CC BY-NC-ND 4.0 · Revista Iberoamericana de Cirugía de la Mano 2021; 49(01): 024-036
DOI: 10.1055/s-0041-1730393
Original Article | Artículo Original

Arthroscopic Management of Intra-articular Ligament Lesions on Distal Radius Fractures

Article in several languages: English | español
1  Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil
,
2  Santa Casa de Misericórdia, Porto Alegre, RS, Brazil
,
1  Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil
,
Gary Alan Montano
1  Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil
,
Fernando Towata
1  Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil
,
3  Hospital Britanico de Buenos Aires, Argentina
,
4  Università Degli Studi Di Milano, Orthopaedics Department, Milano, MI, Italy
› Author Affiliations
 

Abstract

Articular distal radius fractures (DRFs) have increased in incidence in recent years, especially among the economically active population. Most of the treatment approaches are based on plain X- rays, and do not give us any information on how to treat these fractures. In the search for solutions with greater precision in diagnosis, in reducing the joint surface of the fracture, and envolving minimally-invasive techniques, we found arthroscopy as the main tool for these patients. Therefore, an enhanced understanding of the biomechanics of the different types of fracture associated with ligamentous lesions should facilitate the right decision regarding the treatment. The present paper aims at providing a management-oriented concept to diagnose and treat ligamentous lesions associated with intra-articular DRFs based on a arthroscopy-assisted procedure, and showing the objective and patient-reported outcomes and a new classification. The objective and patient-reported outcomes were: the mean range of motion (ROM) was of 94.80% on the non-affected side; the mean score on the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) was of 3.6 (range: 1 to 12). The score on the Visual Analog Scale (VAS) was of 1.66 (range: 1 to 3). Complications were observed in 2 (13.33%) patients: extensor tendon synovitis in 1 patient, and a limitation (stiffness) in ROM in 1 patient, both treated with wrist arthroscopy release. The mean time until the return to work was of 6.4 weeks. In patients with unstable intra-articular DRFs associated with ligamentous lesions, the fixation of specific osseous-ligamentous fragments and ligamentous repair/reconstruction by wrist arthroscopy prove to be a safe and reliable treatment. The clinical and functional results predict that the patients can return to work more quickly.


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Introduction

The incidence of articular distal radius fractures (DRFs) has increased recently, especially among the economically-active population. The frequency of surgery for patients with DRF has also increased. Arthroscopy is considered the primary tool available for these patients, as it utilizes minimally-invasive techniques, reduces the joint surface of the fracture, and enables a higher precision in diagnosis. Arthroscopic techniques enable surgeons to perform surgery for DRFs via a direct and anatomical reduction of the joint surface, with sufficient stability for early mobility of the joint, preserving the proprioception and the vascularization of the tissues, often resulting in the patients resuming their regular personal or professional activities. Arthroscopy of the wrist requires specific characteristics and tools that generally follow these basic principles: creation of work or vision portals, identification of the lesion, and a specific treatment procedure; the standard of conduct for the postoperative care of these patients is very similar to that of procedures in other joints. Imaging scans of upper-limb joint fractures have been used for the initial diagnosis for many years. In recent years, plain radiography is often the first test to be ordered; however, the computed tomography (CT) scan has gained momentum, and is particularly useful to measure deviations and to check bone consolidation.[1] [2] Furthermore, magnetic resonance imaging (MRI) is useful to diagnose occult fractures[3] and associated ligament injuries; however, it is not superior to arthroscopy, so it is not widely used. Articular fractures appear differently, depending on the pattern and the associated trauma mechanism. Thus, torsional and indirect traumas present avulsion fracture patterns, and traumas in which the upper limb is used for protection (to support the body load, for example) are considered direct fractures by compression.[4] Arthroscopically-assisted techniques have broadened the technique spectrum, particularly when reducing intra-articular fractures and in the diagnosis of ligamentar lesions. Therefore, understanding the enhanced biomechanics of the different fracture types associated with ligament lesions should help facilitate an accurate treatment protocol.[5] Conservative treatment is an acceptable option for ligament injuries, fractures without deviation, and stable fractures, as it poses fewer risks and enables earlier mobilization by keeping the radiocarpal joint congruent. Another important factor is the time elapsed between the injury and the start of treatment. As with all injuries, prompt treatment generally results in a better prognosis.[6] The present study sought to provide a management-oriented concept for the diagnosis and treatment of ligament lesions associated with the stabilization of intra-articular DRFs based on a arthroscopy-assisted procedure through the presentation of objective and patient-reported outcomes (range of motion [ROM], Quick Disabilities of the Arm, Shoulder and Hand [QuickDASH] questionnaire, Visual Analog Scale [VAS], grip strength. and time until return to work) for classification.

