Several studies have found a high incidence of intra-articular soft tissue injuries associated with displaced intra-articular fractures of the distal radius. Mohanti and Kar ² and Fontes and colleagues,³ in two separate wrist arthrography studies, identified a high incidence of injury to the triangular fibrocartilage complex associated with fractures of the distal radius.²^,³ Mohanti and Kar reported a 45% incidence of tears to the triangular fibrocartilage complex in 60 patients.² In a similar study, Fontes and coworkers found a 66% incidence of tears of the triangular fibrocartilage complex among 58 patients.³

Other arthroscopic studies have demonstrated a high incidence of injury to the triangular fibrocartilage complex. Geissler and colleagues reported their experience with 60 patients with displaced intra-articular fractures of the distal radius.⁴ In the series, 49% of the patients had a tear of the triangular fibrocartilage complex, most of which were peripheral and reparable. Injury to the scapholunate interosseous ligament was identified in 32%, and tears of the lunotriquetral interosseous ligament were reported in 15% of the patients.⁴ Landau and coworkers, in a similar arthroscopic study of 50 patients, found tears of the triangular fibrocartilage complex were the most common type and occurred in 78% of patients.⁵ Tears of the scapholunate interosseous ligament were identified in 54%, and tears of the lunotriquetral interosseous ligament were found in only 16% of the patients. In an arthroscopic study, Hanker reported that tears of the triangular fibrocartilage complex were present in 55% of the 65 patients in his series.⁶ Common in all three studies were injuries of the triangular fibrocartilage complex in which ulnar-sided pathology was most commonly associated with displaced intra-articular fractures of the distal radius.

Geissler and associates described an arthroscopic classification of interosseus ligament injuries based on their experience with the arthroscopic management of intra-articular distal radius fractures.⁴ They observed that a spectrum of interosseous ligament injury occurred. The interosseous ligament stretches and attenuates, and it eventually tears from a volar to dorsal direction from increased rotation between the carpal bones. The classification of carpal instability is based arthroscopic observation of the interosseous ligament from the radiocarpal and midcarpal spaces, and it evaluates injuries to the scapholunate and lunotriquetral interosseous ligaments (Table 26-1).

TABLE 26-1 Geissler Arthroscopic Classification of Carpal Instability

Grade	Description	Management
I	Attenuation or hemorrhage of the interosseous ligament is seen from the radiocarpal joint. There is no incongruence of carpal alignment in the midcarpal space.	Immobilization
II	Attenuation or hemorrhage of interosseous ligament is seen from the radiocarpal joint. Incongruence or step-off is seen from the midcarpal space. A slight gap (less than width of a probe) between the carpal bones may be present.	Arthroscopic reduction and pinning
III	Incongruence or step-off of carpal alignment is seen in the radiocarpal and midcarpal spaces. The probe may be passed through the gap between the carpal bones.	Arthroscopic or open reduction and pinning
IV	Incongruence or step-off of carpal alignment is seen in the radiocarpal and midcarpal spaces. Gross instability with manipulation is identified. A 2.7-mm arthroscope may be passed through the gap between the carpal bones.	Open reduction and repair

In the Geissler classification, grade I injuries have a loss of the normal concave appearance between the carpal bones as the interosseous ligament attenuates and becomes convex, which can be seen with the arthroscope in the radiocarpal space. Hemorrhage may be seen within the ligament in acute injuries, such as a fracture. In the midcarpal space, the interval between the carpal bones is congruent, and there is no step-off.

In Geissler grade II injuries, the interosseous ligament continues to attenuate and becomes convex as seen from the radiocarpal space. There is no gap between the carpal bones when viewed with the arthroscope in the radiocarpal space. In the midcarpal space, an interval between the carpal bones is no longer congruent, and a step-off exists. In scapholunate instability, palmar flexion of the scaphoid, compared with the lunate, can be seen arthroscopically. The dorsal lip of the lunate is distal in relation to the lunate. In lunotriquetral instability, increased translation is seen through the triquetrum and lunate when palpated with a probe.

