Wrist arthroscopy in the management of articular distal radius fractures

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1 British Medical Bulletin, 2016, 119: doi: /bmb/ldw032 Advance Access Publication Date: 22 August 2016 Invited Review Wrist arthroscopy in the management of articular distal radius fractures Francesco Smeraglia, Angelo Del Buono, and Nicola Maffulli, **, * Department of Orthopaedic Surgery, University of Naples Federico II, via Sergio Pansini 5, Naples, Italy, Department of Orthopaedic and Trauma Surgery, Ospedale Vaio Via Don Enrico Tincati, 5, Fidenza (PR), Italy, Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Salerno, Italy, and ** Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK *Correspondence address. Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Salerno, Italy. n.maffulli@qmul.ac.uk Accepted 19 July 2016 Abstract Introduction: Fractures of the distal radius account for 15% of all fractures. The use of arthroscopy is increasingly popular in the last years, with the goal to achieve a better anatomical reduction of the articular fragments. Sources of data: We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords wrist, distal radial fracture, distal radius fracture and arthroscopy. Twenty-eight studies were identified. The quality of the studies was assessed using the Coleman Methodological Score. Areas of agreement: Arthroscopy allows to detect intra-articular, ligamentous and triangular fibrocartilage complex injuries in an acute setting with a better prognosis. Arthroscopy increases the quality of the intra-articular reduction compared to fluoroscopy. Areas of controversy: The main limitation of the selected studies is the short follow-up: the average follow-up in 20 studies was 12 months, a period long enough to assess functional outcomes, but not to assess the occurrence of post-traumatic degenerative changes and their impact on function. Better stratification of the fracture population is needed. Growing points: The shorter recovery time and the low incidence of adverse effects are the main advantages of this new technology. The Author Published by Oxford University Press. All rights reserved. For permissions, please journals.permissions@oup.com

2 158 F. Smeraglia et al., 2016, Vol. 119 Areas timely for developing research: There is need to perform randomized controlled trials reporting on the use of volar locking plates as, at the present time, they are the standard management for these fractures. In addition, the different pattern of fracture should be better classified to manage the patients who will benefit after the management. Key words: wrist arthroscopy, distal radius fracture, distal radial fracture Introduction Fractures of the distal radius account for 15% of all fractures. 1 Extra-articular alignment, volar tilt, radial height and congruence of the distal radioulnar joint should all be restored. 2 Knirk and Jupiter 3 reported that an articular step-off >2 mm leads to an unsatisfactory functional score and to radio carpal arthritis. Recently, this limit has decreased to 1 mm. 4,5 Wrist arthroscopy has increased its popularity since the first report of Whipple. 6 The potential advantages of arthroscopically assisted reduction of radius fractures are the excellent visualization of the joint surface and potential treatment of ligamentous and chondral injuries. This procedure may be easily performed in combination with Kirschner wiring and/or external fixation; it is more demanding when using volar plates, which have become the most popular fixation tools. This systematic review aims to ascertain whether wrist arthroscopy exerts a positive influence on outcomes, providing better reduction. Also, at present it is not known which method of fracture fixation is more suitable to be accompanied by wrist arthroscopy. Finally, we wished to assess the methodological quality of the studies published on this topic. Materials and methods We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 