Principles of Biomechanics

The biomechanics of the wrist involves both kinetic (performing the movement) and cinematic (bearing load) motion. The basic prerequisites for regular motion of the carpus are ([Fig. 1]):

Zoom Image
Fig. 1 Perfect relationship between carpal bones and ligaments.
  • (1) Intact bone stock of the radius and ulna.

  • (2) Intact intrinsic ligaments conjoin the proximal carpal row to a variable geometrical condyle versus the invariable proximal and distal counterparts.

  • (3) Intact extrinsic ligaments coordinate the proximal row with the radius and ulna against the distal carpal row, which acts as a monolith.[7]

  • (4) The role of proprioception and neuromuscular control in carpal stability.

The rather strong palmar ligaments support the proximal row like a cummerbund and act against forces of the dorsal side like a tension band ([Fig. 2]).[8]

Zoom Image
Fig. 2 The dorsal v-ligaments are on the dorsal aspect of the wrist, and the two proximal and distal v-ligaments are situated on the palmar aspect of the wrist, and they keep the carpus in position.

The basic factors that cause DRF include the acting forces, the position of the wrist, and the resistance of the ligaments. Specific fracture types arise from the interaction among these parameters. These ligaments appear to reinforce the bone at their origin. Fracture patterns in two-part fractures generally occur in the area between the ligamentous zones. Intra-articular fractures show six different patterns, and at least one corner remains intact with the shaft. From a biomechanical standpoint, these bone-ligament fragments form a unit and tend to dislocate in different directions depending on their ligamentous attachment sites.[9] [10] [11] ([Fig. 3]). Recent laboratory research has revealed that carpal ligaments exhibited different kinetic behaviors depending on the direction and point of application of the forces to the wrist. The helical antipronation ligaments were usually active when the wrist was axially loaded; whereas the helical antisupination ligaments constrained the supination torques to the distal row. This novel way of interpreting the function of the carpal ligaments might assist in developing improved strategies for the treatment of carpal instabilities ([Fig. 4]).[12]

Zoom Image
Fig. 3 In partial intra-articular fractures, six different patterns can be observed. At least one corner remains intact and in continuity with the shaft (A). The origins of the extrinsic ligaments are shown, which seem to reinforce the bone (B).[6]
Zoom Image
Fig. 4 Three groups of ligaments play a specific role in the primary stabilization of the axially-loaded carpus. (A) The helical antipronation ligaments become simultaneously taut (yellow arrows) when the distal row is torqued in pronation (curved white arrow). (B) The medial helical antisupination ligaments (HASLs) resist (yellow arrows) the tendency of the ulnar-side bones to translocate palmarly (curved white arrow). (C) The lateral HASLs become particularly active (yellow straight arrow) when the distal row is forced into supination (curved white arrow).[12]

In the past decade, a fourth factor in carpal stability has been proposed, which involves the neuromuscular and proprioceptive control of the joints ([Fig. 5]). The proprioception of the wrist originates from afferent signals, and is elicited by sensory end organs (mechanoreceptors) in the ligaments and joint capsules. It elicits spinal reflexes for immediate joint stability, and a higher order of neuromuscular influx to the cerebellum and sensorimotor cortices for planning and executing joint control.[11] [12]

Zoom Image
Fig. 5 Schematic design to understand the proprioception of the wrist - neuromuscular control. APL, abductor pollicis longus; ECRL, extensor carpi radialis longus.

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Clinical Relevance

However, many of these injuries have a mixed or complex trauma mechanism, as well as other ligament injuries not observed on the X-ray exam. The clinical relevance of the present article lies in the identification of occult lesions (perilunate injuries, not displaced, PLINDs)[13] associated with distal radius fractures, in which the fixation of the bone-ligament fragments is not sufficient to maintain the stabilization of the wrist joint, and in the proposal of a new classification and appropriate and specific treatment for these injuries.


