- Orthopedic surgeons at Massachusetts General Hospital have added intraoperative use of a bone reduction forceps to the standard volar approach to treating intra-articular fractures of the distal radius involving the dorsal lunate facet
- Comparison of pre- and postoperative computed tomography scans showed that 87% of 60 patients achieved complete reduction or an articular gap/step <1 mm
- More than half of the patients had no ulnar subluxation
- Patients ended with good range of motion and few had postoperative pain
When an intra-articular fracture of the distal radius involves the dorsal lunate facet, it can be difficult to restore normal to near-normal articular anatomy. As a result, patients tend to have poorer functional outcomes and a higher grade of joint arthrosis.
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Jonathan Lans, MD, research fellow in Hand and and Arm Center, Sezai Ozkan, MD, research fellow in the Hand Surgery Clinical Research Unit, and Jesse B. Jupiter, MD, orthopaedic surgeon in the Hand and Arm Center of the Department of Orthopaedics at Massachusetts General Hospital, are taking a new approach to these injuries. In the Journal of Wrist Surgery, they report success in using a bone forceps to reduce the dorsal lunate facet fragment.
The surgical technique begins with a standard volar longitudinal approach between the flexor carpi radialis and the radial neurovascular bundle. Volar fragments are reduced by manipulation, under radiographic visualization using a C-arm, and dorsal fragments are reduced indirectly through ligamentotaxis.
To improve the anatomical reduction of the dorsal lunate facet fragment, the surgeons use a bone reduction forceps over the volar plate to relocate the fragment, again under radiographic visualization. A bone reduction forceps comprises a tongue that is placed over the dorsal wrist to press the dorsal distal radius while a second pinpoint tongue is placed onto the volar plate to create compression across the fracture.
The operative technique is illustrated and described in more detail in the journal article.
A Retrospective Study
The researchers studied 60 skeletally mature patients who had the surgery between 2007 and 2015. All required closed manipulation, and all were operated on by the same surgeon within 10 days after injury. The median duration of follow-up was 44 weeks.
The patients were evaluated by comparing preoperative and postoperative computed tomography scans.
At final follow-up, the principal results were:
- Flexion was 92.1% of the unaffected wrist, extension was 96.4%, pronation was 99.7% and supination was 99.3%
- Articular gap or step: none in 80% of patients, <1 mm in 6.7%, 1–2 mm in 10% and >3 mm in 0.3%
- Median articular gap: 2 mm preoperatively (interquartile range, 1.1–3.2 mm) and 0 mm postoperatively (IQR, 0–0.7 mm) (P < .01)
- Average radioulnar ratio (RUR, a measure of distal radioulnar subluxation): 51%, with 80% of the patients having RUR of 38%–68%, and 54% having no ulnar subluxation
- Average volar tilt: – 3.9° degrees, with 36% of patients having volar tilt that was 0° or positive
- Average postoperative radial height: 12 mm
- Pain score: 0 in 46 patients, 2 in seven patients and 4 in one patient
A Key Advantage
By adding the bone forceps it is often unnecessary to use additional soft tissue or an additional dorsal approach, the authors report. They do caution that if dorsal carpal subluxation is noted on intraoperative fluoroscopy after fracture reduction with the volar plate, an additional dorsal approach may be needed.
For More Information
The authors have made the patients' preoperative and postoperative images available in the ICUC database along with intraoperative photographs and fluoroscopy images.
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