Plate Presetting and Arthroscopic Reduction Technique (PART) for Treatment of Distal Radius Fractures

Abstract

Background: Arthroscopy has been reported to be an efficient adjunct for the surgical treatment for distal radius fractures (DRF). However, performing wrist arthroscopy during palmar locking plate fixation seems to be troublesome. We have developed a surgical technique involving presetting of a palmar locking plate and an arthroscopic reduction technique (PART) of the fracture that can facilitate the procedure. This study is aimed to investigate the effectiveness of our technique in the treatment of DRF.

Patients and Methods: 249 fractures of the distal radius were treated by PART. 205 fractures in 200 patients were followed-up on average for 15 (12–60) months. There were 46 men and 154 women with an average age of 62 (16−85) years. According to the AO/ASIF fracture classification system there were 51 extra-articular fractures, and 154 intra-articular fractures. Scapholunate interosseous ligament injuries were classified according to Geissler and tears of the triangular fibrocartilage complex according to Abe. On arthroscopic inspection, residual intra-articular fragment dislocation after reduction under fluoroscopy was evaluated. Final evaluation included a radiological examination, measurements of wrist and forearm motion, grip strength, the Mayo modified wrist score (MMWS), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results: On arthroscopic inspection, intraarticular dislocations were found to be residual in 22.7%, even if reduction seemed to have been achieved when viewed by fluoroscopy. Scapholunate interosseous ligament tears were recognized in 29.8%, and triangular fibrocartilage complex tears in 62.4%. The mean palmar tilt was 5.7 (− 10 to 16)°, radial inclination 26.0 (18−31)°, and ulnar variance 0.1 (− 2  to  5) mm. The mean extension of the wrist was 71 (50−85)°, and the mean flexion was 62 (40−79)°. The mean pronation of the forearm was 87.5 (70−90)°, and the mean supination was 89.1 (75−95)°. The mean grip strength was 90.0% (31−133%) of the opposite side. According to the MMWS there were 156 excellent, 47 good, and 2 fair results. The mean DASH score was 3.9.

Conclusions: The palmar locking plate in combination with arthroscopic reduction technique (PART) leads to good and excellent results. It can be recommended for all fractures of the distal radius needing operative treatment. Arthroscopic reduction of intra-articular fragments is superior to reduction under fluoroscopy. PART allows also the detection of intra-articular soft tissue lesions such as scapholunate ligament tears and injuries of the triangular fibrocartilage complex.

Zusammenfassung

Hintergrund: Die Handgelenksspiegelung ist ein effizientes Hilfsmittel in der Behandlung der distalen Radiusfraktur. Allerdings bringt die Handgelenksarthroskopie im Rahmen einer ­palmaren winkelstabilen Plattenosteosynthese Schwierigkeiten mit sich. Wir haben deshalb eine Operationstechnik entwickelt, bei der eine ­palmare winkelstabile Platte nach manueller Grobreposition provisorisch vormontiert, die Fraktur dann unter arthroskopischer Sicht fein reponiert und dann definitiv fixiert wird. Die vorliegende Arbeit beschreibt unsere Technik und dient zugleich der Ergebniskontrolle.

Patienten und Methoden: 249 distale Radiusfrakturen wurden mittels unserer Technik (PART) versorgt. 200 Patienten, 46 Männer und 154 Frauen mit einem Durchschnittsalter von 62(16–85) Jahren, mit 205 Frakturen konnten nach durchschnittlich 15 (12−60) Monaten nachuntersucht werden. Es handelte sich um 51 extra- und 154 intraartikuläre Frakturen. Verletzungen des skapholunären Bandes wurden nach Geissler, Verletzungen des triangulären fibrokartilaginären Komplexes (TFCC) nach Abe klassifiziert. Bei der Arthroskopie wurden bei der Reposition unter Bildwandlerkontrolle verbliebene Dislokationen erfasst. Bei der Nachuntersuchung wurden Röntgenaufnahmen gefertigt, die Handgelenks- und Unterarmbeweglichkeit und die Grobkraft gemessen sowie der modifizierte Mayo Wrist Score und der DASH Score erhoben.

Ergebnisse: Obwohl das Repositionsergebnis unter Bildwandlerkontrolle als anatomisch eingestuft wurde, fand sich bei der anschließenden Arthroskopie in 22,7% immer noch eine intraartikuläre Fehlstellung. Läsionen des skapholunären Bandes wurden in 29,8% und des TFCC in 62,4% der Frakturen beobachtet. Die palmare Inklination der Radiusgelenkfläche betrug durchschnittlich 5.7 (− 10–16)°, die Ulnarinklination 26,0 (18−31)° und die Ulnavarianz 0,1 (− 2–5) mm. Die Extension lag im Durchschnitt bei 71 (50−85)° und die Flexion bei 62 (40−79)°. Die durchschnittliche Pronation betrug 87,5 (70−90)° und die Supination 89,1 (75−95)°. Die Grobkraft lag im Durchschnitt bei 90% (31−133%) der Gegenseite. Nach dem MMWS wurden 156 sehr gute, 47 gute und 2 befriedigende Ergebnisse erzielt. Der DASH-Score lag im Durchschnitt bei 3,9.

Schlussfolgerung: Die Versorgung distaler Radiusfrakturen mit einer palmaren winkelstabilen Platte in Kombination mit einer arthroskopischen Feinreposition führt zu guten und sehr guten Ergebnissen. Sie kann für alle operationsbedürftigen Frakturen des distalen Radius empfohlen werden. Die Reposition unter arthroskopischer Sicht ist der Reposition unter Bildwandkontrolle überlegen. Darüberhinaus können mit der Arthroskopie Weichteilverletzungen, wie Läsionen des skapholunären Bandes und des TFCC, festgestellt werden.

Key words

distal radius fractures - arthroscopy - articular step-offs - ligament injuries

Schlüsselwörter

distale Radiusfrakturen - Arthroskopie - Gelenkstufe - Bandverletzungen

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