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Methods

In total, 150 patients with articular DRFs were selected as subjects in the present study, which was conducted at Centro Hospitalar Municipal de Santo André (CHMSA), in the city of Santo André, Brazil. The patients were diagnosed, treated, and subjected to clinical follow-up ([Figs. 6] and [7]). The surgical procedures used included[1] temporary fixation of the joint fragments with Kirschner wires, or procedures associated with a volar or dorsal plate under fluoroscopic control;[2] arthroscopic fine adjustment of the reduction (we mainly use radiocarpal portals 3–4 and 6-R);[3] rigid fixation of the joint fragments with screws, under arthroscopic guidance;[4] and exploration of the radiocarpal, scapholunate, lunotriquetral ligament complex, and of the triangular fibrocartilage complex (radio carpal portals 3–4, 6-R, and central volar).[14] Following the arthroscopic identification of the lesions, we started with the stabilization of the radius fracture:

Zoom Image
Fig. 6 Complete arthroscopy classification of distal radius fractures (Aita et al.).
Zoom Image
Fig. 7 Algorithm for the steps of the treatment for distal radius fractures (Aita et al.).
  • 1) rigid fixation with the volar locking plates (extra-articular fragments);[15] 2) arthroscopic control of the joint reduction.

In avulsion-fractures (bone ligament fragments), cannulated headless compression screws (HCSs) and Kirschner wires, or specific fragment-type hook plates, were used ([Fig. 8]). Compression-type fractures ([Figs. 9],[10],[11]) cannulated HCSs, Kirschner wires, blocked intramedullary nail (Micronail, Wright Medical Memphis, TN, US), or a graft (autologous or synthetic) were used to fill the bone gap that appeared following fracture reduction.

Zoom Image
Fig. 8 Pre- and postoperative radiographic aspects: fracture-dislocation radiocarpal-avulsion of the radial styloid process by the radioscaphocapitate (RSC) ligament – surgical treatment with headless compression screw (HCS, Synthes, Solothurn, Switzerland) and reconstruction of the RSC ligament |1A with InternalBrace and mini pushlock anchor (Arthrex, Inc., Naples, FL, US), assisted by arthroscopy.
Zoom Image
Fig. 9 Pre- and postoperative radiographic aspects: articular compression fracture of the distal end of the radius and avulsion styloid process of the ulna by the triangular fibrocartilage (TFC) ligament – surgical treatment with intramedullary nail Micronail (Wright Medical Technology, Orlando, FL, US) and Micro Acutrak (Acumed, Hillsboro, OR, US) compression screw.
Zoom Image
Fig. 10 Pre- and intraoperative aspects: Essex-Lopresti lesion associated with articular DRF – surgical treatment assisted by arthroscopy.
Zoom Image
Fig. 11 Pre- and intra operative aspects: (A,B) fracture of the distal radius articular complex associated with scaphoid fracture and scapholunate ligament lesion – surgical treatment assisted by arthroscopy; (C,D) a minimally-invasive volar plate/HCS fixation (E,F). Post-operative radiographic and clinical aspects (G,H).

The ideal approach and type of implant: regarding the large number of implants available on the market, it is important to consider which type would be the most suitable to stabilize a specific fracture type, with regard to economic considerations, and not every fracture type necessarily requires the most expensive treatment.[5]

The first step was to determine the correct approach and use it to assess the subsequent measures necessary to prevent secondary dislocation of the carpus (to check ligament lesions associated the bone-ligament fragments). This seems to be more important than a perfect reduction. Specific fragments of the plates did not compromise the flexor tendons; however, they offered only limited possibilities to grasp and stabilize the very distal fracture elements. For the treatment of single fragments, cannulated self-tapping screws are becoming increasingly popular, and the minimally-invasive arthroscopy-assisted methods, in our opinion, were state-of-art, with the plate or nail or screw as the best solution.

  • 3) Approach to associated ligament injuries

    • a) Reparable:

      • - thermal shrinkage[16] or thermal shortening (by radiofrequency) of the ligament fibers;

      • - direct suture[17] (with or without anchors; InternalBrace, Arthrex, Inc., Naples, FL, US) ([Figs. 12],[13], and [14]);

      • - indirect suture[18] (with or without anchors; InternalBrace)( [Fig. 15] and [Video 1]);

      • - reinsertion[19] (with or without anchors / InternalBrace) [Fig. 16]);

      • - dorsal or palmar capsulodesis[20] [21] (with or without anchors; InternalBrace) ([Figs. 17],[18], and [Video 1]).

    • b) Irreparable:

      • - arthroscopic debridement of the joint extension (removing scar or pulvinar fibrosis)[22] ([Video 2]);

      • - reconstruction: graft, bone tunnels, augmentation[23] [24] [25] [26] ([Fig. 10] and [Videos 3],[4]);

      • - transarticular stabilization if necessary.


