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Distal Radius Fractures: Techniques in Reduction and Volar Locking Plate Fixation
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Distal Radius Fractures: Techniques in Reduction and Volar Locking Plate Fixation
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
JEFF YAO: Today on behalf of the Department of Orthopedics at Rutgers, Robert Wood Johnson Medical School, we will be discussing and demonstrating an assortment of reduction techniques for use in conjugation with roller locking plate fixation of distal radius fractures. The authors have no disclosures or conflicts of interest report, though the premises saw bone models, tools and implants utilized were provided by Trimed Inc.
TODD ALTER: These fractures are the most common upper extremity fracture and they thus represent a large area of focus among hand surgeons. Furthermore, there remains a wide variety of treatment modalities that can be used to treat these fractures. These include closed reduction and splinting or casting external fixers, percutaneous pinning, open reduction internal fixation with the choice of dorsal roller and fragment specific plates and bridge plating.
TODD ALTER: Initially introduced in the early 2000s, the Volar locking plate quickly gained popularity, and it is now the most commonly used fixation device for distal radius fracture, open reduction internal fixation. Several advantages have been reported, including a favorable complication profile with a lower incidence of extensor tendon injury, the ability to obtain an anatomical reduction followed by early mobilization, good functional outcomes and high patient satisfaction.
TODD ALTER: As these implants have been utilized more and more frequently, countless reduction techniques have been developed to be used in conjugation with the volar locking plate. Outcomes for volar locking plates reported in the literature over the past two decades have been largely favorable. While volar locking plate fixation is not suitable for all fracture types and patients, there continues to be substantial evidence that it is a highly valuable option for many injuries.
TODD ALTER: One such study by Selles at al in 2021 compared acceptably reduced intra articular fractures treated with volar locking plates to nonoperative management and they found better functional outcomes at all time points, in addition to a 28% crossover rate from the non operative group. Gou et al performed a systematic review and meta analysis comparing volar locking plates to external fixators and found better functional and pain scores in the volar locking plate group as well as lower complication rates.
TODD ALTER: While there remains no absolute indication for the use of a volar locking plate, there are many patient and injury specific variables that must be considered. The patient's age, pre injury functional level, medical comorbidities and ability to comply with treatment protocols can all affect the success of volar locking plating. Associated injuries, such as bilateral or concomitant ipsilateral fractures, open injuries and median nerve dysfunction must also be considered. When the patient factors allow for it,
TODD ALTER: the primary indications for volar locking plating are volar shear injuries, radial shortening, dorsal tilt and intra articular step off. Contraindications include severe comminution, dorsal shear injuries, radial carpal dislocations, and some distal volar ulnar corner fractures. When a volar locking plate is selected, there are countless methods of fracture reduction that can be implemented.
TODD ALTER: Here is a non-exhaustive list of examples. Prior to plate application, these include manual reduction, use in osteotomy or freer elevator to restore volar tilt, use of a lobster claw clamp or lamina spreader to restore coronal alignment, insertion of intra focal pins, application of an external fixator for indirect reduction via ligamentotaxis or arthroscopic assisted reduction of intra articular components.
TODD ALTER: Once the plate has been applied, it can be used as a template, a push pull tool or a lamina spreader, can restore radio length and coronal alignment. The plate can be used as a kickstand. K wires can be used as joysticks for articular fragments or a dental pick can be used for fine adjustments. In this video, we will discuss the various reduction techniques for volar locking plate use in the context of a patient case.
TODD ALTER: Our patient is a 40-year-old right hand dominant male with no past medical history who works as an accountant and injured his left wrist after slipping on the ice. He was evaluated in the emergency room where he was noted to have a close deformity of his wrist without any neurovascular injury. He was then diagnosed with a distal radius fracture and promptly underwent a closed reduction in splinting by the orthopedic on call resident.
TODD ALTER: Here we see his injury films demonstrating an extra articular distal radius and ulnar styloid fracture with substantial dorsal displacement and angulation. Following closed reduction and splinting, the dorsal tilt returned to neutral, but the volar cortex had not fully re-engaged and the radial height remained suboptimal with associated collapse due to comminution. He followed up in our clinic approximately one week later, where his repeat radiographs appeared largely unchanged.
TODD ALTER: Following discussion of risks and benefits with the patient,
TODD ALTER: he elected and consented for open reduction, internal fixation with the volar locking plate. Prior to induction of anesthesia, the correct site was signed by the surgeon in the preoperative suite and the correct surgery and patient were confirmed with a timeout prior to incision. A non-sterile tourniquet is applied to the operative extremity and the arm is prepped and draped in a general fashion.
