Patient Preparation and Positioning

The patient lies supine with the arm abducted to 90° and resting on a hand table. The procedure is typically performed with regional anesthesia. The surgeon stands at the patient’s head, and the assistant stands across from the surgeon. The fluoroscopy unit is placed at the patient’s feet and the arthroscopy tower is located on the side of the nonoperated arm ( Fig. 17.1 ). Traction is applied and removed as necessary throughout this procedure; thus a sterile wrist traction tower or sterile finger traps are recommended.

All of the standard arthroscopy portals may be used during arthroscopically assisted distal radius fracture fixation. The anterior portals can be useful for some fractures located on the posterior margins.

First Surgical Phase: Provisional Fixation

There is no specific instrumentation for arthroscopically assisted fixation of intra-articular distal radius fractures. Surgeons can use their preferred instrumentation. Provisional fixation aims to achieve acceptable reduction–stabilization based on intraoperative fluoroscopic controls, while allowing the fixation to be subsequently altered based on arthroscopic findings. Locking plates simplify fracture fixation and ensure distal stability. Screw fixation is used only in patients with isolated lateral radial styloid fractures ( Fig. 17.2 ). K-wires are used from time to time to hold the articular fragments or to prop up the articular surface.

The Henry anterior approach passes between the radial neurovascular bundle laterally and the flexor carpi radialis medially. After identifying the flexor pollicis longus (FPL), a Beckmann retractor is placed between the radial neurovascular bundle and the flexor digitorum superficialis, flexor digitorum profundus, and FPL tendons. The pronator quadratus is detached from its radial insertion and abraded with a rasp. The extra-articular portion of the fracture site is exposed. The fracture can be initially reduced by pulling the distal radius along its main axis and, if needed, by using a thin bone rasp (3 mm) to consolidate the bone fragments. A volar locking plate is secured through its oval slot to the volar side of the radius with a nonlocking screw ( Fig. 17.3a, b ). If the fragments are displaced posteriorly, one or two K-wires are manually inserted into the dorsal side of the distal radius through the fracture line and pushed into the radial shaft. Fluoroscopy verifies the quality of the reduction. One or two locking screws are inserted into the epiphyseal portion of the plate over the areas that show the best reduction on the fluoroscopic images. The posterior K-wires (if they were used during the reduction) are then removed so as not to interfere with the arthroscopy phase.

When volar plate fixation is used, a minimum of epiphysis screws are initially inserted. If any of these screws have to be changed after the arthroscopic inspection, the profusion of bone tunnels will weaken the construct’s stability.