Quality:

Quality:

Quality:

Quality:
Zoom Image
Fig. 12 Intraoperative aspects: InternalBrace in brachioradialis tendon graft.
Zoom Image
Fig. 13 Intraoperative and second-look images – knee arthroscopy: ligamentization.[25]
Zoom Image
Fig. 14 (A,B) Direct repair with anchor through the scapholunate ligament (SLL), with the sutures tied and uncut. (C,D) The arthroscope is in the 6R portal. Complete repair of the SLL tear is shown in a left wrist.[18]
Zoom Image
Fig. 15 Schematic procedure for SLL indirect repair (InternalBrace): All arthroscopy and intraoperative fluoroscopy procedures showed bone tunnels and the DRF treated with dorsal hook plate for fixation of the ulnar dorsal lip and two HCSs for radial/ulnar styloid fractures.
Zoom Image
Fig.16 Foveal reinsertion of the triangular fibrocartilage complex (TFCC) with anchor.[20]
Zoom Image
Fig. 17 Schematic SLL indirect repair (InternalBrace) associated with wrist dorsal capsulodesis: scapholunate axis method[19] and procedure by Mathoulin et al.[21]
Zoom Image
Fig. 18 Wrist palmar capsulodesis – scapholunate lesion (volar portion)[22] L, lunate; LRL, long radiolunate; S, scaphoid.

Postoperative Period

The rehabilitation protocol included the use of static orthosis in the first two weeks, with exercises of proprioception and the “dart throw movie” for the wrist, elbow flexion, and fingers since the first day after surgery.[27] Active kinesiotherapy exercises and dynamic orthoses, assisted by physiotherapy or occupational therapy professionals, were used from the third week onwards. The retrn to work or sports activities was faster than with the conventional surgical approach. This assessment must be individualized, associated with trauma, applied as a surgical technique, and dependent on the profession or sports-related function of each patient. The study participants were encouraged to perform activities that avoided overload or changes in function.


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Results

The idea of improving the diagnosis with the inclusion of arthroscopy in the treatment of these injuries also establishes a greater precision in the choice of the treatment method, and that is how we obtained the results herein described.

The objective and patient-reported outcomes are shown in [Table 1]. The mean ROM was of 94.80% on the non-affected side. The mean score on the QuickDASH was of 3.6 (range: 1 to 12). The mean score on the VAS was of 1.66 (range: (1 to 3). There were complications in 2 (13.33%) of the patients, including extensor tendon synovitis in 1 patient, and a limitation in ROM (stiffness) in the other patient; both were treated with wrist arthroscopy release. The mean time until the return to work was of 6.4 weeks. The present study describes the intraoperative arthroscopic findings, a new classification ([Fig. 6]), the treatment algorithm used ([Fig. 7], [Tables 2],[3]), and the clinical and functional results of the patients ([Table 1]).

Table 1

Age

Gender

Trauma/injury

VAS

QuickDASH

Grip strength

(% opposite side)

ROM

(% opposite side)

Return to work (weeks)

Complications

17

F

Sports (capoeira)

1

1

97

100

6

————

56

F

Car accident

1

5

95

100

4

————

24

M

Car iaccident

1

1

98

100

4

————

35

F

Fall from skate

1

1

97

100

6

————

43

M

Fall from motorcycle

2

5

89

88

8

————

51

F

Fall from ladder

2

5

91

93

8

————

42

M

Fall from 3 meters

3

5

88

86

8

————

43

M

Fall during soccer

3

12

97

100

2

Synovitis extensor tendons (EDC)

28

M

Fall from motorcycle

2

5

89

86

8

————

25

M

Fall from motorcycle

1

1

99

100

6

Stiffness (new arthroscopy release)

31

M

Fall from 2.5 meters

1

1

100

100

6

————

28

M

Fall from motorcycle

2

5

97

91

6

————

26

M

Fall from 4 meters

2

5

93

90

10

————

50

F

Skiing accident

1

1

95

99

6

————

56

F

Fall from ladder

2

1

88

89

8

————

Table 2

Fracture type

Bone ligament fragment

Associated lesion

Surgical strategy

Compression

Scaphoid fossa

SL

Nail/HCS + graft + SLAM + capsulodesis (see [video 1])

Compression

Central

SL/LT

Nail or HCS + graft + SLAM + capsulodesis (SL/LT)

Compression

Lunate fossa

SL/LT

Nail or HCS + graft + SLAM + capsulodesis (SL/LT)

