If visual control of the articular surface during reduc- tion is necessary, a single volarapproach is contraindi- cated unless sufficient control of the articular surface can be provided by arthroscopy . This can be the case in joint depression fractures, in fractures with com- pletely displaced joint fragments or in fractures of the dorsal rim. These fractures are therefore also inap- propriate for the described technique. In the present study, polyaxial locking plates were exclusively used. The technique is also suitable for uniaxial plates. This may be an advantage for stability, but is disadvantageous for optimal placement of screws.
Surgical interventions were all performed 5 to 7 days after the time of injury when the posttraumatic edema had completely subsided. The volarapproach was ap- plied with flexor carpi radialis and median nerve pulled in the ulnar side and radial artery in the radial side. The soft tissue was carefully protected during operation. After pronator quadratus dissected longitudinally, the fracture was well exposed. With regard to the extra- articular fracture (Type A3), the temporary fixation k- wire was used immediately after the radius length, palmar tilt and radial inclination restored. For the intra- articular fractures (TypeB2, B3, C1, C2, C3), the arthros- copy technique was performed to check the articular surface anatomically restored and confirm the disappear- ance of the step-off. Locking screws were used in all the distal fracture fragments to support the articular surface. The position of the plate and correct reduction were confirmed using radiographic views. Range of motion and fracture stability were examined before skin closure. Active wrist mobilization began supervised by a physio- therapist immediately after operation.
After 1 week, the patients allocated to Cohort 2 will visit the orthopaedic outpatient clinic at the hospital where the treatment was initially started. This visit is part of the study protocol. If reduction is maintained, the pa- tients will undergo standard follow-up visits (=Arm 4). If reduction is lost to fulfill the inclusion criteria for surgery (> 10° dorsal tilt and/or > 2 mm step-off and/ or > 3 mm ulnar variance) the patient will be asked to participate to phase 2 of the study. After enrollment of the patients has been confirmed and informed con- sent signed, the patients will be randomized to either non-operative (=Arm 3 N) or operative treatment (=Arm 3O). If allocated to non-operative treatment, patients will undergo the same protocol as those in Arm 1. Patients allocated to operative treatment will undergo surgery with a volar locking plate by modified Henry’s volarapproach as described above. In addition, physiotherapy and exer- cises will be conducted as described above.
Surgery was performed under general or regional anaes- thesia with use of an arm tourniquet and administration of antibiotics according to local policy. A standard volarapproach through the bed of Flexor Carpi Radialis was performed. The Stryker Matrix Smartlock volar locking plate (Stryker Leibinger GmbH & Co. Germany) was used in all cases. This is a low profile, titanium plate incorporating 20 degree variable angle locking for all screws. Skin closure and postoperative immobilisation was according to the operating surgeon ’ s preference. Bone grafting and carpal tunnel decompression were not routinely performed, although carpal tunnel decom- pression was done at the time of internal fixation in 10 patients at the discretion of the operating surgeon. Rea- sons for decompression included pre-existing carpal Table 1 Outcome grading for Quick DASH and MAYO wrist scores
The linear external fixator to be used will be a radiotransparent bar with two pin fastening platforms, with one platform being proximal on the radius and the other platform distal on the second metacarpal, offered by Synthes (code – 03.304.220S). Four threaded self-drilling pins will be used with the proximal platforms that are 4.0 mm in diameter and the distal platforms that are 2.5 mm in diameter. Osteosynthesis with an external fixator will be achieved by the following surgical technique: closed reduction of the fracture by the reduction technique employing traction and contraction manipulation; confirmation of reduction with the image intensifier; a longitudinal incision of 1.5 mm in the dorsal aspect of the forearm and 8 cm proximal from the wrist joint on the longitudinal axis of the radius; exposure of the dorsal cortex of the radius by blunt dissection, introduction of the soft tissue protector positioned at a right angle to the coronal plane of the forearm; introduction of two 4.0 mm self-drilling Schanz pins with a T-handle; double 0.01 cm incisions over the dorsal aspect of the diaphysis of the second metacarpal with a 1 cm spacing between them; dissection and exposure of the dorsal cortex of the metacarpal; placement of the soft tissue protector at a right angle to the coronal plane of the hand; introduction of two 2.5 mm self-drilling Schanz pins, with a technique similar to that for the proximal pins, in the diaphyseal region of the second metacarpal. Should the fracture be intra-articular, this surgical technique may be combined with percutaneous fixation with 1.5 or 2 mm K-wires. Where dorsal comminution is present, a bone graft may be performed with bone removed from the iliac. Open reduction with volarapproach and volar locked plate.
