Journal List > J Korean Orthop Assoc > v.48(2) > 1013218

Gong, Bae, and Baek: Intra-Articular Injury Associated with Distal Radius Fracture

Abstract

Distal radius fractures are commonly associated with intra-articular injuries such as carpal ligament injuries and triangular fibrocartilage complex (TFCC) injuries. Such injuries occurring in elderly patients with a low-energy distal radius fracture can be treated successfully with cast immobilization and do not usually lead to clinical problems. However, despite healing of the fracture, some intra-articular injuries, especially in active patients with a high-energy fracture, can result in persistent pain and disability. In addition, the current trend of internal fixation and early use of the wrist may actually increase instability due to inadequate healing of the ligament injuries. Due to a lack of typical symptoms and physical findings in acute fracture settings, detection of these injuries is not easy. Arthroscopic examination, as well as radiographs and intraoperative fluoroscopic findings, are useful in detection of carpal ligament injuries. Complete ruptures of intercarpal interosseous ligaments warrant temporary interosseous fixation using K-wires. In TFCC injuries, distal radioulnar joint (DRUJ) instability should be assessed after anatomical reduction and fixation of a distal radius fracture. Operative treatments such as open or arthroscopic repair of TFCC to the fovea can guarantee greater stability of the DRUJ. For optimal results, early detection and appropriate treatment of intra-articular injuries associated with distal radius fractures is critical.

Figures and Tables

Figure 1
Scapho-lunate interosseous ligament injury associated with a distal radius fracture. (A) The initial radiograph showed an increase in the scapho-lunate distance. (B) The post-reduction radiograph showed a manually reduced radius fracture, which was immobilized with a cast. (C) Radiograph taken three weeks later showed scapho-lunate dissociation and displacement of the radial styloid fragment. Due to the lack of early treatment, open reduction of the fracture and repair of the dorsal interosseous ligament was necessary. (D) One year after open repair of the dorsal interosseous ligament and dorsal plate fixation of the radius, a normal scapho-lunate gap was observed, although the scaphoid appeared to be flexed.
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Figure 2
Triangular fibrocartilage complex injury associated with a distal radius fracture. (A) The preoperative radiograph showed an intra-articular comminuted fracture of the distal radius and an ulnar styloid tip fracture. Intraoperative stress testing after fixing the radius revealed increased instability of the distal radioulnar joint, compared with the normal side. (B) Through the ulnar approach protecting the dorsal cutaneous branch of the ulnar nerve, the distal radioulnar ligament insertion that avulsed from the fovea was exposed (asterisk). (C) After trans-osseous repair of the radioulnar ligament to the fovea using pull-out sutures, the distal radioulnar joint stability was immediately recovered.
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References

1. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996. 78:357–365.
crossref
2. Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am. 1997. 22:772–776.
crossref
3. Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients. J Hand Surg Br. 1997. 22:638–643.
4. Pechlaner S, Kathrein A, Gabl M, et al. Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism. Handchir Mikrochir Plast Chir. 2002. 34:150–157.
5. Smith DW, Henry MH. Comprehensive management of soft-tissue injuries associated with distal radius fractures. J Am Soc Surg Hand. 2002. 2:153–164.
crossref
6. Leversedge FJ, Srinivasan RC. Management of soft-tissue injuries in distal radius fractures. Hand Clin. 2012. 28:225–233.
crossref
7. Geissler WB, Fernandez DL, Lamey DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clin Orthop Relat Res. 1996. 327:135–146.
crossref
8. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am. 2000. 25:464–468.
crossref
9. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000. 376:229–235.
crossref
10. Lindau T, Runnquist K, Aspenberg P. Patients with laxity of the distal radioulnar joint after distal radial fractures have impaired function, but no loss of strength. Acta Orthop Scand. 2002. 73:151–156.
crossref
11. Berger RA, Imeada T, Berglund L, An KN. Constraint and material properties of the subregions of the scapholunate interosseous ligament. J Hand Surg Am. 1999. 24:953–962.
crossref
12. Ritt MJ, Bishop AT, Berger RA, Linscheid RL, Berglund LJ, An KN. Lunotriquetral ligament properties: a comparison of three anatomic subregions. J Hand Surg Am. 1998. 23:425–431.
crossref
13. Kwon BC, Baek GH. Fluoroscopic diagnosis of scapholunate interosseous ligament injuries in distal radius fractures. Clin Orthop Relat Res. 2008. 466:969–976.
crossref
14. Kwon BC, Choi SJ, Song SY, Baek SH, Baek GH. Modified carpal stretch test as a screening test for detection of scapholunate interosseous ligament injuries associated with distal radial fractures. J Bone Joint Surg Am. 2011. 93:855–862.
crossref
15. Forward DP, Lindau TR, Melsom DS. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg Am. 2007. 89:2334–2340.
crossref
16. Cooney WP, Dobyns JH, Linscheid RL. Arthroscopy of the wrist: anatomy and classification of carpal instability. Arthroscopy. 1990. 6:133–140.
crossref
17. Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg Am. 1996. 78:348–356.
crossref
18. Tang JB, Shi D, Gu YQ, Zhang QG. Can cast immobilization successfully treat scapholunate dissociation associated with distal radius fractures? J Hand Surg Am. 1996. 21:583–590.
crossref
19. Stoffelen D, De Mulder K, Broos P. The clinical importance of carpal instabilities following distal radial fractures. J Hand Surg Br. 1998. 23:512–516.
crossref
20. Laulan J, Bismuth JP. Intracarpal ligamentous lesions associated with fractures of the distal radius: outcome at one year. A prospective study of 95 cases. Acta Orthop Belg. 1999. 65:418–423.
21. Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. Injury. 2002. 33:499–502.
crossref
22. Wiesler ER, Chloros GD, Mahirogullari M, Kuzma GR. Arthroscopic management of distal radius fractures. J Hand Surg Am. 2006. 31:1516–1526.
crossref
23. Peicha G, Seibert F, Fellinger M, Grechenig W. Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures. Knee Surg Sports Traumatol Arthrosc. 1999. 7:327–333.
crossref
24. Shih JT, Lee HM, Hou YT, Tan CM. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue management of distal radius. Hand Surg. 2001. 6:127–135.
crossref
25. Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg Am. 1993. 18:492–498.
crossref
26. Kihara H, Palmer AK, Werner FW, Short WH, Fortino MD. The effect of dorsally angulated distal radius fractures on distal radioulnar joint congruency and forearm rotation. J Hand Surg Am. 1996. 21:40–47.
crossref
27. Kwon BC, Seo BK, Im HJ, Baek GH. Clinical and radiographic factors associated with distal radioulnar joint instability in distal radius fractures. Clin Orthop Relat Res. 2012. 470:3171–3179.
crossref
28. Fujitani R, Omokawa S, Akahane M, Iida A, Ono H, Tanaka Y. Predictors of distal radioulnar joint instability in distal radius fractures. J Hand Surg Am. 2011. 36:1919–1925.
crossref
29. Kim JP, Park MJ. Assessment of distal radioulnar joint instability after distal radius fracture: comparison of computed tomography and clinical examination results. J Hand Surg Am. 2008. 33:1486–1492.
crossref
30. Scheer JH, Hammerby S, Adolfsson LE. Radioulnar ratio in detection of distal radioulnar joint instability associated with acute distal radius fractures. J Hand Surg Eur Vol. 2010. 35:730–734.
crossref
31. Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol. 2009. 34:582–591.
crossref
32. Henry MH. Distal radius fractures: current concepts. J Hand Surg Am. 2008. 33:1215–1227.
crossref
33. Moritomo H. The distal interosseous membrane: current concepts in wrist anatomy and biomechanics. J Hand Surg Am. 2012. 37:1501–1507.
crossref
34. Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg. 2004. 8:116–123.
crossref
35. Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures. Arthroscopy. 2003. 19:511–516.
crossref
36. Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008. 12:226–235.
crossref
37. Iwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A. Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2- to 4-year follow-up study. Arthroscopy. 2011. 27:1371–1378.
crossref
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