Avulsion

Radial styloid

RSC/RL

HCS or lateral plate + RSC repair or reconstruction

Avulsion

Ulnar styloid

TFCC

HCS and/or TFCC repair/reconstruction

Avulsion

Radial dorsal lip

RT/capsule

Hook plates/anchors + dorsal capsulodesis + InternalBrace

Avulsion

Radial palmar lip

RL/capsule

Hook plates/anchors + capsulodesis + InternalBrace

Avulsion

Ulnar dorsal lip

SL/capsule

Hook plates/anchors + SLAM + capsulodesis

Avulsion

Ulnar volar lip

UC/capsule

Hook plates/anchors + capsulodesis + InternalBrace

Combined

Radial and ulnar styloid

SL/LT/TFCC

HCS + SLAM + capsulodesis (SL/LT) + TFCC repair or reconstruction

Combined

Radial styloid and ulnar dorsal lip

SL/TFCC/capsule

HCS or lateral plate + TFCC repair or reconstruction

Combined

Articular complex/radial head

TFCC/DIOM

Radial head plate/volar plate/DIOM reconstruction (see [video 3])

Table 3

Age

Gender

Trauma injury

Fracture type

Occupation

Bone ligament fragment

Associated lesion

Surgical strategy

17

F

Sports (capoeira)

Compression

Student

Radioulnar lip

SL/TFCC

Volar plate + SLAM + capsulodesis

56

F

Car accident

Avulsion

Hair stylist

Radial styloid

SL/TFCC

HCS + SL thermal shinrkage + TFCC repair

24

M

Car iaccident

Combined

Engineer

Radial/ulnar styloid + dorsal ulnar radio lip

SL/TFCC/dorsal capsule

HCS + dorsal ulnar hook plate + SLAM + capsulodesis + TFCC repair

35

F

Fall from skate

Compression

Salesperson

Lunate fossa + ulnar styloid

LT/TFCC

Micronail + HCS + LT thermal shrinkage + TFCC repair

43

M

Fall from motorcycle

Avulsion

Engineer

Radial styloid+ radiocarpal dislocation + ulnar translation

RSC/RL/CTS

HCS+ RSC/RL reconstruction + CTS decompression

51

F

Fall from ladder

Compression

Lawyer

Articular complex

TFCC + radial head + unstable DRUJ

Kirschner wire + volar plate + radial head prosthesis + IOM reconstruction

42

M

Fall from 3 meters

Compression

Bricklayer

Lunate fossa

TFCC/radial head/IOM

HCS in DRF + radial head + IOM reconstruction

43

M

Fall during soccer

Avulsion

Salesperson

Radial styloid

SL

HCS + SLAM + capsulodesis

28

M

Fall from motorcycle

Avulsion

Salesperson

Radial styloid

RSC/RL/TFCC/CTS

HCS +TFCC reinsertion

25

M

Fall from motorcycle

Combined

Designer

Radial and ulnar styloid + ulnar lip

SL/capsule/TFCC

Volar plate + volar casulodesis + SL shrinkage + TFCC repair + dynamic external fixation

31

M

Fall from 2.5 meters

Compression

triathlete

Radial fossa

SL

Micronail + SL thermal shrinkage

28

M

Fall from motorcycle

Combined

Engineer

Radial/ulnar styloid + ulnar dorsal lip

RL/TFCC

HCS + ulnar hook plate + radial head plate/RL shrinkage + TFCC repair

26

M

Fall from 4 meters

Compression

Bricklayer

Lunate fossa + ulnar styloid

UC/capsule

Volar hook plate/TFCC reinsertion

50

F

Skiing accident

Avulsion

Dentist

Volar lip

RL/capsule

Volar hook plate/capsulodesis

56

F

Fall from ladder

Compression

Lawyer

Articular complex

Scaphoid fracture/SL

Volar plate + HCS + SL thermal shrinkage


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Discussion

Scientific studies[10] claim that the lack of anatomical restoration and on-going osteoarthritis might be associated with the clinical outcome after DRFs. Contrary to this belief, the reduction assisted by arthroscopy in DRFs could be conducted simply and with minimal consumption of resources in the operating room. The proposed technique combines the benefits of rigid fixation with volar locking plates (for the extra-articular component), arthroscopic reduction control, and associated ligament injuries (for the articular component). It is important that the operation is performed using the dry arthroscopic technique.[15] Perilunate injuries, not displaced,[13] were recently described, and we proposed a new arthroscopic classification for articular DRFs associated with PLINDs.