osteoporosis, the anesthesia risk is high and it may be difficult to obtain good outcome via volar locking plate. A prospective randomized trial by Arora et al. found that older patients treated by volar locking plate fixation for dis- placed and unstable distal radial fractures had better grip strength than those by nonopera- tive treatment. Additionally, some other previ- ous studies also found that there were many satisfactory results of the volar locking plate in elderly patients with unstable DRFs [11-15]. However, the patients in these studies were in a large range of age (49-78 years or 17-79 years) or their age were not very old (above 65 years). Therefore, this retrospective study was aimed to investigate the efficacy of the locking plate fixation via volarapproach for the treatment of unstable DRFs in elderly population (75 years old and older).
Volar plate fixation has been recognized to be an effective and safe treatment in unstable distalradius fractures [1, 2]. Long volar plates are available in most surgical instrumen- tation boxes to manage distal radial fractures that extend to the diaphysis. The reasoning behind this treatment is that long volar plates can reduce the distalradius, stabilize the metadiaphyseal junction, and fix the diaphysis firmly, restoring the articular congruity and relationship, as well as the radial length and alignment. Wrist immobilization is limited to 3 or 4 weeks, allowing early functional recovery. We report the results of 21 cases treated with this technique using an extended Henry’s volarapproach. M. Rampoldi ( & ) D. Palombi
Open reduction and internal fixation using pre-contoured plates has become a surgical treatment option for dis- placed, unstable and comminuted fractures of the distalradius. They provide immediate stable fixation allowing early mobilization, which can result in rapid recovery and improved regain of function [1, 2]. Fixed angle plates using locking-screw technology allow surgeons to manage complex periarticular fractures since they give distal sta- bility by direct support of the subchondral bone and do not depend on distal screw purchase to maintain reduction . Distalradius plating can be performed using a dorsal or volarapproach; however, a higher rate of tendon irritation and rupture has been reported with the use of dorsal plates . Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conven- tional orthopedic materials, including the lack of metal allergies, radiolucency, low artifact interference on mag- netic resonance imaging scans and the possibility of tai- loring mechanical properties . In fact, compared with clinically used metallic implants, CFR-PEEK implants can L. Tarallo ( & ) R. Mugnai F. Zambianchi F. Catani
This prospective study was performed between 2005 and 2012. Inclusion criteria were a malunion following conservative treatment, with a dorsal tilt of the distal radial articular surface of more than 20°, articular dis- placement of more than 2 mm or incongruity of the distal radio-ulnar joint due to shortening of the distalradius in association with wrist pain and poor wrist range of movement. A total of 20 patients (8 women, 12 men) with a mean age of 40 years (range 17–64) were included in this study. The dominant arm was involved in 13 patients and the non-dominant arm in seven. Anesthesia was obtained by axillary nerve block. In all patients, a volarapproach to the distalradius was per- formed. A longitudinal incision along the flexor radialis carpi was made. The radial artery was preserved and dislocated radially. The pronator quadratus was released using an ‘‘L’’ incision from the radial insertion. After exposure of the volar margin of the distalradius, the distal portion of the DVR Ò plate (Hand Innovation) was held against the distalradius with K-wires. At this stage fluoroscopy was necessary to identify the correct posi- tioning of the plate on the volar surface of the radius and for planning the level of the osteotomy. The plate was then removed after marking the position of the plate
Use of this plate enables early joint mobilization with stable fixation construct owing to its close forming near articular margin and availability of different screw directions; proving its biomechanical superiorities. As well, the use of volarapproach poses minimal soft tissue trauma and good space for implant placement, avoiding the pitfalls of the dorsal approach like irritation of extensor tendon e and possibly late tendon ruptures (Schnur and Change, With volarapproach the large volar fragment, small fragment near the lunate fossa, the radial styloid and the ulnar fragment of the distalradius should be fixed with buttressing itself and with the use of spatially oriented small threaded screws as and when necessary. Separate screws, k- wires or tension band should be utilized to fix the radial or ulnar styloid fractures and unstable DRUJ. The very absence of fracture fragment displacement and shortening in our case is related to the proper plate placement within 2mm of the articular margin and securing each fragment with accurate placement of fixation screws.
