**11. Arthroscopy in the treatment of articular distal radius fractures (DRF)**

Hand surgeons began applying wrist arthroscopy to the surgical treatment of the DRF in the late 90's of the last century. Arthroscopic reduction of intraarticular fragments, as opposed to conventional methods, may improve outcomes regardless of the method of fixation, volar locking plates or external fixator and K-wires [63–69]. Failure to reduce intra-articular fractures of the distal radius predisposes to pain, restricted movement and degenerative arthritis. The functional results of treatment for articular DRF's are determined by alignment of fragments of extraarticular fracture, by restoring bone shape, length and fold, anatomical reposition of joint surface, prevention of additional damage to soft tissue, as well as potential post-operative complications [70–74]. Fluoroscopy alone provides an image that has poorer resolution than that of the magnified camera used for direct arthroscopic visualization, whereas even a small degree of displacement is obvious arthroscopically [75]. It is obvious that optical visualization of the articular space gives an opportunity to detect a greater number of soft tissue lesions more often, than only fluoroscopic and clinical evaluation or surgeon's mistrust about the possibilities of such injuries [76]. Wrist arthroscopy is currently recommended for the treatment of any articular distal radius fracture (**Figure 32a,** and **b**), but some possible contraindications have been identified. As one of these are elderly and low-active patients, open fractures and polytrauma patients, particularly at the early stage of treatment, since this procedure can significantly increase the duration of surgery. As another major objection to the use of arthroscopic treatment, is a lack of technical equipment and surgeon's experience [64, 77, 78].

There are two controversial fracture fixation techniques. In cases of volar plating, standard flexor carpi radialis approach can be used. Once the fracture is preliminarily fixed with the volar locking plate (VLP) (**Figure 33**), the wrist joint is assessed arthroscopically using the 3-4 and 4-5, 6R, 6 U or 1-2 portals to remove blood clots, small articular fragments or to make an additional reposition and

**Figure 32.** *Dorsally displaced articular fracture of the distal radius.*

**Figure 33.** *Preliminary fixation of the volar plate before arthroscopic part of the surgery.*

fixation with K-wires. Distal screws can be inserted only after arthroscopic inspection of the radiocarpal joint and a fluoroscopic confirmation of the correct position for the screws (**Figures 34a, b** and **35a, b**).

After treatment includes 2 weeks in short plaster cast and early mobilization can be allowed as volar locking plate provides rigid fixation.

In cases of comminuted fractures when fixation with VLP is impossible, arthroscopically assisted fracture reposition and fixation with K-wires and external fixator is recommended (**Figures 36a**–**c** and **37a, b**). This surgery is commenced with a primary closed reduction and fixation with several K-wires, under

**Figure 34.** *Additional fragment reposition and fixation.*

fluoroscopic guidance. Following fixation in a traction tower, the articular surfaces are assessed using the standard arthroscopic technique. Further fragment reductions are performed, if required, using a probe or K-wires as joysticks through elongated 3-4, 4-5, 1-2 and in some cases, volar portals. Additional K-wire fixation is used as required. Once satisfactory reposition is achieved, the bridging external fixator can be applied. The external fixator is removed 4 weeks after surgery. K-wires are usually removed between 4 and 6 weeks after surgery.

The associated soft tissue lesions can be found from 30 to 66% of DRFs, but not all of them require surgical treatment [79–81]. In cases of associated soft tissue injuries like SLIL and LTIL acute ruptures or TFCC lesions, arthroscopically guided, debridement of the injured ligaments or TFCC is advised, as well as trans-articular

**Figure 36.**

*Position of the monolateral external fixator over the wrist joint. a and b - Comminuted volar, distal, articular fracture of the radius.*

fixation of the scapholunate and/or lunotriquetral joints with K-wires, or application of peripheral sutures for TFCC tears.

Authors have never experienced severe complications as tendon ruptures or infection but we have found that the more extensive use of K-wires in reduction and/or fixation during external fixation and K-wire fixation is more likely to result in nerve damage. Furthermore, the complication of subsequent loss of position of fragments also occurred in patients treated with K-wires and external fixator [81].

In last two decades several minimally invasive plate osteosynthesis (MIPO) techniques using volar locking plates on DRF are presented [82–84]. In cases of comminuted articular DRF's this technique can be supplemented with an arthroscopic visualization. After all, two major lines of MIPO techniques evolved and got new promoters: single longitudinal incision and double transverse incision, leading to the creation of new special volar plates setups adapted to each technique's pitfalls and benefits [85, 86]. Unfortunately authors do not have any personal experience with MIPO technique.

**Figure 37.** *Final x-ray after the application of external fixation and K-wires.*