In the last three years, a new treatment (repair) for ligament injuries, using InternalBrace as an augmentation, has been developed ([Fig. 12]). This treatment enabled a new focus on the restoration of the normal anatomy and function of the traumatized joint. It supports the early mobilization of the repaired ligament and enables the natural tissues to be strengthened and recover progressively with minimal surgical morbidity. Reconstruction only should be indicated if the tissues did not heal properly after augmentation and ligament repair.[24]

These injuries were also treated with ligament reconstruction with a tendon graft (non-vascularized tissue) and bone tunnels, and this graft, which was termed ligamentization ([Fig. 13]), enabled the clinical and functional recovery of the joint.[25] [26] The rehabilitation protocol included the use of static orthosis in the first two weeks, with proprioception and “dart-throwing motion” exercises since the first day after surgery.[27] Around the third week, active kinesiotherapy exercises were started, and dynamic orthoses were also used.

The Advantages of Using Wrist Arthroscopy are:

  • - Preservation of the mechanisms of proprioception on the wrist (dorsal capsule);[28]

  • - accurate diagnosis of associated injuries;

  • - it favors more anatomical ligament repairs and reconstruction;[29] and

  • - it enables direct visualization of the reduction of the articular surface.


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The Disadvantages are:

  • - Higher cost;

  • - long learning curve; and

  • - greater difficulty in the integration of fluoroscopy and arthroscopy.

Sufficient stability, joint congruence, and anatomical reduction of the fractures remain the main goals of the treatment. The best result appeared when early joint mobility was allowed, and the patients were allowed to return to their personal and professional activities. Minimally-invasive techniques, guided by arthroscopy, were the most advantageous way to assist these patients.

The proper treatment of DRFs often involved bone-ligament fragments (avulsion), ligament injuries in other sites, and, radiocarpal or intercarpal instability (PLIND) in the patients. Here, the role of arthroscopy was essential for the diagnosis and treatment of these injuries. The present study suggested techniques for anatomical and biological ligament reconstruction and repair. We were able to observe in these patients stable and congruent wrist joints, absence of osteolysis in the bone tunnels, and signs of posttraumatic osteoarthritis. The clinical results and rate of complications in the present study showed the most favorable results compared with the other techniques.[10] The mean ROM was of 94.80% on the non-affected side. The mean score on the QuickDASH was of 3.6 (range: 1 to 12). The mean score on the VAS was of 1.66 (1 to 3). Complications were observed in 2 (13.33%) patients: extensor tendon synovitis in 1 patient, and a limitation in ROM (Stiffness) in another patient; both were treated with wrist arthroscopy release. The mean time until the return to work was of 6.4 weeks.


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Author Recommendations

Many authors have used arthroscopy for the treatment of joint fractures; therefore, the tips and ideas have increased in the existing literature.[6] [14] [15] Furthermore, new classifications have appeared, and the procedure becomes increasingly reproducible. The authors would like to stress the importance of university courses with a cadaver laboratory, on going publications, and exchanges of information with colleagues from Europe (Spain, France, Italy), the United States, and Latin America (Brazil, Argentina, Chile, Mexico, and Colombia). Information regarding new treatments for acute articular fractures of the upper limb are lacking, and new studies are required in the future. Most of the available articles were heterogeneous, such as case reports.[18] [19] [21] [23] [24] All of the articles either found or emphasized the role of arthroscopy as the exam/tool that leads to the most favorable diagnoses of fractures and associated injuries. In the treatment of these fractures, reduction guided by arthroscopy was associated with percutaneous fixation, and had sufficient stability to enable immediate mobility. This procedure imparted advantages to the conventional methods of open reduction, primarily by what was involved in the concept of biomechanics and proprioception, as well as the accuracy of joint reduction and respect for the minimal aggression to adjacent tissues.

This surgery required substantial arthroscopic education for the most complicated cases; however, it was easily performed in simple cases. The paradox was that the cases that benefited the most from arthroscopy were the most complex.[16]


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Conclusion

Basic understanding of the essential biomechanic characteristics in DRFs appeared crucial to maintaining the wrist proprioception and achieve sufficient stabilization of the bone ligament fragments and the associated ligament lesions, thereby avoiding secondary dislocation. The present paper provided a management-oriented concept for the diagnosis and treatment of the ligament lesions associated with the stabilization of intra-articular DRFs based on an arthroscopy-assisted procedure through a new classification shown here.