In Geissler grade III injuries, the interosseous ligament starts to tear, usually in a volar to dorsal direction, and a gap is seen between the involved carpal bones and the radiocarpal space. The probe can be used to separate the involved carpal bones in the radiocarpal space. In the midcarpal space, a 2-mm probe may be placed between the carpal bones and twisted. A portion of the interosseous ligament is still intact, and complete disruption of the interosseous ligament is not observed.

In Geissler grade IV injuries, the interosseous ligament is completely detached and disrupted. The drive-through sign occurs when the arthroscope may be freely passed through the radiocarpal space and the torn interosseous ligament into the midcarpal space.

TREATMENT

Management of Carpal Instability

Geissler grade I injuries are consistent with a typical wrist sprain, and these tears respond to a short period of immobilization. Geissler grade II and III injuries may be easily arthroscopically reduced and stabilized in an acute situation. Anatomic reduction of the carpal interval is best viewed with the arthroscope in the midcarpal space opposite to the tear. For example, correction of the rotation to scapholunate instability is best viewed with the arthroscope in the ulnar midcarpal portal. For lunotriquetral instability, the reduction is best viewed with the arthroscope in the radial midcarpal portal. The carpal interval is reduced, and Kirschner wires are placed across the involved interval in oscillation mode to protect the cutaneous nerves. Geissler grade IV injuries have complete detachment of the interosseous ligament, and open repair is recommended for the best prognosis in acute situations.

Arthroscopic Techniques

A patient who sustains a fracture of the distal radius usually presents with a swollen wrist. Because of the swelling, it is usually difficult to palpate the extensor tendon landmarks traditionally used for arthroscopy. However, the bony landmarks are usually easily palpated, and they include the bases of the metacarpals, the ulnar head, and the dorsal lip of the radius.⁷

The wrist is suspended in a traditional traction tower. The standard 3-4 portal is made between the third and fourth dorsal extensor compartments. The 3-4 portal is made in line with the radial border of the long finger when the extensor tendons cannot be palpated. I recommend placing an 18-gauge needle into the proposed location of the 3-4 portal before committing to a skin incision. The arthroscope may be placed within the fracture itself if the portal is placed too proximal or can injure the articular cartilage of the carpus if the portal is placed too distally. After the precise location of the portal is determined, the portal is made on the skin against the surgeon’s thumb with the tip of a no. 11 blade. In this manner, the possibility of injury to the dorsal sensory cutaneous branches is decreased. Blunt dissection is continued with a hemostat to the level of the joint capsule, and the arthroscope is then reduced with a blunt trocar inserted into the 3-4 portal.

Intra-articular fractures of the distal radius are usually associated with abundant fracture hematoma and debris.⁸ Thorough irrigation of the fracture hematoma is required to evaluate the fracture fragments and to improve the field of view to judge rotation to the fracture fragments. Inflow may be provided through the wrist arthroscopic cannula or through a 14-gauge needle inserted into the 6-U portal. The small cannula used in wrist arthroscopy does not allow much space between the cannula itself and the arthroscope to allow fluid irrigation into the wrist joint. Because of this, separate inflow through the 6-U portal is recommended. Outflow is provided through the arthroscopic cannula with, intervenous extension tubing that drains into a basin on the hand table so the fluid does not go into the surgeon’s lap or onto the floor. Separate inflow and outflow cannulas limit fluid extravasation into the soft tissues.

The 4-5 or 6-R working portal may be used to remove debris and hematoma to improve visualization. The 4-5 working portal is made in line with the midaxis of the ring metacarpal when the extensor tendons cannot be palpated. The 6-R portal may be made just radial to the extensor carpi radialis tendon. Similarly to making the 3-4 portal, an 18-gauge needle should be inserted into the proposed location and viewed arthroscopically before committing to a skin incision.

