William B. Geissler

Intracarpal Soft-Tissue Lesions Associated with an Intra-Articular Fracture of the Distal End of the Radius*

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

Treatment of displaced articular fractures of the radius

Forty patients with articular fractures of the distal radius in which anatomic reduction of the joint surface could not be obtained by closed manipulation or by ligamentotaxis with external fixators had a combination of percutaneous and/or open reduction techniques to restore articular congruity. X-ray films taken after treatment with an average follow-up of 4 years showed satisfactory extraarticular alignment in 85% of the cases, and 37 (92.5%) patients demonstrated an articular step-off of 1 mm or less at late follow-up examination. Radiographic evidence of radiocarpal arthritis was present in 5% of the cases at follow-up examination.

Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist : A multicenter study

A multicenter study to assess arthroscopic reconstruction of the peripheral attachment of the triangular fibrocartilage complex was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Twenty-seven of the 45 wrists had associated injuries, including distal radius fracture (4), partial or complete rupture of the scapholunate (7), lunotriquetral (9), ulnocarpal (2), or radiocarpal (2) ligaments. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAC) wrist deformity. The peripheral tears were repaired using a zone-specific repair kit. The patients were immobilized in a munster cast, allowing elbow flexion and extension, but no pronation or supination for 4 weeks, followed by 2 to 4 weeks in a short arm cast or VersaWrist splint. All patients were reexamined independently 1 to 3 years postoperatively by a physician, therapist, and registered nurse. The results were graded according to the Mayo modified wrist score. Twenty-nine of the 45 wrists were rated excellent. 12 good, 1 fair, and 3 poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. One patient had chronic pain, and two patients had ulnar nerve symptoms, although motion was normal in all, and their grip strength was at least 75% of the opposite hand. Arthroscopic repair of peripheral tears of the triangular fibrocartilage complex (TFCC) is a satisfactory method of repairing these injuries.

Distal radioulnar joint injuries associated with fractures of the distal radius.

The most common cause of residual wrist disability after fractures of the distal radius is the distal radioulnar joint. The 3 basic conditions that produce radioulnar pain and limitation of forearm rotation are instability, joint incongruency, and ulnocarpal abutment. The last 2 entities initiate irreversible cartilage damage that eventually leads to degenerative joint disease. Early recognition and management in the acute stage aim at the anatomic reconstruction of the distal radioulnar joint including bone, joint surfaces, and ligaments in an effort to reduce the incidence of painful sequelae and functional deficit. This article provides a description and the treatment options of the distal radioulnar joint lesions that occur in association with fractures of the distal radius, and the results obtained with open and arthroscopic techniques. Both acute and chronic disorders are analyzed, and a prognostic and treatment oriented classification is presented. Furthermore, the pathoanatomy and management of chronic distal radioulnar joint derangement after fracture of the distal radius are reviewed briefly.

Intraarticular abnormalities in association with posterior cruciate ligament injuries

The effect of an isolated injury of the posterior cruciate ligament on the articular cartilage and menisci has not been extensively studied. Intraarticular abnormalities in 88 arthroscopically proven posterior cruciate ligament tears in symptomatic patients with straight unidirec tional posterior instability were reviewed. There were 33 patients with acute injuries (range, 3 to 21 days; mean, 14) and 55 patients with chronic tears (range, 28 to 3650 days; mean, 786). Of the acute injuries, chondral defects occurred in 4 patients (12%) and meniscal tears in 9 patients (27%; 6 lateral and 3 medial). Chondral defects of both the lateral femoral condyles and patella were present in all 4 patients. Of the chronic injuries, chondral defects occurred in 27 (49%) and meniscal tears in 20 patients (36%) (7 lateral and 17 medial). Chondral defects of the medial femoral condyle were most common. The mechanism of injury resulting in an isolated injury of the posterior cruciate ligament is most likely to affect the lateral compartment or the articular cartilage of the patella. The incidence of articular defects and the incidence of meniscal tears increased in patients with chronic posterior cruciate ligament injuries; both lesions increased most in the medial compartment.

Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach.