TODD ALTER: The FCR tendon is palpated and a longitudinal incision is marked along this tendon for approximately 6 to 8 centimeters, proximal to the wrist crease. The arm is then exsanguinated and the tourniquet inflated. The incision is made in a modified volar henry approach, is utilized between the FCR and radial artery, which must be accounted for at all times.
TODD ALTER: After incising the FCR sheath, the tendon is retracted and the sub-sheath is subsequently incised. The FPL is then exposed and retracted ulnarly thereby exposing the pronator quadratis. This is incised with a hockey stick shaped incision and elevated off the distal radius, exposing the fracture site.
TODD ALTER: An extended breaker radialis release can optionally be employed to enhance visualization and eliminate its pull on the radial styloid. A manual reduction is first performed with a combination of traction and manipulation by hand. A freer elevator may be then inserted at the fracture site and utilized as a lever to restore voter tilt.
TODD ALTER: When satisfied with the provisional reduction, an 0.45 k wire can be placed through the radial styloid from radial to ulnar to secure the distal fragment to the shaft. The volar locking plate is then inserted with care not to protrude beyond the watershed line and secured to the shaft with 2 k-wires.
TODD ALTER: The oblong shaft hole is drilled by cortically in the most distal aspect and filled with a cortical screw. This allows for later lengthening as needed. A dental pick tool can be used to create fine adjustments in the reduction and a rolled towel can be placed under the wrist distally to aid in the maintenance of the reduction. A locking guide is attached and a lunate fascet hole is drilled unicortically.
TODD ALTER: The locking screw is inserted until it is one to two turns from locking. In a volar locking plate with pulley axial bearings such as the one used here, the screwdriver can be used as a lever to push the screw head proximally, thereby lifting the distal end of the screw. When the volar tilt has been proximally restored, the screws advance until it is locked.
TODD ALTER: If volar tilt remains suboptimal, the shaft screws can be loosened prior to locking the distal locking screws, thereby increasing the plate shaft angle. Once the locking screws are fastened, the shaft screws can once again be tightened, serving as a kickstand. The correction of the plate shaft angle will now correspond with a similar correction in volar tilt. The remainder of the distal screw holes can be drilled unicortically and filled with locking screws or pegs with care taken not to reach the dorsal cortex, which would put the extensor tendons at risk.
TODD ALTER: Once the plate is secured distally, a push pull tool can be used to make fine adjustments to radial length and coronal alignment. One tong of the device is placed into the oblong hole screw head, while the other is placed in an empty distal hole. The oblong hole screw is loosened and the handles are squeezed, leading to an increase in radial height.
TODD ALTER: The device can also be rotated to create fine changes in chrono alignment. The screws can be fastened when a reduction is adequate. When satisfied with the final reduction in plate position, the remainder of the shaft holes are drilled by cortically and filled with cortical screws. If a push pull tool is not available, a lamina spreader and proximal by cortical shaft screw can achieve similar results.
TODD ALTER: The final intraoperative fluoroscopy images demonstrate reconstitution of radial height and coronal alignment, as well as a neutral volar tilt. A skyline view confirms that none of the distal screws have breached the dorsal cortex. Additional reduction techniques that were not utilized in the case have been demonstrated on sawbones models. Coronal plane deformity can be corrected by using a lobster claw to rotate the distal fragment. For dorsally displaced fractures,
TODD ALTER: a k-wire is placed into the fracture site dorsally and the pin is angled proximally into the medullary canal to push the distal fragment volarly and serve as a buttress. For fractures with radial displacement, a k-wire is placed at the radial most aspect of the fracture and angled proximally into the medullary canal to push the distal fragment ulnarly and serve as a buttress. Freer elevator can be used for intra articular sagittal split fractures to elevate the lunar facet fragment.
TODD ALTER: Once reduced, a k-wire is inserted through the scaphoid and lunate facet fragments for temporary fixation before plating. The wounds are closed with 12 vicryl subcutaneous interrupted sutures and then 4-0 nylon horizontal mattress sutures. The dressing consists of petroleum gauze, woven gauze, cotton roll, elastic bandage and an optional volar resting splint. The patient is instructed to ice and elevate their hands with finger motion as tolerated.
TODD ALTER: They return to clinic for suture removal at 10 to 14 days post operatively. Two weeks postoperatively, the patient did not require pain medications and had begun working on finger motion. His dressings and suture removals were removed and repeat x-rays were taken, which demonstrated maintained alignment. He was transitioned to a removable wrist splint and encouraged to begin focusing on wrist range of motion.
TODD ALTER: Six weeks postoperatively repeat X-ray showed maintained alignment and fracture consolidation. The patient's edema had resolved and he lacked only 10 degrees of wrist flexion and extension compared to his contralateral side. At this point, the removable wrist splint was discontinued and he was allowed to continue with activities as tolerated. This concludes our discussion of reduction techniques in volar locking plate fixation of distal radius fractures.