In the treatment of patients with unstable intra-articular DRFs associated with ligament lesions, the ligaments were either repaired or reconstructed, and the fixation of specific bone-ligament fragments was performed through wrist arthroscopy, which proved to be a safe and reliable treatment. Ultimately, the clinical and functional results predicted whether the patients could return to work.


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Conflict of Interests

The authors have no conflict of interests to declare.


Address for correspondence

Marcio Aurelio Aita, PhD
Faculdade de Medicina do ABC
Santo André, São Paulo, SP
Brazil   

Publication History

Received: 19 August 2020

Accepted: 04 February 2021

Publication Date:
02 July 2021 (online)

© 2021. SECMA Foundation. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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Zoom Image
Fig. 1 Perfect relationship between carpal bones and ligaments.
Zoom Image
Fig. 2 The dorsal v-ligaments are on the dorsal aspect of the wrist, and the two proximal and distal v-ligaments are situated on the palmar aspect of the wrist, and they keep the carpus in position.
Zoom Image
Fig. 3 In partial intra-articular fractures, six different patterns can be observed. At least one corner remains intact and in continuity with the shaft (A). The origins of the extrinsic ligaments are shown, which seem to reinforce the bone (B).[6]
Zoom Image
Fig. 4 Three groups of ligaments play a specific role in the primary stabilization of the axially-loaded carpus. (A) The helical antipronation ligaments become simultaneously taut (yellow arrows) when the distal row is torqued in pronation (curved white arrow). (B) The medial helical antisupination ligaments (HASLs) resist (yellow arrows) the tendency of the ulnar-side bones to translocate palmarly (curved white arrow). (C) The lateral HASLs become particularly active (yellow straight arrow) when the distal row is forced into supination (curved white arrow).[12]
Zoom Image
Fig. 5 Schematic design to understand the proprioception of the wrist - neuromuscular control. APL, abductor pollicis longus; ECRL, extensor carpi radialis longus.
Zoom Image
Fig. 1 Relación perfecta entre los ligamentos y la articulación radiocarpiana.
Zoom Image
Fig. 2 Los ligamentos V dorsales están en la cara dorsal de la muñeca, y los dos ligamentos V proximales y distales están situados en la cara palmar de la muñeca, y mantienen el carpo en posición.
Zoom Image
Fig. 3 En las fracturas intraarticulares parciales, se pueden observar seis patrones diferentes. Al menos un eje permanece intacto y en continuidad con la diáfisis (A). Se muestran los orígenes de los ligamentos extrínsecos, que parecen reforzar el hueso (B).[6]
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Fig. 4 Tres grupos de ligamentos tienen un papel específico en la estabilización primaria del carpo cargado axialmente. (A) Los ligamentos helicoidales antipronación se tensan simultáneamente (flechas amarillas) cuando se gira la fila distal en pronación (flecha blanca curva). (B) Los ligamentos helicoidales antisupinación (LHAS) mediales resisten (flechas amarillas) la tendencia de los huesos del lado cubital a translocarse palmarmente (flecha blanca curva). (C) Los LHASs laterales se vuelven particularmente activos (flecha amarilla recta) cuando la fila distal se fuerza a la supinación (flecha blanca curva).[12]
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Fig. 5 Diseño esquemático para comprender la propiocepción de la muñeca: control neuromuscular. APL, abductor pollicis longus; ECRL, extensor carpi radialis longus.
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Fig. 6 Complete arthroscopy classification of distal radius fractures (Aita et al.).
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Fig. 7 Algorithm for the steps of the treatment for distal radius fractures (Aita et al.).
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Fig. 8 Pre- and postoperative radiographic aspects: fracture-dislocation radiocarpal-avulsion of the radial styloid process by the radioscaphocapitate (RSC) ligament – surgical treatment with headless compression screw (HCS, Synthes, Solothurn, Switzerland) and reconstruction of the RSC ligament |1A with InternalBrace and mini pushlock anchor (Arthrex, Inc., Naples, FL, US), assisted by arthroscopy.
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Fig. 9 Pre- and postoperative radiographic aspects: articular compression fracture of the distal end of the radius and avulsion styloid process of the ulna by the triangular fibrocartilage (TFC) ligament – surgical treatment with intramedullary nail Micronail (Wright Medical Technology, Orlando, FL, US) and Micro Acutrak (Acumed, Hillsboro, OR, US) compression screw.
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Fig. 10 Pre- and intraoperative aspects: Essex-Lopresti lesion associated with articular DRF – surgical treatment assisted by arthroscopy.
