Several clinical investigations have confirmed the relationship between displaced intraarticular distal radius fractures and the development of radiocarpal arthrosis (1,2,3). Catalano et al. evaluated 26 young adult patients 7.1 years after fracture treatment and used computed tomography to demonstrate osteoarthrosis in 16 wrists (76%) (1). The radiocarpal arthrosis in those patients was noted to worsen (67% decrease in joint space) at 15-year follow-up (3), although clinical symptoms were not severe. In order to decrease the risk of arthrosis, authors have recommended operative reduction and fixation when greater than 2 mm (2) or 1 mm of displacement (4,5) is noted.

Although these investigations emphasize the importance of an anatomic reduction of the articular surface, the means of assessing the articular surface has varied. Plain radiography is most commonly used preoperatively and postoperatively, whereas fluoroscopy is used intraoperatively. Both of these modalities are helpful, but they may not provide a true assessment of the articular surface. Routine posteroanterior and lateral images are difficult to interpret due to the inclination and tilt of the articular surface and the overlap of the styloid on the lateral view, but fluoroscopy does have the high image definition.

Three options exist to better define the articular surface involvement. Outside the operating room, the most easily obtained alternative is anatomic films, which are angled to allow an ideal profile of the articular surface. These images are significantly more accurate than standard radiographs (6) in imaging the joint surface. Computed tomography is also an excellent tool for fracture assessment. Intraoperatively, arthroscopy should be considered the ideal means to assess the articular surface. Arthroscopy is the gold standard, as it is the only modality that provides a true assessment of the entirety of the joint surface.

Three manuscripts have examined the role of arthroscopy in the evaluation of the articular surface after distal radius fractures. Edwards et al. reported the intraarticular step and gap deformity by fluoroscopy, plain radiograph, and arthroscopy in 15 cases and reported that plain radiograph and fluoroscopy both significantly underestimated the gap deformity (although not step deformity). In five of the seven cases in which arthroscopy demonstrated a larger deformity than radiograph or fluoroscopy, the step or gap deformity was greater than 1 mm (7). Auge and Velazquez reported on 33 patients treated with closed reduction and external fixation with additional K-wire fixation and bone grafting as necessary. Arthroscopy was performed after fixation and 12 of the 33 wrists had greater than 1 mm of articular displacement, requiring modification of the reduction. Higher-energy fractures demonstrated a greater likelihood of needing modification after arthroscopy (8). Finally, Lutsky et al. reported on 16 patients treated with open reduction and internal fixation with volar
plating for intraarticular distal radius fractures. Arthroscopy was performed after fixation to allow assessment of fracture alignment. The magnitude of the step and gap deformity, as identified arthroscopically, was larger than expected in eight patients and was greater than 1 mm in each of these patients (9).

Taken together, these data suggest that fluoroscopy and plain radiography have limitations in the evaluation of the joint surface and that there is a role for arthroscopy in the treatment of certain distal radius fractures. Surgeon comfort and skill with the arthroscope will naturally affect the surgical decision for any particular fracture. Although some surgeons will feel comfortable addressing markedly comminuted fractures using arthroscopy to assist in the realignment of a fragmented articular surface, many will not. However, there are a few fracture types that lend themselves to treatment through a limited open approach with arthroscopic assistance. For the purposes of this chapter, two fractures types are considered ideal indications for arthroscopy: the radial styloid fracture (Chauffeur fracture) and the die-punch fracture (lunate facet depression fracture). Surgeons inexperienced with the techniques discussed below have the option of treating the fracture through a standard, open technique and then arthroscopically evaluating the articular surface after fixation; an unacceptable alignment may be modified. With increased experience, the surgeon may use arthroscopy as a tool during reduction and fixation of the fracture. Finally, increasingly complex fractures may be addressed with arthroscopic assistance as the surgeon’s experience and skill increases.

Arthroscopy is quite safe for the treatment of distal radius fractures, but a few contraindications exist.