Background: Preliminary reports have indicated that selected scaphoid nonunions—i.e., those that are well aligned and without extensive sclerosis or bone resorption at the nonunion site—can be treated effectively with internal fixation alone. We examined the feasibility of percutaneous fixation in a series of such nonunions. Methods: A consecutive series of fifteen patients with fibrous union or nonunion of a carpal scaphoid fracture with minimal sclerosis or resorption at the nonunion site were treated with rigid fixation alone (without bone graft) with a headless compression screw inserted with a dorsal percutaneous technique. Results: Clinical examination, standard radiographs, and computed tomography scans confirmed union in all patients at an average of fourteen weeks. Nonunions treated less than six months after the injury healed faster than those treated later (p < 0.02). According to the Mayo modified wrist score, there were twelve excellent and three good results. Conclusions: The results in our series were due to careful examination and grading of the scaphoid nonunions preoperatively. The findings in this small series support the observation in earlier reports that percutaneous repair of selected scaphoid nonunions requires only rigid fixation to achieve healing.

Arthroscopically Assisted Reduction of Intraarticular Distal Radial Fractures

Anatomic restoration of the joint surface and extraarticular alignment is the goal in management of displaced distal radial fractures. Arthroscopy provides well lit, magnified conditions in which to reconstruct the fractured joint surface and to detect and manage intracarpal soft tissue injures associated with distal radial fractures. Percutaneous and limited open reduction techniques combined with wrist arthroscopy in the arthroscopically assisted management of displaced distal radial fractures is described.

Arthroscopic suture fixation of displaced tibial eminence fractures

The purpose of this article is to describe a technique for arthroscopic reduction and suture fixation of avulsion fractures of the tibial eminence involving the anterior cruciate ligament (ACL). Six patients (five type III, one type II) with tibial eminence fractures underwent arthroscopic evaluation when closed reduction after aspiration failed to yield an anatomic reduction. The study population was composed of five males and one female. Average age was 24 years (range 16-36). One fracture (type II) was easily reduced after manipulating the interposed anterior horn of the lateral meniscus. In five patients the fragment was stabilized with multiple sutures. The technique involved arthroscopic placement of multiple sutures of 2-0 polydioxanone suture (PDS) into the base of the ACL pulled through a tibia drill hole and tied onto a 4.5-mm screw post. Patients were placed in a standard postoperative ACL protocol. All fractures demonstrated radiographic healing by 8 weeks, and no patients had subjective complaints of instability at 1 year. All patients obtained full extension intraoperatively, and only one patient lost 2 degrees of terminal extension at latest follow-up. Arthroscopic reduction and suture fixation of avulsion fractures of the tibial eminence restores the length of the ACL, provides stable fixation promoting early motion with minimal morbidity, and does not require a second operation for metal removal.

Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. A headless cannulated compression screw (standard Acutrak) is implanted by way of a dorsal percutaneous approach with the aid of fluoroscopy and arthroscopy to confirm screw position and fracture reduction. This technique is indicated in the correction of acute proximal pole fractures, acute waist fractures, and delayed unions that are not associated with avascular necrosis or collapse. The details of this technique are reviewed. In a consecutive series of twenty-seven fractures (seventeen waist fractures and ten proximal pole fractures) treated with arthroscopically assisted dorsal percutaneous fixation, computed tomographic scanning confirmed 100% union at an average of twelve weeks. Eighteen fractures were treated within one month after the injury, and nine were treated more than one month after the injury. In this series, the fractures that were treated early (less than one month after the injury) healed more quickly than those treated later.

ARTHROSCOPIC MANAGEMENT OF WRIST TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES IN THE ATHLETE

Wrist arthroscopy can facilitate early definitive diagnosis of debilitating soft tissue injuries in athletes. Many such injuries can be treated successfully with minimally invasive arthroscopic techniques, reducing the morbidity associated with surgical exposure and permitting earlier return to competition. The triangular fibrocartilage complex (TFCC) is vulnerable to injury from rotational forces or axial load applied to the hand. Under arthroscopic control, injuries to the central articular disk can be treated by excision of unstable tissue fragments; peripheral separation of the disk from the dorsal or volar ligaments can be repaired with sutures to achieve complete healing. Avulsion fractures from the dorsal ulnar margin of the sigmoid notch of the radius are better treated through a small arthrotomy after initial arthroscopic evaluation.