The ideal timing for arthroscopically assisted reduction of intra-articular distal radius fractures is usually between 3 and 10 days.⁹ Other attempts at arthroscopic fixation may result in troublesome bleeding, which may obscure visualization. Fractures more than 10 days old may be difficult to disimpact and mobilized percutaneously.

Indications and Operative Setup

Intra-articular fractures of the distal radius without extensive metaphysial comminution are best for arthroscopically assisted management.¹⁰ They include radial styloid fractures, die-punch fractures, and three- and four-part fractures.

Large joint instrumentation is not appropriate for wrist arthroscopy. Small joint instrumentation is essential for arthroscopically assisted reduction of intra-articular distal radius fractures. The small joint scope is approximately 2.7 mm in diameter, and even smaller arthroscopes may be used. A small joint shaver (≤3.5 mm) is mandatory to clear fracture hematoma and debris to improve visualization. An oscillating drill is useful when inserting Kirschner wires for visualization and stabilization to prevent injury to the dorsal cutaneous nerves that surround the wrist.

A traction tower is very useful in arthroscopic management of distal radius fractures. The traction tower allows the surgeon to flex, extend, and radial and ulnar deviate the wrist to facilitate reduction of the fracture fragments while maintaining constant traction for visualization. Previous towers suspended the wrist using a traction bar and extended the forearm and hand, which made simultaneous fluoroscopic evaluation of the reduction very difficult. A newer traction tower design allows the surgeon to simultaneously arthroscopically reduce the intra-articular fracture of the distal radius and monitor the reduction fluoroscopically. The traction bar is uniquely placed at the side of the wrist rather than at the center, so it does not block fluoroscopic visualization. The wrist can be manipulated in traction to help reduce the fracture fragments. The tower may be flexed to allow the surgeon to perform wrist arthroscopy in the vertical or horizontal plane, depending on the surgeon’s preference. If a traction tower is not available, the wrist may be suspended with finger traps in a shoulder holder or over the end of a hand table. A small bump may be placed in the volar aspect of the wrist to help maintain slight wrist flexion when weights are being used over the end of the hand table.

Injuries Treated Arthroscopically

Radial Styloid Fractures

An isolated fracture of the radial styloid is an ideal fracture pattern to manage arthroscopically, particularly if the surgeon is just beginning to gain experience in arthroscopic management of wrist fractures. The simplest of several techniques is to advance two guidewires under fluoroscopic guidance into the tip of the radial styloid fragment but not across the fracture site. A small incision is made to insert the guidewires through a soft tissue protector or insert the guidewires with an oscillating drill to limit injury to the cutaneous nerves. The position of the guidewires into the radial styloid fragment is evaluated with fluoroscopy.

The wrist is then suspended in the traction tower, and standard portals were made. The radiocarpal space is cleared of hematoma and fracture debris to help facilitate visualization, particularly to judge rotation of the radial styloid fragment. The arthroscope is then transferred to the 6-R or 4-5 portal to view the reduction of the radial styloid fragment by looking across the wrist. It is much easier to assess rotation of the fracture fragment by looking across the wrist joint. The previously placed guidewires are used as joysticks, and the fracture is manipulated under direct observation and anatomically reduced back to the radial shaft. A trocar inserted into the 3-4 protal can aid reduction of the radial styloid fragment and control rotation.

The guidewire is advanced across the fracture site into the radial shaft after the fracture reduction is judged to be anatomic. The articular reduction and the position of the guidewires are evaluated with fluoroscopy. Initially, Kirschner wires were used alone. Headless screws are now recommended to stabilize the fracture because they provide good stability while decreasing soft tissue irritation and the likelihood of pin track infections compared with Kirschner wires. Headless screws may allow earlier range of motion.