The palmar ulnar cortex is richly embedded bone with the greatest trabecular density. The success of internal fixation techniques thrives on the fact that this superior quality thick bone, found in even the osteoporotic cadaver specimens. Distally, the radius attains a roughly trapezoidal shape. The radial styloid rotates palmarly 15 degrees off the axis of the radius. This makes it difficult to keep in reduced position from a dorsal approach. The lunate facet of the radius harbours the strongest bone. The line of force passes down the long finger axis, traversing through the capitolunate
Between February and November 2013, all patients with unstable distalradius fractures, treated with a poly- axial locking plate fixation [2.4 mm variable angle LCP Two-Column volardistalradius plate (Synthes GmbH, Oberdorf, Switzerland)], were prospectively included. Ex- clusion criteria were: I, patient’s age under 18 years; II, re- fusal of participation; or III, need for a dorsal approach or use of other implants. Surgical procedure: The operation was performed according to the manufactures technique guide. After final fixation of the distalradius fracture in- cluding the intraoperative control of fracture reduction and implant placement in the standard 2D fluoroscopy (postero-anterior and true lateral), the additional 2D fluo- roscopic tangential view was performed first, followed by the final intraoperative 3D fluoroscopic scan. If any screw misplacement was detected, an exchange of screws was performed immediately after each image control (tan- gential view or 3D fluoroscopy). The senior consultant classified the fracture types according to the AO-Müller (AO) classification system and analyzed all intraopera- tive control images. The number and cause for screw exchanges, as well as procedure time (in minutes) and radiation exposure (no. of fluoroscopic images, fluoros- copy time and dose area product) were recorded for each step. Additionally, the number of surgeons and their level of education were documented.
With the use of tourniquet, we made the tradi- tional Henry approach and extended it distally 2 cm if necessary but without crossing the wrist crease for adequate exposure of fracture frag- ment. After retracting flexor carpi radialis, medi- al nerve medially and brachioradialis and radial artery and vein laterally, the pronator quadr- ates was exposed and incised from proximity of its radial insertion, with 1-2 cm preserved for suture. Then, retract the pronator quadrates ulnar, fracture site is exposed; fracture frag- ments are identified and reduced under fluoro- scopic guidance. For classical Die-punch frac- ture that fracture line at the plane of impaction is transverse, periosteum elevator is introduced into the transverse impaction line to elevate the fragments until obtaining eveness of the subchondral bone line of the lunate facet with that of the scaphoid facet. For the other non- classical type of die-punch fracture that frac- ture fragments are impacted longitudinally and separated from the lunate facet, periosteum elevator is introduced into the longitudinal frac-
surgical approach was through the sheath of the flexor carpi radialis tendon. The Synthes oblique 3.5 mm LCP T-plate was used for 17 patients and the 2.4 mm LCP distalradius plate (Synthes, Paoli, Pensylvania) was used for the remaining 4 patients. The plate was applied to the volar aspect of the distalradius under direct vision and fixed proximally using the oblong hole to allow fine adjustment, the fracture was reduced and temporary fixation was maintained with K-wires. The reduction and plate position were routinely checked under image intensification. Distal locking screws were subsequently sited so as to reach but not penetrate the dorsal cortex. A measurement of 2 millimetres was routinely sub- tracted from the distal screw length measurement in order to avoid penetration of the dorsal cortex and to minimise the potential for extensor tendon irritation. Distal locking screws were positioned aiming to site them 2 mm below the joint line in order to provide sub- chondral support . A final check was made for plate and screw positions with image intensification using a standard postero-anterior view, two oblique views and a true lateral view of the wrist in order to ensure that the joint had not been penetrated .
Distal fractures of the radius comprise the largest por- tion of orthopaedic fractures, accounting for one sixth to one fourth of all fractures treated in clinical emer- gency departments . These fractures are more com- mon in postmenopausal women. The lifetime risk of sustaining a fracture of the distalradius is 15 % for women and 2 % for men . Among all fractures, dor- sally displaced distalradius fractures (DDDRF) are the most common. As the population is ageing, the specific incidence of this fracture type will, undoubtedly, in- crease in the coming years. In the past, many of these fractures were managed nonoperatively. However, the high incidence of malunion, associated with nonopera- tive management led to poor clinical outcomes, includ- ing pain and disability. Advances in internal fixation techniques have resulted in increased reliance on opera- tive approaches for the management of DDDRF. Closed reduction and fixation with percutaneous Kirschner wires (K-wire) has historically been the most common operative approach for distalradius fractures, providing a relatively quick and inexpensive treatment method .