TODD ALTER:
Segment:0 .
JEFF YAO: Today on behalf of the Department of Orthopedics at Rutgers, Robert Wood Johnson Medical School, we will be discussing and demonstrating an assortment of reduction techniques for use in conjugation with roller locking plate fixation of distal radius fractures. The authors have no disclosures or conflicts of interest report, though the premises saw bone models, tools and implants utilized were provided by Trimed Inc.
TODD ALTER: These fractures are the most common upper extremity fracture and they thus represent a large area of focus among hand surgeons. Furthermore, there remains a wide variety of treatment modalities that can be used to treat these fractures. These include closed reduction and splinting or casting external fixers, percutaneous pinning, open reduction internal fixation with the choice of dorsal roller and fragment specific plates and bridge plating.
TODD ALTER: Initially introduced in the early 2000s, the Volar locking plate quickly gained popularity, and it is now the most commonly used fixation device for distal radius fracture, open reduction internal fixation. Several advantages have been reported, including a favorable complication profile with a lower incidence of extensor tendon injury, the ability to obtain an anatomical reduction followed by early mobilization, good functional outcomes and high patient satisfaction.
TODD ALTER: As these implants have been utilized more and more frequently, countless reduction techniques have been developed to be used in conjugation with the volar locking plate. Outcomes for volar locking plates reported in the literature over the past two decades have been largely favorable. While volar locking plate fixation is not suitable for all fracture types and patients, there continues to be substantial evidence that it is a highly valuable option for many injuries.
TODD ALTER: One such study by Selles at al in 2021 compared acceptably reduced intra articular fractures treated with volar locking plates to nonoperative management and they found better functional outcomes at all time points, in addition to a 28% crossover rate from the non operative group. Gou et al performed a systematic review and meta analysis comparing volar locking plates to external fixators and found better functional and pain scores in the volar locking plate group as well as lower complication rates.
TODD ALTER: While there remains no absolute indication for the use of a volar locking plate, there are many patient and injury specific variables that must be considered. The patient's age, pre injury functional level, medical comorbidities and ability to comply with treatment protocols can all affect the success of volar locking plating. Associated injuries, such as bilateral or concomitant ipsilateral fractures, open injuries and median nerve dysfunction must also be considered. When the patient factors allow for it,
TODD ALTER: the primary indications for volar locking plating are volar shear injuries, radial shortening, dorsal tilt and intra articular step off. Contraindications include severe comminution, dorsal shear injuries, radial carpal dislocations, and some distal volar ulnar corner fractures. When a volar locking plate is selected, there are countless methods of fracture reduction that can be implemented.
TODD ALTER: Here is a non-exhaustive list of examples. Prior to plate application, these include manual reduction, use in osteotomy or freer elevator to restore volar tilt, use of a lobster claw clamp or lamina spreader to restore coronal alignment, insertion of intra focal pins, application of an external fixator for indirect reduction via ligamentotaxis or arthroscopic assisted reduction of intra articular components.
TODD ALTER: Once the plate has been applied, it can be used as a template, a push pull tool or a lamina spreader, can restore radio length and coronal alignment. The plate can be used as a kickstand. K wires can be used as joysticks for articular fragments or a dental pick can be used for fine adjustments. In this video, we will discuss the various reduction techniques for volar locking plate use in the context of a patient case.
TODD ALTER: Our patient is a 40-year-old right hand dominant male with no past medical history who works as an accountant and injured his left wrist after slipping on the ice. He was evaluated in the emergency room where he was noted to have a close deformity of his wrist without any neurovascular injury. He was then diagnosed with a distal radius fracture and promptly underwent a closed reduction in splinting by the orthopedic on call resident.
TODD ALTER: Here we see his injury films demonstrating an extra articular distal radius and ulnar styloid fracture with substantial dorsal displacement and angulation. Following closed reduction and splinting, the dorsal tilt returned to neutral, but the volar cortex had not fully re-engaged and the radial height remained suboptimal with associated collapse due to comminution. He followed up in our clinic approximately one week later, where his repeat radiographs appeared largely unchanged.
TODD ALTER: Following discussion of risks and benefits with the patient,
TODD ALTER: he elected and consented for open reduction, internal fixation with the volar locking plate. Prior to induction of anesthesia, the correct site was signed by the surgeon in the preoperative suite and the correct surgery and patient were confirmed with a timeout prior to incision. A non-sterile tourniquet is applied to the operative extremity and the arm is prepped and draped in a general fashion.
TODD ALTER: The FCR tendon is palpated and a longitudinal incision is marked along this tendon for approximately 6 to 8 centimeters, proximal to the wrist crease. The arm is then exsanguinated and the tourniquet inflated. The incision is made in a modified volar henry approach, is utilized between the FCR and radial artery, which must be accounted for at all times.
TODD ALTER: After incising the FCR sheath, the tendon is retracted and the sub-sheath is subsequently incised. The FPL is then exposed and retracted ulnarly thereby exposing the pronator quadratis. This is incised with a hockey stick shaped incision and elevated off the distal radius, exposing the fracture site.
TODD ALTER: An extended breaker radialis release can optionally be employed to enhance visualization and eliminate its pull on the radial styloid. A manual reduction is first performed with a combination of traction and manipulation by hand. A freer elevator may be then inserted at the fracture site and utilized as a lever to restore voter tilt.
TODD ALTER: When satisfied with the provisional reduction, an 0.45 k wire can be placed through the radial styloid from radial to ulnar to secure the distal fragment to the shaft. The volar locking plate is then inserted with care not to protrude beyond the watershed line and secured to the shaft with 2 k-wires.
TODD ALTER: The oblong shaft hole is drilled by cortically in the most distal aspect and filled with a cortical screw. This allows for later lengthening as needed. A dental pick tool can be used to create fine adjustments in the reduction and a rolled towel can be placed under the wrist distally to aid in the maintenance of the reduction. A locking guide is attached and a lunate fascet hole is drilled unicortically.
TODD ALTER: The locking screw is inserted until it is one to two turns from locking. In a volar locking plate with pulley axial bearings such as the one used here, the screwdriver can be used as a lever to push the screw head proximally, thereby lifting the distal end of the screw. When the volar tilt has been proximally restored, the screws advance until it is locked.
TODD ALTER: If volar tilt remains suboptimal, the shaft screws can be loosened prior to locking the distal locking screws, thereby increasing the plate shaft angle. Once the locking screws are fastened, the shaft screws can once again be tightened, serving as a kickstand. The correction of the plate shaft angle will now correspond with a similar correction in volar tilt. The remainder of the distal screw holes can be drilled unicortically and filled with locking screws or pegs with care taken not to reach the dorsal cortex, which would put the extensor tendons at risk.
TODD ALTER: Once the plate is secured distally, a push pull tool can be used to make fine adjustments to radial length and coronal alignment. One tong of the device is placed into the oblong hole screw head, while the other is placed in an empty distal hole. The oblong hole screw is loosened and the handles are squeezed, leading to an increase in radial height.
TODD ALTER: The device can also be rotated to create fine changes in chrono alignment. The screws can be fastened when a reduction is adequate. When satisfied with the final reduction in plate position, the remainder of the shaft holes are drilled by cortically and filled with cortical screws. If a push pull tool is not available, a lamina spreader and proximal by cortical shaft screw can achieve similar results.
TODD ALTER: The final intraoperative fluoroscopy images demonstrate reconstitution of radial height and coronal alignment, as well as a neutral volar tilt. A skyline view confirms that none of the distal screws have breached the dorsal cortex. Additional reduction techniques that were not utilized in the case have been demonstrated on sawbones models. Coronal plane deformity can be corrected by using a lobster claw to rotate the distal fragment. For dorsally displaced fractures,
TODD ALTER: a k-wire is placed into the fracture site dorsally and the pin is angled proximally into the medullary canal to push the distal fragment volarly and serve as a buttress. For fractures with radial displacement, a k-wire is placed at the radial most aspect of the fracture and angled proximally into the medullary canal to push the distal fragment ulnarly and serve as a buttress. Freer elevator can be used for intra articular sagittal split fractures to elevate the lunar facet fragment.
TODD ALTER: Once reduced, a k-wire is inserted through the scaphoid and lunate facet fragments for temporary fixation before plating. The wounds are closed with 12 vicryl subcutaneous interrupted sutures and then 4-0 nylon horizontal mattress sutures. The dressing consists of petroleum gauze, woven gauze, cotton roll, elastic bandage and an optional volar resting splint. The patient is instructed to ice and elevate their hands with finger motion as tolerated.
TODD ALTER: They return to clinic for suture removal at 10 to 14 days post operatively. Two weeks postoperatively, the patient did not require pain medications and had begun working on finger motion. His dressings and suture removals were removed and repeat x-rays were taken, which demonstrated maintained alignment. He was transitioned to a removable wrist splint and encouraged to begin focusing on wrist range of motion.
TODD ALTER: Six weeks postoperatively repeat X-ray showed maintained alignment and fracture consolidation. The patient's edema had resolved and he lacked only 10 degrees of wrist flexion and extension compared to his contralateral side. At this point, the removable wrist splint was discontinued and he was allowed to continue with activities as tolerated. This concludes our discussion of reduction techniques in volar locking plate fixation of distal radius fractures.
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