7 We searched the literature using the keywords wrist, distal radial fracture, distal radius fracture, arthroscopy, with no limitations for year of publication. Medline (PubMed), Web of Science and Scopus were accessed up to December 16, Articles in English, Spanish, Italian and French published in peer-reviewed journals were identified. Reviews, biomechanical studies, studies on animals or cadavers, technical notes, letters to the editor and instructional courses lectures were excluded. Two authors (A.D.B. and F.S.) independently assessed the abstract of each publication. When it was not possible to include or exclude an article based on the abstract or the abstract was not available, a full-text version of the article was downloaded. In addition, we checked the reference list of each selected article to identify additional studies missed at the first electronic search. The two investigators assessed each study according to the Coleman Methodological Score (CMS). 8 This score ranges from 0 to 100, according to which a 100 score is referred to the best study design. Both investigators performed the CMS assessment twice, with a 10-day interval between the two assessments. The two investigators discussed the scores when more than a 2-point difference was present, until consensus was reached. Data on demographic features, operative readings, diagnostic methods, follow-up periods, fracture s classification, fixation method, operative day after the injury, associated soft tissue injuries, complication, imaging outcomes, objective and subjective outcomes measures were recorded. Results Three hundred forty-seven articles were identified after the first search based on the abstracts. Of 64 studies selected, 28 were included in the systematic review after the full texts had been read (Fig. 1). All the studies were published between the 1995 and

3 Wrist arthroscopy in distal radius fracture, 2016, Vol Fig. 1 PRISMA flow diagram. 2015; the total number of patients was 1294, 36% (357) were males and 64% (642) females; gender data were not available in six studies The age of the patients averaged years. Quality assessment The selected articles and the relevant CMS scores are shown in Table 1. Articles on cost analysis without any clinical variable were excluded from the CMS. A Coleman score >85 is considered excellent, good, moderate and <50 poor. The mean CMS was (range 25 78) indicating a moderate methodological quality. Quality scores were good in six studies. Stratification of the population by age Only three studies stratified patients according to the age. 13,23,32 Hardy 13 and Zemirline 32 considered a population younger than 50 years, Hattori 23 instead included just patients over 70 years. Fracture s classification The Association for Osteosynthesis/Association for the Study of Internal Fixation (AO-ASIF) classification system 5,14,15,17,20 27,29 32,35 was the most used, followed by Frykman s classification. 5,13,17,23 Several authors preferred to use a descriptive classification. 9,10,16,18,34 Other classifications are used just in one paper each (Table 2). Table 2 shows that just few studies have homogeneous fracture subgroups: four studies included just AO fracture type C fractures, 21,23,24,35 Wolfe et al. 15 included just AO type C3 fractures, Kamano et al. 22 included C3.2 fractures, Levy et al. 27 included articular fractures with posterior displacements and Pinal et al. 34 included articular fractures with diaphyseal-metaphyseal comminution. Fixation method In 12 studies, all published from 1995 to 2008, a combination of Kirschner wires and external fixation 5,9 13,15 18,21,24 was used. Volar locking plate was implanted in nine studies 22,25,26,28,30 32,34,35 published from 2005 to Plating, external fixation and Kirschner wiring were used on the basis of the pattern of fracture in four studies. 19,23,29,33 Two studies used only Kirschner wiring. 