Alternatively, closed reduction and percutaneous stabilization of the radial styloid fragment are performed under fluoroscopic guidance, and guidewires are advanced across the fracture site. The fracture is suspended in the traction tower, and the fracture hematoma is débrided. The arthroscope is then placed in the 4-5 or 6-R portal, and the arthroscopist looks across the wrist to evaluate the articular reduction. If the fracture fragment is rotated, the guidewires may be backed out of the shaft, leaving them only in the radial styloid fragment to use as joysticks to again reduce the fracture and then advanced across the fracture site.

Radial styloid fractures have a high incidence of associated injury to the scapholunate interosseous ligament. The zone of injury may pass through the fracture and continue distally through the scapholunate interosseous ligament. After reduction of the fracture, the scapholunate interosseous ligament is evaluated from the radiocarpal and midcarpal spaces.

Three-Part Fractures without Metaphysial Comminution

Displaced three-part fractures involve radial styloid and lunate facet fracture fragments (Fig. 26-1). The radial styloid fragment usually can be reduced by closed manipulation (Fig. 26-2). The radial styloid fragment is reduced and provisionally stabilized with Kirschner wires inserted by an oscillating drill, thereby stabilizing the styloid fragment back to the radial shaft. The wrist is then suspended in a traction tower, and the fracture debris and hematoma are evacuated (Figs. 26-3 to 26-5). The reduced radial styloid fragment may be used as a landmark to reduce the depressed lunate facet fracture fragment (Fig. 26-6). The arthroscope is placed in the 3-4 portal, and an 18-gauge needle is placed percutaneously into the radiocarpal space over the depressed lunate facet fragment. A large Kirschner wire may then be placed about 2 cm proximal to the previously placed 18-gauge needle, and it is used to elevate the depressed lunate facet fragment (Fig. 26-7). A bone tenaculum can further reduce the fracture gap between the fragments. Guidewires are placed transversely from the radial styloid just beneath the articular surface into the lunate facet fragment after the fracture fragments are anatomically reduced, as confirmed arthroscopically (Figs. 26-8 to 26-10). If a dorsal die-punch fragment is present, it is important to aim the transverse wires dorsally to capture and stabilize this dorsal fragment.

FIGURE 26-1 Posteroanterior radiographs show a three-part intra-articular fracture of the distal radius on the associated base of the ulnar styloid fragment.

FIGURE 26-2 The radial styloid is closed reduced, and a headless cannulated screw is inserted to support the fracture fragment.

FIGURE 26-3 The wrist is suspended in the Acumed traction tower (Hillsboro, OR).

FIGURE 26-4 Patients with fractures of the distal radius usually present with swollen wrists. It is useful to identify the proposed portal with an 18-gauge needle before committing to a skin incision.

FIGURE 26-5 Washing out the fracture hematoma and debris can improve visualization. A separate inflow is provided through a needle through the 6-U portal, and outflow is provided through an extension through the arthroscopic cannula.

FIGURE 26-6 The depressed lunate facet fragment is identified with the arthroscope in the 3-4 portal.

FIGURE 26-7 With the arthroscope in the 3-4 portal, the depressed fragment is percutaneously elevated with a large Kirschner wire inserted approximately 2 cm proximal to the fracture, and it is elevated as viewed arthroscopically.

FIGURE 26-8 The arthroscopic view shows reduction of the impacted lunate facet fragment. After the fragment is elevated, transverse guidewires are placed through the radial styloid into the impacted lunate facet fragment.

FIGURE 26-9 The Acumed wrist traction tower (Hillsboro, OR) is mini-C-arm friendly. The Orthoscan C-arm (Phoenix, AZ) is brought in to confirm the articular reduction to the lunate facet and position of the guidewires.

FIGURE 26-10 The fluoroscopic view confirms anatomic reduction to the articular surface and ideal placement of the guidewires volar and dorsal to the previous hemi-screw inserted into the radial styloid.