In locking plate fixation, the locking plate is applied through an incision over the volar (palm) aspect of the wrist. The details of the surgical approach, the type of plate, and the number and configuration of screws were decided by the surgeon. The only stipulation was that the screws in the distal portion of the bone were “fixed angle”—that is, screwed into the plate—but this is the standard technique for the use of these plates. Some surgeons use a temporary plaster cast after the procedure, but the fixed angle stability provided by the locking plate is generally sufficient to allow early controlled range of movement exercises. The use or otherwise of a cast was again at the discretion of the surgeon.
We report a 38-year-old male with a nonunion followed by plate breakage after volar plating of a distalradius osteotomy. Volar locking plates have added a new approach to the treatment of distalradius malunions, due to a lower morbidity of the surgical approach and the strength of the final construction, allowing early mobilization and return to function. Conclusion. Plate breakage is an uncommon complication of volar locking plate fixation. To our knowledge, few cases have been described after a distalradius fracture and no case has been described after a distalradius corrective osteotomy. In the present case, plate breakage appears to have occurred as a result of a combination of multiple factors as the large corrective lengthening osteotomy, the use of demineralized bone matrix instead of bone graft, and the inappropriate fixation technique as an unfilled screw on the osteotomy site, rather than the choice of plate.
Both the severity of fracture and the damage of soft tissue will increase the risk of postoperative complica- tions. In this study, it was shown that open injury and AO type C fracture were independently associated with these complications. Sirnio et al.  studied 881 cases of distalradius fractures treated by VLP and found that open fracture was associated with a higher risk of post- operative complications (9% vs 7%), although the result did not reach statistical significance. In that study, it was speculated that the smaller size sample was related to the non-significant result because there were only 22 open fractures included. Glueck et al.  included 42 cases of open distalradius fractures and suggested the degree of wound contamination was significantly related to the postoperative infections, but not the classification level according to Gustilo and Anderson or Swanson system. Tsang et al.  found the rate of complications following VLP for treatment of AO type C distalradius fractures was 22.2%, which was slightly higher than ours (16.4%); the authors found the non-significantly different complication rate between volar and dorsal surgical approach (25% vs 19.0). We recommend that type C frac- tures especially with contamination should be treated with multiple and thorough debridements as part of the initial treatment plan to reduce or prevent the complications.
In all cases, the deformity started during the first year of life and worsened afterward. Wrist and upper extremity radiographs revealed that the radius was shorter than ulnar bone. In anteroposterior radiograph, there was a slope in distal articular surface of the radius from ulnar to radial side. A triangular radiolucent area was located at the lateral half of distal metaphyseal area of the radius surrounded by sclerotic rim. In lateral view, there was a focal volar angulation at the deforming area with V shape apex dorsal indentation. Imaging modalities of MRI and CT scan (performed for two of our patients) did not help in diagnosis and treatment. All routine tests including CBC, ESR and CRP had normal findings in our patients. We did dorsoradial approach for all three cases and we noticed that the extensor tendons in radial side were short and the extensor carpi radialis longus and brevis had subluxation to the volar side. The median nerve in volar side was very close to the concave side of the radius and we found it very susceptible to iatrogenic damage in surgical approach because of the altered anatomy. This was true for brachioradialis muscle tendon and ra- dial artery and nerve. Distalradius was distorted three dimensionally by traction force of tethering band. A thin fascia had covered the pathologic tissue in all cases. An extra-osseous tethering band originated proximally from radial half of volardistal metaphysis of the radius and terminated to its epiphysis in distal. There was no insertion to the physis. It was taut rectangular fibrous band with approximate dimensions of 15 × 10 × 3 mm. The pathologic examination revealed that the specimens consisted of fibrous tissue with mild hypercellularity containing areas of hyaline cartilage and admixed with pieces of collagenous tissue. After resection of the band, a V shape sclerotic and dense indentation remained in volar side of the distalradius.