14,27 Outcomes measure Several outcome measures were utilized (Table 1). Fluoroscopy versus arthroscopy accuracy Seven articles 11,18,25 28,30 studied arthroscopically the accuracy of fluoroscopic reduction. Soft tissue-associated injuries Associated soft tissue injuries were reported in 21 studies (Table 2). The percentage of scapho-lunate lesions varies from 2.7% (1/37 patients) 35 to 88.4% (23/26), 5 the percentage of luno-triqueteral injury varies from 0% 13 16,20,27,30 32,35 to 61.5% (16/26). 5 Lesions of the triangular fibrocartilage complex occurred in a percentage between 0% (0/ 7) 15 and 63.2% (98/155). 30 Post-traumatic arthritis The occurrence of degenerative changes over time was assessed in four studies, all using Kirk and Jupiter s criteria 3 (Table 3). Three studies were case series; the study by Doi et al. 17 was a case-control

4 160 F. Smeraglia et al., 2016, Vol. 119 Table 1 General features of the studies Author Year of publication Number of patients Follow-up (m) Kind of study CMS Outcome measures Wolfe Case series 54 Gartlant and Werley Culp Case series 41 Gartlant and Werley, ROM Geissler Case series 34 Mayo wrist score Adolfsson Case series 47 Mayo wrist score Doi Randomized 74 Rom, swelling, grip strength controlled trial Augé Case series 35 Mehta Case series 56 Gartlant and Werley, ROM, VAS, satisfaction, grip strength, New York Orthopedic score Shih Case series 47 Mayo wrist score Edwards Case series 33 Mathoulin Case series 57 ROM, grip strength Chen Case series 58 Mayo wrist score Ruch Prospective 55 ROM,DASH, grip strength case-control matched Kamano Case series 57 Gartlant and Werley Hardy Case series 44 Green and O Brien modified by Cooney Hattori ,9 Case series 63 ROM,DASH, grip strength, Green and O Brien Varitimidis Randomized controlled trial 74 ROM,DASH, grip strength, Mayo wrist score Lutsky Case series 25 Ono Case series 29 Kordiasewicz Case control 56 Levy Case series 38 ROM, DASH Ono Case series 47 ROM, DASH, grip strength, Mayo wrist score, VAS Khanchandani Case series 55 Mayo wrist score Abe Case series 75 ROM, DASH, grip strength, Mayo wrist score Abe Case series 71 ROM, DASH, grip strength, Mayo wrist score Zemirline ,3 Case series 62 ROM, quick DASH, grip strength, VAS Lalone Case series 32 ROM, grip strength, PRWE, SF-36, dextrity test Pinal Case series 75 ROM, grip strength, PRWE, DASH, VAS Yamazaki Randomized controlled trial 78 ROM, grip strength, DASH

5 Wrist arthroscopy in distal radius fracture, 2016, Vol Table 2 Fracture s classification and associated soft tissue injuries Author Year of publication Fracture classification s system Fracture subgroups Scapho-lunate lesions Lunotriqueteral lesions Triangular fibrocartilage lesions Wolfe AO 2 C3.1, 4 C3.2, 1 C3.3 3/7 (42,8%) 0/7 0/7 Culp /27 (55%) 6/27 (22%) 15/27(55%) Geissler Not reported Not reported Not reported Adolfsson AO + Frikman 2 B1.1, 2 B2.1, 1 B2.2, 1 B3.3, 1 C1.1, 3 C1.2, 4 C2.1, 8 2/27 (7,4%) 0/27 8/27 (29,6%) C3.1,3 C3.2, 2 C3.3 Doi AO + Frikman 1 B1.3, 1 B2.2, 1 B3.1, 7 B3.2, 4 B3.3, 10 C1.1, 3 C1.2, 1 C1.3, 1 C2.2, 2 C2.3, 25 C3.1, 23 C3.2, 3 C3.3 8/34 (23,5%) 4/34 (11,7%) 12/34 (35,3%) Augé Melone 7 I, 8 II, 9 III, 7 IV Not reported Not reported Not reported Mehta AO + Frikman 2 B3.3, 4 C1.2, 4 C1.3, 1 C2.2, 10 C3.1, 4 C3.2, 1 C3.3 23/26 (88,4%) 16/26 (61,5%) 15/26 (57,7%) Shih Mayo System 6 II, 10 III, 17 IV 6/33 (18%) 4/33(12%) 18/33(54%) Edwards Not reported Not reported Not reported Mathoulin Letrosne-Mathoulin 4 II, 6 IIIA, 11 IIIB, 4 IV 10/26 (38,4%) 4/26 (15,3%) 7/26 (26,9%) Chen AO 3 B, 17 C 6/20 (30%) 0 2/20 (10%) Ruch AO All C2 and C3 5/30 (16,6%) 4/30 (13,3%) 10/30 (33,3%) Kamano AO All C3.2 7/15 (46,6%) 1/15 (6,6%) 1/15 (6,6%) Hardy Frikman 10 type III, 4 type IV, 2 type II and 2 type VII 5/18 (27,7%) 0 1/18 (5,5%) Hattori AO + Frikman 5 C1, 4 C2, 19 C3 5/25 (20%) 3/25(12%) 8/25 (32%) Varitimidis AO All C 9/20 (45%) 4/20 (20%) 12/20 (60%) Lutsky AO AO: 1B1, 1 B2, 7 C1, 1 C2, 6 C2 Not reported Not reported Not reported Ono AO 4 A2, 3 A3, 1B1, 5B2, 4 C1, 9C2, 5C3 Not reported Not reported Not reported