After placement of the transverse guidewires, the forearm is pronated and supinated to ensure the guidewires have not violated the distal radioulnar joint. Headless cannulated screws may then be placed over the guidewires to stabilize the radial styloid fragment and the impacted lunate facet fragment. Typically, one headless screw is used to stabilize the radial styloid fragment (Figs. 26-11 and 26-12). One or two headless screws placed volar and dorsal to the radial styloid screw may then be placed to stabilize the lunate facet fragment. Further stabilization of the lunate facet fragment may be performed by adding bone graft through a small incision placed between the fourth and fifth dorsal compartments to avoid late settling of the fracture fragments. Cancellous allograft bone chips or bone substitutes may be used.

FIGURE 26-11 The postoperative fluoroscopic view shows anatomic reduction to the articular surface and ideal placement of the headless cannulated screws. The articular disk had lost its tension when palpated, and no peripheral tear was identified. In this instance, a micro-Acutrak (Acumed, Hillsboro, OR) was placed through the ulnar styloid fragment.

FIGURE 26-12 The fluoroscopic lateral view confirms anatomic reduction to the articular surface, with headless screws placed anteroposterior to the radial styloid screw.

Three- and Four-Part Fractures with Metaphysial Comminution

A combination of open surgery and adjunctive wrist arthroscopy is used for three-part and four-part fractures with metaphysial comminution. A standard volar approach is made to the distal radius over the radial side of the flexor carpi radialis tendon. The flexor pollicis longus tendon is identified and retracted to protect the median nerve, and the pronator quadratus is released from the radial border of the distal radius. The brachioradialis may be further released from the radial styloid to facilitate fracture reduction. The joint capsule is not opened. The fracture is provisionally reduced and stabilized with a volar plate. The first screw is placed in the offset hole in the volar plate to stabilize the plate to the radial shaft. The articular reduction is manipulated as anatomically as possible as viewed by fluoroscopy, and Kirschner wires to the plate provide provisional stabilization.

The wrist is then suspended in the traction tower, and the articular reduction is viewed arthroscopically. If the articular reduction is not anatomic, the pins are removed from the plate, and the reduction is fine-tuned under arthroscopic visualization. After the reduction is judged to be anatomic arthroscopically, the pins are placed back through the plate to provide provisional stabilization to the fracture fragments. The wrist must be solidly flexed in the traction tower to help reduce the distal radius to the plate and prevent a gap. A nonlocking distal screw is initially placed in the distal aspect of the plate to further reduce the fracture fragments to the plate so there is no gap. The remaining distal screws are inserted, and the reduction is viewed fluoroscopically and arthroscopically. In distal dorsal lip fragments, arthroscopy is useful to judge stability as the distal screws are being inserted, and they can be seen stabilizing the dorsal distal fragments. Dorsal lip fragments are best seen with the arthroscope in the 6-R portal or through a volar radial portal between the radial scaphocapitate and long radial lunate ligament.

In four-part fractures, the lunate facet is divided into volar and dorsal fragments (Figs. 26-13 and 26-14). The volar ulnar fragment is reduced under direct observation through the volar approach, reducing it back to the shaft into the radial styloid fragment, and it is provisionally pinned (Fig. 26-15). The volar distal radius plate is used to provisionally stabilize the radial styloid and volar ulnar fragments (Figs. 26-16 and 26-17). The wrist is then suspended in the traction tower. With the arthroscope in the 6-R portal, the dorsal lunate fragment is visualized and percutaneously elevated (Fig. 26-18). After the articular surface is anatomic as seen arthroscopically, the provisional fixation is advanced from volar to dorsal aspects to provisionally stabilize the dorsal fragment (Figs. 26-19 and 26-20). The distal screws are then placed in the volar plate (Figs. 26-20 and 26-21).

FIGURE 26-13 The posteroanterior radiograph shows a displaced intra-articular fracture of the distal radius with radial shortening.

FIGURE 26-14 The lateral view demonstrates a four-part fracture of the distal radius with a displaced volar ulnar fragment. This fracture cannot be closed reduced and requires open reduction and stabilization.

FIGURE 26-15 The intraoperative view shows reduction of the radial styloid and the volar ulnar fragment back to the radial shaft.

