Discussion
Use of wrist arthroscopy in DRF management has allowed assessment of the incidence of intra-articular injuries, including ligament and chondral surface injuries. Although the literature on the incidence of these injuries has been expanding, their clinical significance remains unclear.
Authors have postulated that some patients do not do well after DRF repair because of undetected ligament injuries. With the current trend of internal fixation, locked plating, and early motion—contrasting with older trends of prolonged immobilization in a cast or external fixation—concerns have been raised that early mobilization results in inadequate treatment of ligament injuries. However, data from the present study suggest no significant morbidity from early mobilization despite the presence of ligament injuries in more than half of all operatively treated DRFs. It is possible morbidity was not appreciated, as most patients with DRFs end up with some stiffness, which masks the effects of ligament injuries during healing.
We found no correlation between injury radiographic parameters, observed soft-tissue injuries, or final subjective outcomes. Interestingly, in this study, there was some discordance between the appearance of intra-articular fractures on radiographs and the direct arthroscopic observation of intra-articular fracture extension. With the present data and with arthroscopic visualization as the gold standard, radiographs had 74% sensitivity and 73% specificity for detecting intra-articular fractures (the corresponding positive predictive value was 83%, and the negative predictive value was 61%). As we typically rely on radiographs as the primary tool in assessing the articular component of a fracture, these results should be taken into account when basing management decisions exclusively on static injury films.
Observational studies of arthroscopy in DRFs have revealed a wide range of injury rates: For SLILs, the average injury rate was 44%; for LTLs, 13%; for TFCCs, 43%; and for chondral surfaces, 32% (Table 4).
This study had several limitations, including loss to follow-up at the primary endpoint (we were unable to contact 29% of patients). In addition, because of resource limitations, we were able to enroll only a limited number of patients, and as a result were able to power the study to detect only major effects on DASH scores. Therefore, although our 32 patients with long-term follow-up are within the range dictated by the power analysis, this study was not powered to capture more subtle differences in disability. Furthermore, because we used 1 year as the longest follow-up point, the long-term sequelae (eg, arthritis) of these injuries may not have been captured. Last, despite the high incidence of soft-tissue injuries overall, the number of patients with severe ligament injuries was relatively low, which makes it difficult to make definitive statements about their contribution to outcomes. A likely explanation is that patients with high-energy injuries and significant intra-articular displacement requiring open arthrotomies were excluded.
At 1-year follow-up, with use of DASH as the gold standard for disability, we found no major difference in subjective or objective outcome measures between patients with and without ligament injuries. Radiographs did not predict soft-tissue injury or ultimate outcome. Rates of ligament injuries in our operatively treated DRFs were similar to those in the literature. Overall, these findings suggest that “minor” injuries incidentally discovered with arthroscopy during DRF surgery may not have a significant effect on outcomes, with the caveat that the significance of very severe injuries (eg, Geissler grade 4 injuries with frank scapholunate diastasis) remains incompletely understood. The decision by the treating surgeon to perform arthroscopy and/or to repair soft-tissue injuries should be made on a case-by-case basis.
Am J Orthop. 2017;46(1):E41-E46. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.