Kordiasewicz AO All B1 and C1 11/27 (40,7%) 0 16/27 (59,2%) Levy Castaing All articular fractures with posterior displacement 7/35 (20%) 0 3/35 (8,5%) Ono AO 6 A2, 7 A3, 1B1, 5B2, 29C1, 13C2, 9C3 Not reported Not reported Not reported Khanchandani AO 3 B1, 1 B2 C1, 12 C2, 2 C3 8/27(29,6%) 1/27 (3,7%) 17/27 (62,9%) Abe AO 7 A2, 30 A3, 6 B3, 40 C1, 18 C2, 54 C3 44/155 (28,8%) 0 98/155 (63,2%) Abe AO 6 A2, 45 A3, 4 B3, 66 C1, 15 C2, 69 C3 61/205(29,7%) 0 128/205(62,4%) Zemirline AO 5 B, 14 C 6/20 (30%) 0 0 Lalone Mc Murtry (cit Fernandez) 45 two parts, 48 three parts, 23 four parts, 32 five or more parts Pinal All articular fractures with diaphyseal- metaphyseal commnution Not reported Not reported Not reported Not reported Not reported Not reported Yamazaki AO 7 C1, 24 C2, 39 C3 1/37 (2,7%) 0 13/37 (35,1%)

6 162 F. Smeraglia et al., 2016, Vol. 119 Table 3 Follow-up and ostoarthritis Follow-up (m) Kirk and Jupiter Grade 0 Kirk and Jupiter Grade 1 Kirk and Jupiter Grade 2 Kirk and Jupiter Grade 3 Wolfe /7 1/7 3/7 3/7 Doi /34 13/34 3/34 Kamano /15 10/15 Hattori 23 24,9 14/25 12/25 1/25 study showing lower occurrence of degenerative changes in the group of patients who had undergone wrist arthroscopy (the rate of osteoarthritis was 47%, 16/34 patients) compared to the control group (58%, 28/48 patients). Discussion The average quality of the studies included in the present investigation is moderate, with an average CMS of 53.3 points, and only six studies (Table 1) with good CMS values. The main limitation of the selected studies is the short follow-up. The longest follow-up 34 was 36 months, but the number of patients of that study was low (4). On the other hand, the average follow-up in 20 studies was at least 12 months (Table 1), a period long enough to assess the functional outcomes, not to assess the occurrence of post-traumatic degenerative changes and their impact on function. Most of studies were case series. The seminal work for the use of arthroscopy in the management of distal radius fractures by Knirk and Jupiter 3 included a small number of patients, with a 91% occurrence of osteoarthritis in patients with an articular step-off >2 mm within six years. Many studies agree with these findings, 11,18,36 but others 37,38 did not find any correlation between the residual step-off/gaps and final outcomes. The studies with longer follow-up have reported that degenerative joint disease is evident on plain radiographs several years after the trauma in young adults. 36,37,39 We have also to consider that the clinical manifestation of post-traumatic arthritis may not be disabling. 40 Mehta et al. 5 reported that a step-off >1mm was significantly related to pain. The lack of long follow-up studies does not allow to give a direct answer about the importance of a better reduction. Complete understanding of the status of the articular surface is essential for accurate fixation: fluoroscopy is less able to evaluate the articular surfaces compared with arthroscopy. For example, Edwards et al. 18 reported that 33% of the patients (5/15) had a step-off >1 mm arthroscopically, while no step-off was apparent at fluoroscopy. Abe et al. 30 reported that the 35.2% of the patients (38/108) who seemed to achieve perfect reduction at fluoroscopy in reality had a step-off or a gap >2 mm. In 2014, this figure was the 22.7% (35/154 patients). Augé and Velázquez 11 reported that, according to Melone s classification, 14.3% of type I fractures, 37.5% of type II fractures, 33.3% of type III fractures, and 71.4% of type IV fractures were modified after arthroscopic visualization. Ono et al. 26 reported that 7 of 24 patients of the patients with type B and C fractures (29.2%) presented a displacement >2 mm, and showed that reduction of the step-off with arthroscopy was better than reduction of the gap using fluoroscopy. Lutsky et al. 25 reported that, in 6 of 16 patients (38%), the maximum gap at arthroscopy was 2 mm after ORIF with fluoroscopy, but 2 out of 16 (12.5%) patients had an articular stepoff of 2mm. Levy 27 reported that 9/35 (25.7%) patients presented an inter-fragmentary distance >1mm, and 2/35 (5,7%) patients had an intraarticular step of up to 2 mm. Another advantage of arthroscopy is the detection of malpositioned screws, although this is a rare event (0.8%, 2/249). 31 The ideal time for surgery should be between 4 and 7 days: earlier arthroscopy could be difficult given the presence of fracture hematoma, 9 while later the beginning of bone healing may make the procedure useless. 23,41