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Fig. 11 Pre- and intra operative aspects: (A,B) fracture of the distal radius articular complex associated with scaphoid fracture and scapholunate ligament lesion – surgical treatment assisted by arthroscopy; (C,D) a minimally-invasive volar plate/HCS fixation (E,F). Post-operative radiographic and clinical aspects (G,H).
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Fig. 12 Intraoperative aspects: InternalBrace in brachioradialis tendon graft.
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Fig. 13 Intraoperative and second-look images – knee arthroscopy: ligamentization.[25]
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Fig. 14 (A,B) Direct repair with anchor through the scapholunate ligament (SLL), with the sutures tied and uncut. (C,D) The arthroscope is in the 6R portal. Complete repair of the SLL tear is shown in a left wrist.[18]
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Fig. 15 Schematic procedure for SLL indirect repair (InternalBrace): All arthroscopy and intraoperative fluoroscopy procedures showed bone tunnels and the DRF treated with dorsal hook plate for fixation of the ulnar dorsal lip and two HCSs for radial/ulnar styloid fractures.
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Fig.16 Foveal reinsertion of the triangular fibrocartilage complex (TFCC) with anchor.[20]
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Fig. 17 Schematic SLL indirect repair (InternalBrace) associated with wrist dorsal capsulodesis: scapholunate axis method[19] and procedure by Mathoulin et al.[21]
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Fig. 18 Wrist palmar capsulodesis – scapholunate lesion (volar portion)[22] L, lunate; LRL, long radiolunate; S, scaphoid.
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Fig. 6 Clasificación completa de artroscopia en fracturas del radio distal (Aita et al.).
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Fig. 7 Algoritmo de etapas de tratamiento para fracturas del radio distal (Aita et al.).
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Fig. 8 Aspectos radiográficos pre y postoperatorios: fractura-luxación radiocarpiana-avulsión de la apófisis del estiloides radial por el ligamento radioescafocapitado (RSC) – tratamiento quirúrgico con tornillo de compresión sin cabeza (Synthes, Solothurn, Suiza) y reconstrucción ligamentaria del ligamento RSC | 1A con InternalBrace y ancla mini pushlock (Arthrex, Inc., Naples, FL, EEUU), asistida por artroscopia.
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Fig. 9 Aspectos radiográficos pre y postoperatorios: Frfctura de compresión articular del extremo distal de la radio y avulsión de la apófisis del estiloides del cúbito por el ligamento fibrocartílago triangular (FCT) – tratamiento quirúrgico con clavo intramedular Micronail (Wright Medical Technology, Orlando, FL, EEUU) tornillo de compresión Micro Acutrak (Acumed, Hillsboro, OR, EEUU).
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Fig. 10 Aspectos pre e intraoperatorios: lesión de Essex-Lopresti asociada a FRD articular – tratamiento quirúrgico asistido por artroscopia.
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Fig. 11 Aspectos pre e intraoperatorios: (A,B) fractura del complejo articular del radio distal asociada a fractura de escafoides y lesión del ligamento escafolunar – tratamiento quirúrgico asistido por artroscopia (C,D); placa volar mínimamente invasiva; fijación con tornillos de compresión sin cabeza (E,F). Aspectos radiográficos y clínicos pós operatórios (G,H).
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Fig. 12 Aspectos intraoperatorios: InternalBrace en injerto de tendón braquiorradial.
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Fig. 13 Imágenes intraoperatoria y de segunda mirada – artroscopia de rodilla: ligamentización.[25]
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Fig. 14 (A,B) Reparación directa con ancla a través del ligamento escafolunar (LEL), con las suturas atadas y sin cortar. (C,D) El artroscopio está en el portal 6R. La reparación completa del desgarro del LEL se muestra en una muñeca izquierda.[18]
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Fig. 15 Esquema de procedimiento para reparación indirecta del LEL (InternalBrace): todos los procedimientos de artroscopia y fluoroscopia intraoperatoria mostraron túneles óseos y FRD tratada con placa de gancho dorsal para fijación del labio dorsal cubital y dos tornillos de compresíón sin cabeza para fracturas del estiloides radial/cubital.
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Fig. 16 Reinserción foveal del FCT con ancla.[20]
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Fig. 17 Esquema de reparación indirecta del LEL (InternalBrace) asociado a capsulodesis dorsal de muñeca: método del eje escafolunar[19] y procedimiento de Mathoulin et al.[21]
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Fig. 18 Capsulodesis palmar de muñeca: lesión escafolunar (porción volar)[22] L, lunate; LRL, long radiolunate; S, scaphoid.