Guidelines on arthroscopic assisted distal radius fracture fixation & TFCC management. indications, treatment options

1. Arthroscopically Assisted
Distal Radius Fixation_TFCC management
Nickolaos A. Darlis, MD, PhD
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13. Arthroscopy cannot
Reduce
Immobilize or
Promote healing
“Thorough knowledge and
facility with classic techniques
of distal radius fracture
treatment is essential for a good
result”
Del Piñal F, MD

14. …however Arthroscopy
can optimize results

15. Indications in Distal Radius Fractures
• Intrarticular (≈ 5-10% of all fx)
• Some extrarticular (DRUJ or
interosseous lig. injuries)

16. The “Miami Revolution”

17. Prognosis of distal radius fractures
AAOS 2010 WORKGROUP
RECOMENDATIONS
• Shortening
3mm
• Angulation
>100
• Step-off
• Ligamentous injuries
Dorsal
2mm

18. Prognosis of distal radius fractures
AAOS 2010 WORKGROUP
RECOMENDATIONS
• Shortening
3mm
• Angulation
>100
• Step-off
• Ligamentous injuries
Dorsal
2mm
BEST CONTROLED WITH
WRIST
ARTHROSCOPY

19. 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

20. Concomitant lesions
•
•
•
•
ΤFCC ≈60% (43-78%)
SL lig.≈ 40% (32-75%)
LT lig. ≈20% (15-61%)
Chondral lesions ≈20% (19-32%)

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

22. Set-up

23. Set-up
• Alternative
– Ex –fix first
– Plate first

24. 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

25. 1. Radial styloid

26. 1. Radial styloid

27. 1. Radial styloid

28. 1. Radial styloid

29. 1. Radial styloid

30. 1. Radial styloid

31. 1. Radial styloid

32. 2. die punch

33. 3. Three & Four part fractures

34. 3. Three & Four part fractures

35. 3. Three & Four part fractures

36. 3. Three & Four part fractures

37. 3. Three & Four part fractures

38. 3. Three & Four part fractures

39. 3. Three & Four part fractures

40. 3. Three & Four part fractures

41. 3. Three & Four part fractures

42. SL management
GEISSLER-DAUTEL GRADING
I
II
L
I
L
S
II
III
L
S
III
IV
C
L
S
IV
S

43. SL management
• Debridement & Pinning

44. SL management
• Thermal shrinkage & Pinning
Darlis & Sotereanos, JHS(A), 2005

45. SL management
• Open repair

46. TFCC - Ulnocarpal Impaction
managment

47. TFCC 3-D structure Nakamoura T et al, 1996

48. The Hammoc paradigm
Nakamoura T et al 1996

50. Volar & Dorsal RU lig.-Deep bundle

51. The Iceberg Concept Atzei &Lucetti 2011

52. Palmer Classification
• Traumatic (Class 1)
• Degenerative (Class 2)- associated with
ulnocarpal impaction syndrome

53. Tear location
Radial tear
Central tear
Peripheral tear)
Deep bundle
of TFCC
Volar radioulnar lig.
radius
ulna

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

55. 1. Central TFCC lesions
• Debridement
± pinning

56. 1. Central TFCC lesions
• Debridement
± pinning
Darlis & Sotereanos, JHS(A), 2006

57. 1. Central TFCC lesions
• Often degenerative and associated
with ulnocarpal impaction
syndrome
• Ulnar recession procedure to
prevent symptom recurrence

58. 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

59. Pronated Grip View Radiographs

60. MRI

61. Arthroscopic Wafer procedure
• Preferred when modest shortening needed

62. Open Ulna Recession Procedures
• Several options…

63. Open Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis& Sotereanos JHS(A), 2005

64. 2. Radial TFCC tears
• Repair or debridement?

65. 2. Radial TFCC tears
• Repair if:
– VRUL or DRUL are involved
– DRUJ instability

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

67. Usual location of peripheral tears
Dorsal

68. Usual location of peripheral tears

69. 3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
TFCC
OR
REATTACH TO FOVEA
TFCC

70. 3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
OR
REATTACH TO FOVEA

71. 3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
TFCC

72. 3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
TFCC

73. TFCC management
REATTACH TO FOVEA
TFCC

74. TFCC management
REATTACH TO FOVEA
TFCC

75. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

76. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

77. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

78. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

79. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

80. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

81. 3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC

82. 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

83. 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)

84. Whatever you do
• Remenber Vit C for disproportionate pain
• Reassess ligaments and TFCC status after fracture
healing
– Still window of opportunity
0
6 months
ACUTE
Good Healing
Potential
3mo
SUBACUTE
Unpredictable
6mo
1 year
CHRONIC
Poor Healing
Potential

85. Customize your approach
There is no single tool for every distal radius fracture

86. Thank you
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