■            Following anatomic reduction of  the distal radius fracture, insert the arthroscope in the dorsal 3/4 portal and the probe in the 6R portal. Palpate the tension of the articular disc.

■       Good tension indicates that the majority of  the pe-

ripheral TFCC fibers are  intact or still attached to the proximal ulna.

■       A  peripheral tear  of   the  articular disc  is  repaired

arthroscopically when detected.21

■            Stabilization of  a large ulnar styloid fragment is considered when the articular disc  is lax  by  palpation and no peripheral TFCC is identified (TECH FIG 5).

■       In this instance, the majority of the fibers of the TFCC

are  attached to the displaced ulnar styloid fragment.

■            Make a small  incision between  the extensor carpi  ulnaris and the flexor carpi  ulnaris tendons and identify the fracture site.

■            Retrieve the distal fragment, which often displaces in a

distal and radial direction.

■            Mobilize the styloid fragment using a no.  15 blade, taking  care  to protect the TFCC insertion.

■            Reduce the fragment anatomically, under direct visual-

ization, and insert a  guidewire in  a  retrograde manner for  provisional stability.

■            Stabilize the ulnar styloid fragment using either a  ten-

sion   band  technique (with wire   and two K-wires)   or, preferably, using a micro  headless cannulated screw.

■            Place  the cannulated headless screw  over  the guidewire and verify  fracture reduction with fluoroscopy.

■            Insert the arthroscope into the 3/4 portal and the probe

into the  6R  portal to  document restoration of   TFCC

tension.

■    The degree of postoperative immobilization depends on numerous factors,  including the mode of  fracture stabilization, the quality of the bone for internal fixation,  the stability of the fixation,  and the management of any associated soft tissue injuries that were addressed during the arthroscopic evaluation.

■    Immediate range of motion of the digits and wrist is initiated in patients with volar plate fixation with good bone stock and solid fixation.

■    In patients with soft osteopenic bone with volar plate fixation,  digital range of  motion  exercises are initiated immediately, but wrist range of motion is delayed approximately 3 to

4 weeks to permit some fracture healing.

■    Soft bone may collapse around the rigid plate.

■    In  patients without  metaphyseal comminution  treated by arthroscopically assisted stabilization with cannulated screws, range of motion is initiated as the patient tolerates.

■    In patients treated with percutaneous K-wires, the wrist is immobilized until the wires are removed, usually 4 to 6 weeks after surgery.

■    A patient with an unstable DRUJ treated by TFCC repair or ulnar styloid reduction and fixation  is restricted from pronation and supination for 2 to 4 weeks.

■    The  literature is relatively sparse regarding the results of arthroscopically  assisted fixation  of  displaced intra-articular distal radius fractures.

■    A comparison study of 12 open and 12 arthroscopic reductions of comminuted AO type VII and VIII fractures of the distal  radius found  that  the arthroscopic group  had  increased range  of   motion   as  compared  to   the  open   stabilization group.23

■    A  second comparison study of 38 patients who underwent arthroscopically assisted fixation compared to open reduction found  the arthroscopically  assisted group  had  better results and improved range of motion.2

■    One  study compared 15 patients with arthroscopically assisted fixation to 15 patients who underwent closed reduction and external fixation.21  In this study, there were 10 tears of the triangular fibrocartilage complex in the group that underwent arthroscopic reduction, of which seven were peripheral and repaired. There were no signs of distal radioulnar joint instability at final follow-up visit. In the 15 patients who underwent stabilization by external fixation alone, four patients had continued complaints of  instability of  the distal radial joint, very possibly the result of undiagnosed and untreated TFCC tears.

■    Failure of fixation

■    Late settling of the fracture despite fixation

■    Flexor and extensor tendon irritation

■    Painful metal requiring removal

■    Neuromas  of  the dorsal sensory branch of  the radial and ulnar nerves

■    Carpal  tunnel syndrome

■    Reflex sympathetic dystrophy

■    Wrist and hand stiffness

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