7 Wrist arthroscopy in distal radius fracture, 2016, Vol Injuries of the interosseus ligament and triangular fibrocartilage complex may be misdiagnosed or underestimated on plain radiographs, while arthroscopy at the time of fracture fixation improves the detection of acute lesions that have a better prognosis compared to chronic injuries. Furthermore, many partial injuries of the scapho-lunate ligament may progress to complete ruptures because the popular volar plate guarantees solid fixation and promotes an early mobilization. 42 Arthroscopy allows to make accurate soft tissue diagnosis, and treat them in an acute setting. The incidence of these lesions is not uniform (Table 2). A wash out of the fracture hematoma and debris potentially improves the ROM and reduces the inflammatory response. 17,30 In the last few years, surgical management of displaced intra-articular distal radial fractures has become more popular, probably because most surgeon feel that traction and ligamentotaxis cannot control intra-articular fragments. However, there is no evidence-based consensus on the fixation method to be used, 43 though volar plating continues to be preferred for the mechanical stability that it imparts, and the early rehabilitation that it allows. Modern external fixators provide a rigid construct and a minimally invasive technique, but the presence of the fixator, prolonged immobilization and difficulties with self-care make them a second choice to volar plating. This systematic review identified three prospective randomized studies 17,24,35 and one retrospective case matched study; 21 all the studies, except the one by Yamazaki, 35 used an external fixator. Doi et al. 17 reported better results (post-traumatic arthritis and Gartland and Werley score) in the arthroscopic-assisted group, but they used different fixation methods in the control group, and this could have influenced the outcomes. Ruch et al. 21 reported better ROM in the arthroscopy group, but no differences in DASH, grip strength and radiographic outcomes. Varitimidis et al. 24 reported a better DASH, Mayo Wrist Score, ROM and grip strength in the arthroscopy group. Yamazaki et al. 35 used volar locking plates, with no significant differences between arthroscopic assisted and control group at 48 weeks, with no mention to the occurrence of ostoarthritic changes. In this study, the average age of the patients was 64 years, an age in which, according to other studies, outcomes are not related to joint congruence. 44 Arthroscopically assisted reduction is complex, and the learning curve is long, but it allows to better reduce the articular fragments, and to manage soft tissue injuries in an acute setting. Technically, it is difficult to perform, probably because surgeons are resistant to use it. In addition, especially during the learning curve, the time of surgery is markedly increased, 45 and the costs are higher. 13 Wrist arthroscopy is simpler when used with Kirschner wires or external fixation, because of the vertical traction that has to be released and applied during volar plating. 