Arthroscopic-Assisted Treatment of Distal Radius Fractures

Key Points

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Arthroscopic assistance allows direct visualization and correction of the reduction of intraarticular distal articular radius fractures
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A high percentage of concomitant scapholunate interosseous ligament (SLIL) and triangular fibrocartilage complex (TFCC) lesions are diagnosed with this technique
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Arthroscopy allows same-stage treatment of SLIL and TFCC injuries after fracture fixation, although its clinical relevance remains debated due to the favorable natural course of the vast majority of these lesions.

Panel 1: Case Scenario

A 25-year-old, right-handed man fell on his outstretched right hand during professional basketball. He presented to the emergency department with a comminuted intraarticular distal radius fracture ( Fig. 1 ). What is the most effective approach for management of this fracture and likely associated ligament injuries?

Importance of the Problem

Arthroscopic-assisted treatment of distal radius fractures allows for potentially improved reduction through direct visualization. Moreover, it provides an accurate diagnosis of associated ligamentous injuries including SLIL or TFCC lesions that can otherwise be underdiagnosed. These injuries could be diagnosed at a state of advanced degenerative changes (such as SLAC wrist) that could lead to palliative surgery. For the TFCC, persistent ulnar-sided wrist pain could occur, as well as distal radio-ulnar joint (DRUJ) instability. Beyond 30 degrees of displacement of the radial epiphysis in the sagittal plane, associated TFCC injuries are very frequent and could be underdiagnosed without arthroscopy evaluation. The functional cost of these lesions makes early management important, especially in young adults.

Main Question

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Can arthroscopic assistance improve the reduction of intraarticular distal radius fractures?
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How does arthroscopy contribute to the diagnosis and treatment of concomitant ligament injuries?
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Does arthroscopic assistance help to improve long-term functional outcome?

Current Opinion

Arthroscopic assistance in the management of intraarticular distal radius fracture (IADRF) allows a better reduction of articular surface and could prevent degenerative arthritis of the wrist. It is also the only tool that allows control of intraoperative reduction of “Die punch” type impaction fractures and check for the absence of intraarticular protruding screws when aiming for the stable subchondral fixation. Furthermore, it allows to assess and manage associated ligament injuries at the same time. Nevertheless, enthusiasm is tempered by inconsistent evidence of its benefits and relevance in routine management of IADRF.

Finding the Evidence

A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The PubMed, Ovid, and Cochrane databases were searched for articles published between January 1, 2006 and March 1, 2020, using the key indexing terms “distal radius fracture,” “articular,” and “wrist arthroscopy.” Articles were potentially eligible if they compared internal IADRF fixation and/or the diagnosis and treatment of acute carpal injuries with versus without arthroscopic assistance or if they were case-series studies of patients managed with arthroscopic assistance. Only studies of adult patients were included. Fracture displacement and interfragmentary gap had to be among the criteria used to assess improvements in IADRF reduction. The diagnosis and treatment of carpal injuries had to be described. Finally, outcomes had to be reported based on the functional scores used for wrist surgery (range of motion, grip strength, visual analog scale [VAS] scores, Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Wrist score, and/or Patient-Rated Wrist Evaluation [PRWE]). The following article types were excluded: literature reviews, biomechanical and anatomical studies, technical notes, letters to editors, continuing medical education articles, and articles in languages other than French or English. The above-described inclusion criteria were assessed by reading the titles and abstracts or, if these were not available, the full-length article. Each abstract was read by two observers after the elimination of duplicates. Disagreements about eligibility for inclusion in the literature review were resolved by the senior author. Selected articles were read in their entirety. For each selected article, the data were categorized as follows: author information; year of publication; study design; level of evidence; number of patients; diagnostic and therapeutic methods that were used or compared; diagnosis and management of concomitant carpal injuries; assessment criteria, with the results; follow-up duration; and clinical and radiological outcomes at final follow-up.

Cochrane Search: “Distal radius fracture arthroscopy,” from 2006 to 2020
Pubmed (Medline): “Distal Radius Fractures” AND “articular” AND “arthroscopy”; date 1/1/2006 to 03/01/2020

Quality of the Evidence

Level I:

Randomized trials: 1

Level II:

Randomized trials with methodological limitations: 4

Level III:

Retrospective comparative studies: 1

Level IV:

Case series: 18

Findings

Can Arthroscopy Improve the Reduction of Intraarticulardistal Radius Fractures (IADRFs)?

