Surgery of supra- and intra-articular wrist fractures
Specificities of supra- and intra-articular wrist fractures
Articular fractures of the distal radius are common; these wrist fractures can be associated with severe wrist lesions (severe sprain of the wrist) and put the patient at risk of early osteoarthritis if a careful anatomic reduction is not carried out.
For distal radius fractures, the case for arthroscopic wrist surgery is very strong. This demanding hand surgery should be performed by a specialist.
Video of wrist surgery for a fracture of the radius:
Wrist fracture diagnosis:
The following x-ray shows a markedly comminuted articular fracture of the distal radius viewed frontally and laterally with a forward avulsion of a joint fragment.
Arthroscopic wrist surgery technique:
This wrist surgery consists in performing a reduction-fixation of the fracture by means of an anterior locking plate. A 3-cm anterior incision in the wrist is necessary and once reduction is achieved, the fixation plate is positioned underneath the square pronator which doesn’t need to be incised.
Extra-articular reduction is then confirmed, first at fluoroscopy.
Once satisfactory reduction is achieved, the arthroscopic assessment of the lesions to the wrist joints can begin through the 3,4 optical radiocarpal portal.
Here the surgeon shows the bleeding inside the wrist joint caused by the fracture; the blood can be drained with a needle to clear up the articular fluid and improve visibility. Similarly, blood clots can be removed with a needle or shaver; lesion assessment can then begin.
The surgeon first verifies the quality of articular reduction, and then the integrity of the triangular fibrocartilage ligament (TFCC) and scapholunate ligament.
These arthroscopic views show a partial TFC tear related to the fracture line that ends in this area.
Scapholunate ligament integrity can be confirmed here.
Once the articular evaluation is complete, the 2-mm arthroscopic incisions are left to heal by secondary intention, the anterior surgical incision can then be closed with absorbable stitches.
This x-ray shows the post-operative result.
Recovery after arthroscopic surgery for wrist fracture
Wrist immobilization using a removable wrist splint will be necessary for 3 weeks, non-resistive wrist movements can resume at 3 weeks, forceful and resistive wrist movements can resume at 6 to 8 weeks.
Surgery of pure articular wrist fractures
Specificities of pure articular wrist fractures
With arthroscopic wrist surgery it is possible to treat some wrist fractures only arthroscopically, and to reduce and fix the fracture without having to open up the wrist. This applies to pure articular wrist fractures with no supra-articular fracture line; these wrist fractures are much less common however.
Video of arthroscopic wrist surgery for a pure articular fracture:
Wrist surgery for a pure articular fracture:
These pure articular wrist fractures do not require any fixation plate, unlike most wrist fractures.In these fractures, fixation is achieved by means of two screws under compression buried in the bone. These fractures are commonly associated with severe wrist sprains, which makes arthroscopic surgery particularly suitable both in the treatment and the diagnosis.
This wrist surgery is performed on an outpatient basis, with the hand numbed. The first stage of this wrist surgery consists in placing the hand under traction so that reduction is made easier, and opening the wrist’s articular space. Thanks to the wrist arthroscope (2 mm), the fracture in the wrist joint is instantly located. In this surgery, fracture reduction is favoured by using the radius as a prop and if necessary a provisional fixation K-wire. When reduction is deemed satisfactory after both arthoscopic and x-ray verification, permanent fixation can be performed. This is the second stage in this wrist surgery; the wrist fracture is fixed permanently using two screws under compression that are completely buried in the radius.
Once the fracture is fixed, the wrist surgeon explores the wrist’s radiocarpal joint, looks for any severe wrist sprains (intracarpal ligament lesions), which are commonly associated. A wrist dressing will be necessary for 10 days. Wrist immobilization will be necessary for one month.
Recovery after wrist surgery for a pure articular fracture
With this minimally invasive surgery, wrist recovery and hand recovery are made easier. The wrist fixation hardware can most of the time stay in place permanently. However, evolution is naturally slower for an articular wrist fracture than for a supra-articular wrist fracture. In some severe forms of articular wrist fractures associated with cartilage damage or a sprain of the scapholunate ligament, there will be permanent after-effects such as occasional stiffness or even pain in the wrist. In these severe forms there can be a rapid evolution toward wrist osteoarthritis. When wrist osteoarthritis occurs secondary to a wrist fracture, partial radiocarpal fusion (arthrodesis) wrist surgery can be discussed with the wrist surgeon. This wrist simplification procedure aimed at easing the pain can also be performed arthroscopically.