FIGURE 26-16 The Acu-Loc (Acumed, Hillsboro, OR) is placed through the volar incision. The fracture is provisionally stabilized with Kirschner wires placed through the radial styloid and the plate to support the articular surface reduction.

FIGURE 26-17 The fluoroscopic view demonstrates the provisional articular reduction to the distal radius.

FIGURE 26-18 The wrist is suspended in the Acumed wrist traction tower (Hillsboro, OR), and articular reduction is evaluated. The tower gives full exposure to the volar aspects of the wrist so the Kirschner wires can be removed and replaced if the articular surface reduction is not satisfactory.

FIGURE 26-19 The arthroscopic view with the arthroscope in the 6-R portal shows displacement of the dorsal ulnar fragment.

FIGURE 26-20 The arthroscopic view shows reduction of the dorsal ulnar fragment back to the volar ulnar fragment as viewed with the arthroscope in the 6-R portal.

FIGURE 26-21 The posteroanterior fluoroscopic view shows placement of the Acu-Loc plate and anatomic restoration to the articular surface.

Volar plate stabilization using wrist arthroscopy as an adjunct to view the articular reduction is preferred if metaphysial comminution is present. This produces a very stable construct and enables early range of motion and rehabilitation compared with the use of Kirschner wires or headless screws alone. Late settling of the fracture fragments is likely to be seen with volar plate stabilization compared with percutaneous Kirschner wires or cannulated screws.

Information gained from arthroscopic evaluation of the wrist after stabilization of the distal radius fracture provides some rationale about when to stabilize an associated ulnar styloid fragment (Fig. 26-22), although recommendations about the timing are controversial. After anatomic reduction of a distal radius fracture, the tension of the articular disk is palpated with a probe. The arthroscope is placed in the 3-4 portal, the probe is inserted through the 6-R portal, and the tension of the disk is evaluated. Most fibers of the triangular fibrocartilage complex are still attached to the base of the ulnar and not to the displaced ulnar styloid fragment when there is good tension on the articular disk when it is palpated. A peripheral tear of the triangular fibrocartilage complex is suspected if there is loss of tension on the disk when palpated. A peripheral tear often is covered with hematoma or synovitis, and the hematoma must be débrided to obtain direct visualization of the periphery of the articular disk.

FIGURE 26-22 The lateral fluoroscopic view confirms anatomic reduction to the articular surface and reduction of the volar and dorsal lunate facet fracture fragments.

When detected, a peripheral tear is repaired arthroscopically. Stabilization of a large ulnar styloid fragment is considered when there is loss of tension on the articular disk and no peripheral ulnar tear of the articular disk is identified. In this instance, most fibers of the articular disk are attached to the ulnar styloid fragment. The incision is made in the interval between the extensor carpi ulnaris and flexor carpi ulnaris, and blunt dissection is carried down to protect the dorsal sensory branch of the ulnar nerve, which runs along the volar aspect of the incision. The ulnar styloid fragment is anatomically reduced and may be stabilized with a tension band, Kirschner wire, or preferably, a small headless cannulated screw.

PEARLS& PITFALLS

• Precise portal placement is mandatory in wrist arthroscopy.

• For a swollen wrist, the external landmarks usually can be palpated to help in portal placement. The 3-4 portal is made in line with the radial border of the long finger; the 4-5 portal is in line with the midaxis of the ring finger; and the 6-R portal is just radial to the extensor carpi ulnaris tendon.

• Place a needle into a portal location before committing to a skin incision.

• Wash out fracture hematoma and debris to improve visualization.

• It is easier to judge rotation of a fracture fragment by looking across the wrist from the fragment. A radial styloid fragment is best visualized with the arthroscope in the 6-R portal, and depressed lunate facet fragments are best visualized with the arthroscope in the 3-4 portal.

• Be wary of the cutaneous sensory nerves about the wrist. Insert guidewires through a small incision, a trocar, or in oscillation mode.