30 However, Abe et al. 30 described a surgical technique (Plate presetting and Arthroscopic Reduction Technique (PART)) to improve the use of arthroscopy when implanting volar plates. Multifragmentary fractures usually occur in young patients after high-energy trauma. Kamano et al. 22 reported good results after arthroscopically assisted reduction and volar plating in patients with AO-OSIF C3.2 fractures. Pinal et al. 34 also reported good outcomes in patients with comminuted intraarticular fractures of the radius with diaphysealmetaphyseal comminution. In that study, the use of the dry technique made it possible to use arthroscopy also in open fractures with low risks of compartment syndrome, and to perform semi-open procedures (foveal reattachments). 42 There is need to perform randomized controlled trials reporting on the use of volar locking plates as, at present, they are the standard management for these fractures. A better stratification of the populations studied would allow to identify which fracture(s) would benefit from arthroscopy, because there are too many factors influencing the outcomes (age, bone quality, comminution). Young adults often suffer from intra-articular distal radius fractures, and ideally we would wish to restore their preinjury wrist anatomy. On the other hand, the increase of active elderly patients gives us a new group of high-demanding patients. The lack of studies with longer follow-up does not allow us to

8 164 F. Smeraglia et al., 2016, Vol. 119 evaluate the most important theoretical advantage of arthroscopic-assisted reduction, i.e. whether a better correction of step-offs and gaps helps in terms of preventing osteoarthritic changes. Furthermore, the influence of soft tissue injuries on the final outcomes has still to be clarified, and it is not clear whether early treatment of associated soft tissue injuries would produce better results. Conflict of interest statement The authors have no potential conflicts of interest. References 1. Sanders WE. Distal Radius Fracture. Hand Surgery Update. Englewood, CO: ASSH, 1994;1. 2. Trumble TE, Culp R, Hanel DP, et al. Intraarticular fractures of the distal aspect of the radius. J Bone Joint Surg 1998;80A: Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68A: Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg Am 1991; 25B: Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intraarticular fractures of the distal radius. J Bone Joint Surg Br 2000;82B: Whipple TL. Intraarticular fractures of the distal radius and carpals. In: Whipple TL. Arthroscopic Surgery of the Wrist. Philadelphia, PA: JB Lippincott Company, 1992; Liberati A, Altman DJ, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339: b Coleman BD, Khan KM, Maffulli N, et al. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scan J Med Sci Sports 2000;10: Culp RW, Osterman AL. Arthroscopic reduction and internal fixation of distal radius fractures. Orthop Clin North Am 1995;26: Geissler WB, Freeland AE. Arthroscopically assisted reduction of intraarticular fractures of the distal radial fractures. Clin Orthop 1996;327: Augé WKII, Velázquez PA. The application of indirect reduction techniques in the distal radius: the role of adjuvant arthroscopy. Arthroscopy 2000;16: Shih JT, Lee HM, Hou YT, et al. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue managementofdistalradius.hand Surg 2001;6: Hardy P, Gomes N, Chebil M, et al. Wrist arthroscopy and intra-articular fractures of the distal radius in young adults. Knee Surg Sports Traumatol Arthrosc 2006;14: Kordiasewicz. Arthroscopic assessment of intraarticular distal radius fractures results of minimally invasive fixation. Ortop Traumatol Rehabil 2011;13: Wolfe SW, Easterling KJ, Yoo HH. Arthroscopic-assisted reduction of distal radius fractures. Arthroscopy 1995; 11: Adolfsson L, Jörgsholm P. Arthroscopically assisted reduction of intraarticular fractures of the distal radius. J Hand Surg Br 1998;23: Doi K, Hatturi T, Otusaka K, et al. Intraarticular fractures of the distal aspect of the radius arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg 1999;81A: Edwards CC, Haraszti CJ, McGillivary GR, et al. Intra-articular distal radius fracture arthroscopic assessment of radiographically assisted reduction. J Hand Surg Am 2001;26: Mathoulin C, Sbihi A, Panciera P. Interest in wrist arthroscopy for treatment of articular fractures of the distal radius: report of 27 cases. Chir Main 2001;20: Chen AC, Chan YS, Yuan, et al. Arthroscopically assisted osteosynthesis of complex intra-articular fractures of the distal radius. J Trauma 2002;53: Ruch DS, Vallee J, Poehling GG, et al. Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures. Arthroscopy 2004;20: Kamano M, Koshimune M, Kazuki K, et al. Palmar plating for AO/ASIF C3.2 fractures of the distal radius with arthroscopically assisted reduction. Hand Surg 2005;10: Hattori Y, Doi K, Estrella EP, et al. Arthroscopically assisted reduction with volar plating or external fixation for displaced intra-articular fractures of the distal radius in the elderly patients. Hand Surg 2007;12: Varitimidis SE, Basdekis GK, Dailiana ZH, et al. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg Br 2008;90: Lutsky K, Boyer MI, Steffen JA, et al. Arthroscopic assessment of intra-articular distal radius fractures after

9 Wrist arthroscopy in distal radius fracture, 2016, Vol open reduction and internal fixation from a volar approach. J Hand Surg Am 2008;33: Ono H, Furuta K, Fujitani R, et al. Distal radius fracture arthroscopic intraarticular displacement measurement after open reduction and internal fixation from a volar approach. J Orthop Sci 2010;15: Levy. Arthroscopic assessment of articular fractures of distal radius osteosynthesis by percutaneous pins. Chir Main 2011;30: Ono H, Katayama T, Furuta K, et al. Distal radial fracture arthroscopic intraarticular gap and step-off measurement after open reduction and internal fixation with a volar locked plate. JOrthopSci2012;17: Khanchandani P, Badia A. Functional outcome of arthroscopic assisted fixation of distal radius fractures. Indian J Orthop 2013;47: Abe Y, Yoshida K, Tominaga Y. Less invasive surgery with wrist arthroscopy for distal radius fracture. J Orthop Sci 2013;18: Abe Y. Plate presetting and arthroscopic reduction technique (PART) for treatment of distal radius fractures. Handchir Mikrochir Plast Chir 2014;46: Zemirline A, Taleb C, Facca S, et al. Minimally invasive surgery of distal radius fractures: a series of 20 cases using a 15 mm anterior approach and arthroscopy. Chir Main 2014;33: Lalone EA, Rajgopal V, Roth J, et al. A cohort study of one-year functional and radiographic outcomes following intra-articular distal radius fractures. Hand (NY) 2014;9: Pinal F, Klausmeyer M, Moraleda E, et al. Arthroscopic reduction of comminuted intra-articular distal radius fractures with diaphyseal-metaphyseal comminution. J Hand Surg Am 2014;39: Yamazaki H, Uchiyama S, Komatsu M, et al. Arthroscopic assistance does not improve the functional or radiographic outcome of unstable intra-articular distal radial fractures treated with a volar locking plate: a randomised controlled trial. Bone Joint J 2015;97-B: Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994;19A: Catalano LW, Cole RJ, Gelberman RH, et al. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg 1997; 79A: Goldfarb CA. Fifteen-year outcome of displaced intraarticular fractures of the distal radius. J Hand Surg 2006; 31A: Fernandez DL L, Jupiter JB. The fracture of the distal end of the radius: an historical perspective. In: Fernandez Deigo L, Jupiter Jesse B. Fractures of the Distal Radius: A Practical Approach to Management. New York: Springer, 1996; Marsh JL, Buckwalter J, Gelberman R, et al. Articular fractures: does an anatomic reduction really change the result?. J Bone Joint Surg 2002;84A: Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin 2005;21: Pinal F. Dry arthroscopy of the wrists: its role in the management of articular distal radius fractures. Scan J Surg 2007;97: Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg 2010;18: Gehrmann SV, Windolf J, Kaufmann RA. Distal radius fracture management in elderly patients: a literature review. J Hand Surg Am 2008;33: Herzberg G. Intraarticular fracture of the distal radius: arthroscopic-assisted reduction. J Hand Surg Am 2010; 35: