTEL GRADING

SL management• Debridement & Pinning

SL management• Thermal shrinkage & Pinning

Darlis & Sotereanos, JHS(A), 2005

SL management

• Open repair

TFCC - Ulnocarpal Impaction

managment

TFCC 3-D structure Nakamoura T et al, 1996

The Hammoc paradigm Nakamoura T et al 1996

Volar & Dorsal RU lig.-Deep bundle

The Iceberg Concept Atzei &Lucetti 2011

Palmer Classification• Traumatic (Class 1)

• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome

Central tear

Peripheral tear)

Radial tear

Tear location

Deep bundle of TFCC

Volar radioulnar lig.radiusulna

N.D

1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of articular disc

• Debridement ± pinning

1. Central TFCC lesions

• Debridement ± pinning

Darlis & Sotereanos, JHS(A), 2006

1. Central TFCC lesions

1. Central TFCC lesions

• Often degenerative and associated with ulnocarpal impaction syndrome

• Ulnar recession procedure to prevent symptom recurrence

Ulnocarpal Impaction Syndrome

Clinical features:• Ulnar sided wrist pain • Associated degenerative changes:

– Ulnar side of the lunate– Radial side of the ulnar dome– TFCC central tear– Triquetrum- LunoTriquetrum lig.

• Usually positive or neutral ulnar variance

Pronated Grip View Radiographs

MRI

Arthroscopic Wafer procedure• Preferred when modest shortening needed

Open Ulna Recession Procedures• Several options…

Open Ulna Recession Procedures

Another approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy

Darlis& Sotereanos JHS(A), 2005

2. Radial TFCC tears• Repair or debridement?

2. Radial TFCC tears• Repair if:

– VRUL or DRUL are involved– DRUJ instability

3. Peripheral (ulnar) TFCC tears• Well vascularized• Repairable

Usual location of peripheral tears

Dorsal

Usual location of peripheral tears

REPAIR TO CAPSULE REATTACH TO FOVEAOR

TFCC TFCC

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

REATTACH TO FOVEA

OR

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

TFCC

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

TFCC

3. Peripheral (ulnar) TFCC tears

TFCC managementREATTACH TO FOVEA

TFCC

TFCC managementREATTACH TO FOVEA

TFCC

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

REATTACH TO FOVEA

TFCC

3. Peripheral (ulnar) TFCC tears

Take Home Message _Fractures

Arthroscopy can optimize results in:• Simple intrarticular fracture patterns amendable to

pin (and /or ex fix) fixation (styloid, die punch)

• Intrarticular or extrarticular fractures with high level of suspicion for ligamentous or TFCC injury

• Young/ Active motivated patients

Take Home Message _ TFCC

Arthroscopy has revolutionalized the way we understand and treat TFCC lesions:

• Beware of ulnocarpal impaction in central tears

• Suspect foveal detachment and treat it (arthro or open)

Whatever you do• Remenber Vit C for disproportionate pain• Reassess ligaments and TFCC status after fracture

healing– Still window of opportunity

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 6 months 1 year

3mo 6mo

Customize your approach

There is no single tool for every distal radius fracture

Thank you

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