• Combining wrist arthroscopy with volar plating for fractures with extensive metaphysial involvement allows anatomic restoration of the joint surface and produces good stability, which enables an early range-of-motion program.

OUTCOMES

Wrist arthroscopy takes advantage of its ability to view the articular surface under bright light and magnified conditions. Two millimeters of articular displacement has become an established criterion for congruency of the distal radius over the past several years. Knirk and Jupiter demonstrated the importance of an articular reduction of the distal radius within 2 mm or less.¹¹ Patients whose articular reduction was greater than 2 mm at the final follow-up visit demonstrated significantly higher incidences of degenerative changes within their wrists. Bradway and Amadio reported similar findings.¹²

Fernandez and Geissler reported their series of 40 patients and observed that the critical threshold might be 1 mm or less.¹³ They reported that the complication rate was substantially lower when the articular reduction was 1 mm or less. Trumble and colleagues, in their review of 52 intra-articular distal radius fractures, found that the factors that most strongly correlated with a successful outcome included the amount of residual radial shortening and articular incongruence.¹⁴

Edwards and colleagues described the advantage of viewing intra-articular reduction by wrist arthroscopy compared with monitoring by fluoroscopy alone.¹⁵ In their series of 15 patients who underwent arthroscopic evaluation of the articular surface after reduction and stabilization under fluoroscopic guidance, 33% of patients still had an articular step-off of 1 mm or more. Frequently, the fracture fragment was rotated. They found that wrist arthroscopy was particularly useful in judging rotation of the fracture fragments, a situation that is not readily identifiable under fluoroscopy alone. It is easy to judge rotation of the fracture fragment by looking across the wrist. For example, to judge rotation of a radial styloid fragment, it is best to place the arthroscope in the 4-5 or 6-R portal. Similarly, to view reduction of a lunate facet fragment, it is best to place the arthroscope in the 3-4 portal to view reduction of the die-punch fragment. Fractures of the dorsal lip may be viewed with the arthroscope in the 6-R portal or the volar portal.

The literature is sparse regarding the results of arthroscopically assisted fixation of displaced intra-articular fractures of the distal radius. Stewart and coworkers compared 12 open and 12 arthroscopically assisted reductions of comminuted AO type C fractures of the distal radius.¹⁶ The arthroscopically treated group had five excellent results, six good results, and one fair result. The open group had no excellent results. The investigators found that the arthroscopic group had increased range of motion compared with the group that underwent open stabilization for similar fracture patterns.

Doi and colleagues reported a similar comparison of 38 patients who underwent arthroscopically assisted fixation or open reduction and fixation.¹⁷ They reported results similar to those of earlier studies, and they observed that the arthroscopic group had improved range of motion compared with the group that underwent open stabilization.

Ruch and coworkers compared 15 patients who underwent arthroscopically assisted reduction and 15 patients who underwent closed reduction and external fixation.¹⁸ Of the 15 patients who underwent arthroscopic reduction, 10 patients had a tear of the triangular fibrocartilage complex, seven of which were peripheral and were stabilized. No patients in the arthroscopic group had any signs of instability of the distal radioulnar joint at the final follow-up visit. In contrast, 4 of the 15 patients who were managed by external fixation alone continued to complain about instability of the distal radioulnar joint. These patients potentially had a peripheral tear of the triangular fibrocartilage complex at the time of fracture that was not repaired.

Geissler and coworkers reported the results of 33 patients who underwent arthroscopically assisted reduction of extra-articular distal radius fractures.¹⁰ In their series, 25 patients had anatomic reduction of the articular surface, and 8 patients had a 1-mm step-off. They analyzed the results based on associated soft tissue injuries and found that a Geissler grade II injury of the scapholunate interosseous ligament did not affect the final prognosis. However, for patients with a Geissler grade III or IV tear and an AO type C fracture, the final result was significantly affected by the soft tissue injury.