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Arthroscopic assisted distal radius fracture fixation & TFCC management 2014

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Information about Arthroscopic assisted distal radius fracture fixation & TFCC management...
Health & Medicine

Published on March 7, 2014

Author: NickDarlis

Source: slideshare.net

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Guidelines on arthroscopic assisted distal radius fracture fixation & TFCC management. indications, treatment options
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Arthroscopically Assisted Distal Radius Fixation_TFCC management Nickolaos A. Darlis, MD, PhD To access this presentation on the web:

Arthroscopy cannot Reduce Immobilize or Promote healing “Thorough knowledge and facility with classic techniques of distal radius fracture treatment is essential for a good result” Del Piñal F, MD

…however Arthroscopy can optimize results

Indications in Distal Radius Fractures • Intrarticular (≈ 5-10% of all fx) • Some extrarticular (DRUJ or interosseous lig. injuries)

The “Miami Revolution”

Prognosis of distal radius fractures AAOS 2010 WORKGROUP RECOMENDATIONS • Shortening 3mm • Angulation >100 • Step-off • Ligamentous injuries Dorsal 2mm

Prognosis of distal radius fractures AAOS 2010 WORKGROUP RECOMENDATIONS • Shortening 3mm • Angulation >100 • Step-off • Ligamentous injuries Dorsal 2mm BEST CONTROLED WITH WRIST ARTHROSCOPY

Articular Reduction • Fluroscopic assessment of step-off, gap and rotation is difficult, arthroscopy is more accurate Catalano et al., 2004, Lutsky et al., 2008 • Accuracy of reduction does not predict final functional outcome or satisfaction in elderly, low demand patients Young & Rayan, 2000

Concomitant lesions • • • • ΤFCC ≈60% (43-78%) SL lig.≈ 40% (32-75%) LT lig. ≈20% (15-61%) Chondral lesions ≈20% (19-32%)

Concomitant lesions • “Most will heal by immobilization alone” but… • We know some will not • We aim at early mobilization

Set-up

Set-up • Alternative – Ex –fix first – Plate first

Arthroscopically assisted reduction • Currently indicated in selected injuries – Radial styloid Fx – Die Punch Fx – Three & Four part Fx – DRUJ instability or interosseous lig tear • No metaphyseal comminution • Especially in young, high demand patients

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

2. die punch

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

3. Three & Four part fractures

SL management GEISSLER-DAUTEL GRADING I II L I L S II III L S III IV C L S IV S

SL management • Debridement & Pinning

SL management • Thermal shrinkage & Pinning Darlis & Sotereanos, JHS(A), 2005

SL management • Open repair

TFCC - Ulnocarpal Impaction managment

TFCC 3-D structure Nakamoura T et al, 1996

The Hammoc paradigm Nakamoura T et al 1996

Volar & Dorsal RU lig.-Deep bundle

The Iceberg Concept Atzei &Lucetti 2011

Palmer Classification • Traumatic (Class 1) • Degenerative (Class 2)- associated with ulnocarpal impaction syndrome

Tear location Radial tear Central tear Peripheral tear) Deep bundle of TFCC Volar radioulnar lig. radius ulna

1. Central TFCC lesions • Poorly vascularized- healing potential minimal • Arthroscopic debridement up to 2/3 of articular disc

1. Central TFCC lesions • Debridement ± pinning

1. Central TFCC lesions • Debridement ± pinning Darlis & Sotereanos, JHS(A), 2006

1. Central TFCC lesions • Often degenerative and associated with ulnocarpal impaction syndrome • Ulnar recession procedure to prevent symptom recurrence

Ulnocarpal Impaction Syndrome Clinical features: • Ulnar sided wrist pain • Associated degenerative changes: – – – – Ulnar side of the lunate Radial side of the ulnar dome TFCC central tear Triquetrum- LunoTriquetrum lig. • Usually positive or neutral ulnar variance

Pronated Grip View Radiographs

MRI

Arthroscopic Wafer procedure • Preferred when modest shortening needed

Open Ulna Recession Procedures • Several options…

Open Ulna Recession Procedures Another approach: Keep it simple… • Step-Cut Ulnar Shortening Osteotomy Darlis& Sotereanos JHS(A), 2005

2. Radial TFCC tears • Repair or debridement?

2. Radial TFCC tears • Repair if: – VRUL or DRUL are involved – DRUJ instability

3. Peripheral (ulnar) TFCC tears • Well vascularized • Repairable

Usual location of peripheral tears Dorsal

Usual location of peripheral tears

3. Peripheral (ulnar) TFCC tears REPAIR TO CAPSULE TFCC OR REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REPAIR TO CAPSULE OR REATTACH TO FOVEA

3. Peripheral (ulnar) TFCC tears REPAIR TO CAPSULE TFCC

3. Peripheral (ulnar) TFCC tears REPAIR TO CAPSULE TFCC

TFCC management REATTACH TO FOVEA TFCC

TFCC management REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

3. Peripheral (ulnar) TFCC tears REATTACH TO FOVEA TFCC

Take Home Message _Fractures Arthroscopy can optimize results in: • Simple intrarticular fracture patterns amendable to pin (and /or ex fix) fixation (styloid, die punch) • Intrarticular or extrarticular fractures with high level of suspicion for ligamentous or TFCC injury • Young/ Active motivated patients

Take Home Message _ TFCC Arthroscopy has revolutionalized the way we understand and treat TFCC lesions: • Beware of ulnocarpal impaction in central tears • Suspect foveal detachment and treat it (arthro or open)

Whatever you do • Remenber Vit C for disproportionate pain • Reassess ligaments and TFCC status after fracture healing – Still window of opportunity 0 6 months ACUTE Good Healing Potential 3mo SUBACUTE Unpredictable 6mo 1 year CHRONIC Poor Healing Potential

Customize your approach There is no single tool for every distal radius fracture

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