Surgical Techniques to Manage the Unstable Volar Lunate Facet Fragment of Distal Radius Fractures.

Abstract

The surgical treatment of distal radius fractures is one of the most common procedures performed by orthopaedic surgeons. Intraarticular fracture patterns, specifically those involving the volar lunate facet, can be particularly problematic because this fragment is crucial to radiocarpal and distal radioulnar joint (DRUJ) stability. The problems associated with these patterns are attributed to the anatomy of the volar ulnar corner of the distal radius as well as the limitations of conventional volar distal radius implants and common surgical exposures. This article will review the distal radius anatomy specific to the volar ulnar corner; a review of conventional distal radius volar plating technique; indications and associated complications of instability of the volar lunate facet; and techniques for volar lunate facet fixation. Fractures of the volar lunate facet are typically associated with fracture patterns involving the entire distal radius articular block with varying degrees of comminution, but it is not uncommon to encounter these fractures in isolation as well. There are many techniques and constructs available to treat these fractures, all of which involve careful preoperative planning and precise execution. The appropriate placement of volar distal radius plates is critical, and when performed, can address most intraarticular distal radius fractures that do not include the subset of fractures with smaller volar lunate facet fragments. Adequate intraoperative fluoroscopy with visualization of the incisura of the DRUJ should furthermore be achieved to avoid intraarticular penetration of the DRUJ. At the conclusion of fixation, lateral and inclined lateral fluoroscopic imaging should be obtained to confirm extraarticular screw placement proximal to the lunate and scaphoid facets, respectively. Consideration of an intraoperative assessment is warranted given the potential instability of these fractures.