Seventeen articles were able to answer this question, with a total of 770 patients, a mean of 45 patients per article, and a mean follow-up of 14.8 months. Of the 17 studies, 11 were case series, 5 were prospective, and 1 was retrospective. The quality of reduction was compared using computed tomography (CT) measurements in two studies, whereas the other studies relied on radiographic parameters, arthroscopic findings, or both. The system used to classify the fractures varied across studies, with the AO classification being used most often and the classifications devised by Frikman and Castaing less often. The internal fixation methods varied as well. Pinning was used alone in some studies and combined with external fixation in others. Several studies used an anterior locking plate or several different fixation methods depending on the type of fracture. In studies comparing two groups, the contribution of arthroscopy was chiefly assessed based on step-off and interfragmentary gap. These same criteria were also used in noncomparative studies. In one study, step-off was evaluated according to the Knirk and Jupiter grade.

Of the 17 studies, 13 indicated a beneficial effect of arthroscopy for IADRF reduction. A beneficial effect was defined in comparative studies as statistically significant improvements in the assessment criteria compared to the group without arthroscopy and in noncomparative studies as improvements in step-off and interfragmentary gap with the use of arthroscopy. Table 1 recapitulates the main findings from these studies.

Table 1

Main Data on Quality of Articular Surface Restoration.

Year/Study	Patients (Ascp)	Level of Evidence	Treatment	Mean Follow-Up, Months	Outcomes	Conclusion	Favorable to ARIF, Yes or No
2006 Hardy et al.	18 (18)	IV	ARIF	12	Mayo Wrist Score decreased with increasing Knirk-Jupiter (step-off) grade	Articular surface restoration is the most important prognostic criterion	Yes
2007 Battistella et al.	80 (40)	II	ORIF versus ARIF	38	With Ascp, better coronal inclination, ulnar variance, and joint surface restoration	ARIF is better than the conventional method	Yes
2007 Hattori et al.	28 (28)	IV	ARIF and volar plate or external fixation in patients > 70 years	24.9	Mayo Wrist Score 80.1 ± 0.5 23 returned to previous activities	ARIF is an effective option in older, physically active patients	Yes
2008 Varitimidis et al.	40 (20)	II	Open reduction external fixation versus ARIF	24	After 24 months, smaller step-off with vs without Ascp (0.3 vs 0.8, P < .01)	ARIF improves articular surface restoration	Yes
2008 Lutsky et al.	16 (16)	IV	Ascp and Fscp to guide reduction compared using a subjective VAS	0	Fscp: 8.2/10 Ascp: 6.4/10	Fscp assessment underestimates residual displacement	Yes
2010 Ono et al.	31 (31)	IV	Ascp to assess step-off and interfragment gap after ORIF with volar locking plate	0	7 patients with displacement ≥ 2 mm	ARIF if preoperative displacement	Yes
2011 Levy et al.	35 (35)	IV	ORIF with Ascp assessment after 6 weeks	12	Only 9 patients with interfragment gap > 1 mm and 2 with step-off > 1 mm	≥ 5.80 mm Reserve ARIF for young patients	No
2012 Ono et al.	70 (70)	IV	Ascp to assess step-off and interfragment gap after ORIF with volar locking plate	13	15 patients with step-off ≥ 1 mm 40 patients with interfragment gap ≥ 1 mm	ARIF is helpful when the preoperative sup of step-off and interfragment gap is > 7.85 mm	Yes
2013 Abe et al.	153 (153)	IV	ARIF and plate presetting arthroscopic reduction technique (PART)	30	35.2% of patients with displacement corrected with Ascp assistance	Plate presetting and ARIF provide effective reduction and decrease surgery invasiveness.	Yes
2013 Khanchandani et al.	27 (27)	IV	ARIF	26	In 5 patients intraoperative IF modification after Ascp evaluation	Ascp assessment allows correction of residual step-off	Yes
2014 Del Pinal et al.	4 (4)	IV	ARIF of comminuted diaphyseal-metaphyseal fractures	36	Step-off < 1 mm in 4 patients	ARIF allows the reduction of intraarticular fractures with diaphyseal-metaphyseal comminution	Yes
2014 Zemirline et al.	20 (20)	IV	ARIF via a 15-mm anterior approach	4	19 patients with step-off < 1 mm	Inconspicuous scar, anatomical reduction, diagnosis and treatment of concomitant ligament injuries	Yes
2015 Yamazaki et al.	74 (37)	II	ORIF versus ARIF	11	No significant difference in step-off or interfragment gap between the 2 groups after 6 or 48 weeks	ARIF does not improve articular surface restoration	No
2016 Thiart et al.	44 (44)	IV	ORIF then intraoperative Ascp assessment	3	Step-off: 0 mm (33 patients) 0–1 mm (3 patients) 1–2 mm (8 patients) Interfragment gap: 0 mm (37 patients) 0–2 mm (6 patients) 3 mm (1 patient)	Ascp showed acceptable step-off and interfragment gap with Fscp assistance. Limited role for Ascp assistance in reducing intraarticular fractures	No
2017 Christiaens et al.	40 (20)	III	ORIF vs ARIF	3	After 3 months, smaller step-off in the Ascp group	ARIF improves the reduction of IADRFs	Yes
2018 Burnier et al.	40 (20)	II	ORIF versus ARIF with CT after 3 months to compare step-off and interfragment gap	3	No Ascp: step-off reduction not significant ( P > .05). With Ascp: significant step-off reduction ( P < .05)	ARIF improves articular surface restoration	Yes
2019 Selles et al	50 (22) 770 (605)	I	Assess reduction in Ascp group after ORIF	12 14.8	No step off for 16 patients 1–2 mm for 4 patients > 2 mm for 2 patients No gap for 16 patients 1–2 mm for 5 patients > 2 mm for 1 patients	Anatomic reduction in 13 patients	No

Ascp , arthroscopy; IF , internal fixation; Fscp , fluoroscopy; VAS , visual analog scale; CT , computed tomography; IADRF , intraarticular distal radius fracture; ARIF , arthroscopic reduction internal fixation; ORIF , open reduction internal fixation.

How Does Arthroscopy Contribute to the Diagnosis and Treatment of Concomitant Ligament Injuries?

Thirteen studies provided information on this topic, with a total of 517 patients and a mean follow-up of 21.4 months. Two studies reported data from the first described cohort of patients with IADRF that were evaluated arthroscopically by Lindau et al. and were followed up for at least 13 years. In nine other studies, follow-up was 1 year or less. Of the 13 studies, 2 were comparative and 10 noncomparative. The assessment criteria in these studies were the proportions of patients diagnosed with injuries to the scapholunate interosseous ligament (SLIL) and/or triangular fibrocartilage complex (TFCC). The methods used to treat these injuries in the noncomparative studies were described. Some studies also analyzed clinical assessment criteria. Arthroscopy was deemed beneficial when its use enabled the diagnosis and/or treatment of carpal injuries or when failure to treat carpal injuries resulted in poorer clinical and radiological outcomes. Arthroscopy was considered unhelpful when the diagnosis and/or treatment of concomitant carpal injuries failed to improve patient outcomes. Arthroscopy provided the diagnosis of SLIL injuries in 41.7% of cases with a total of 200 lesions. SLIL injuries were classified according to Geissler in all but one study, which used the European Wrist Arthroscopy Society (EWAS) classification. Of the 200 lesions, 147 (73.5%) were Geissler grade I or II (partial injuries) and 53 (26.5%) were Geissler grade III or IV (complete injuries). SLIL tears were managed by scapholunate pinning. In some studies, diagnosed SLIL injuries were left untreated, whereas in others pinning was performed routinely in patients with diagnosed injuries, with no concomitant arthroscopic procedure. In one study, grade IV injuries were managed by open repair. Arthroscopy showed TFCC injuries in 52.32% of cases. The 167 lesions were classified according to Palmer, which showed the following distribution: Class 1A, n = 47 (28.14%); Class 1B, n = 55 (32.93%); Class 1C, n = 19 (11.3%); and Class 1D, n = 37 (22.16%); 3 injuries were not classified. In several studies, diagnosed TFCC injuries were left untreated. Class 1B injuries were repaired by arthroscopic suture in all but one study, which used open repair. Other lesion types were generally managed by arthroscopic debridement, although splinting was used in one study for type 1D injuries. In eight studies, the results supported a positive contribution of arthroscopy to the diagnosis and treatment of carpal injuries concomitant to IADRFs. Only seven studies reported lunotriquetral lesions and classified them with the Geissler classification, with a mean of 25% of lesions. Treatment were LT pinning for grade 3–4 lesions. Table 2 lists the data from the selected studies and the main conclusions.

Table 2

Main Data on the Diagnosis and Treatment of Carpal Cigamentous Injuries Concomitant to Intraarticular Distal Radius Fractures.

Year/Study	Patients (Ascp)	Mean FU (mo)	SLIL (%)	Geissler Grade				TFCC (%)	Palmer				Treatment		Conclusion	Favorable to Ascp, Yes or No
				1	2	3	4		1A	1B	1C	1D	SLIL	TFCC
2006 Hardy et al.	18 (18)	12	28	4 “partial”		1 “complete”		17			1	2	SLIL pinning in 2 patients	None	ARIF allows the treatment of concomitant injuries	Yes
2007 Forward et al.	51 (51)	12	86	11	23	10							None	None	After 12 months, significant increase in the SL angle, SL pain and instability if Geissler 3	Yes
2008 Varitimidis et al.	40 (20)	24	45		7	2		60		6		6	SLIL pinning in 9 patients	Debridement of all lesions with Ascp repair in 1 case and open repair in 1 case	The treatment of concomitant lesions may have contributed to the better scores in the Ascp group	Yes
2011 Levy et al. ^a	35 (35)	12	28	3 grade 1 or 2		7 EWAS grade 3, 4 or 5		28		3 ^a			None	None	No correlation between anatomical ligament injuries and functional scores after 1 year	No
2013 Araf et al.	30 (30)	0	36.6	2	6	2	1	76.7	4	7	14	2	Repair of all identified lesions		High incidence of carpal lesions in IADRFs	Yes
2013 Ogawa et al.	85 (85)	0	54.5	39		6	3	40	27	2		5	Grade 1–2: none; grade 3: SLIL pinning; grade 4: open repair	1A: debridement, 1B Ascp suture, 1D = above-elbow cast	High incidence of carpal injuries, independently from the fracture	Yes
2013 Khanchandani et al.	27 (27)	26	29	3	2	1	2	62		15		2	Grades 2–3–4: SLIL pinning 8 weeks	1B suture if large lesion, debridement for 1D and small 1B lesions	Ascp contributes to the diagnosis and treatment of concomitant injuries.	Yes
2012–2015 Mrkonjic et al.	38 (38)	156	68.4	17 grade 1–2	9			86.8	7	7	2	9	None	None	SLIL injuries grades 1–3 and TFCC injuries do not influence the objective or subjective functional scores or the radiographic outcomes after a minimum follow-up of 13 years	No
2015 Kasapinova et al.	40 (40)	6	35	2	5	5	2						Grade 3–4: SLIL pinning		Lower functional scores at 3 and 6 months if SLIL injury ARIF useful for managing these lesions	Yes
2016 Thiart et al.	44 (44)	3	6.8	15				34.1					None	Repair of a single TFCC lesion	Highincidence of carpal lesions in patients with IADRFs	No
2017 Swart et al.	42 (42)	12	45	11	7	1		50	7	6		8	Grade 3: SLIL pinning	Debridement	No difference in functional scores at 12 months between groups with vs without SLIL and/or TFCC injuries	No
2017 Christiaens et al.	40 (20)	3	30	3	1	2		30		2	1	2	Grade 3: SLIL pinning	1B Ascp suture, debridement for 1C and 1D	ARIF allows the management of these lesions.	Yes
2019 Selles et al	50 (22) 517 (472)	12 21.38	50 41.72 (25)	2 Partial lesions (grade 1 or 2): 147/200 (73.5%)	1 Complete lesions (> grade 3): 53/200 (26.5%)	5	3	91 52.32	2 47/167 (28.14%)	10 55/167 (32.93%)	1 19/167 (11.38%)	1 37/167 (22.16%)	None	None	Most of soft-tissue Injuries do not Require treatment	No