A Prospective Observational Assessment of Unicortical Distal Screw Placement During Volar Plate Fixation of Distal Radius Fractures

Anatomic Risks with Overpenetration of the Volar Locking Plates' Proximal Holes

Background  Volar locking plate fixation (VLP) is commonly used to treat distal radius fractures (DRF). Risk of dorsal compartment injury with distal screw hole fixation has been studied; however, the risk with proximal screw hole fixation is not well studied. Purpose  The goal of this study was to investigate the risk of dorsal structure injury from the screw holes proximal to the two distal rows. Methods  Nine cadaveric forearms were used. After volar distal radius exposure, a long VLP was applied. Kirschner wires were placed through the most proximal holes into the dorsal compartments. The extensor structures penetrated were noted and tagged with hemoclips. The distance from the dorsal cortex to the structures was measured. Results  The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle bodies were only penetrated; no tendons were penetrated. Proportion of muscle penetration increased with the more proximal screw holes. EPB was more likely to be penetrated distally and APL proximally; both were injured at holes 2 and 3. The extensors were 2 mm from the dorsal cortex of the radius on average; this did not decrease with compression of the forearm. Conclusions  This is the first study to examine the anatomic risk of extensor structure injury with VLP proximal screw hole penetration. No extensor tendons were penetrated by these proximal screw holes; first dorsal compartment muscle bellies may be irritated with overpenetration. Our findings suggest that proximal VLP screws do not need to be downsized if they are not over 2 mm prominent.

Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study

PURPOSE

Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture.

METHODS

International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results.

RESULTS

Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters.

CONCLUSIONS

Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool.

CLINICAL RELEVANCE

This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.

Evaluation of Unicortical Locking Screw Placement for Torsional Loads in Distal Radius Fractures: A Biomechanical Study in Cadavers

Background We aimed to compare bio-mechanical outcomes of short-length 75%-length uni-cortical screw (SL75UCS) and full-length 100%-length screws (FL100S) under axial compression (AXC) and torsional compression (TRC) in cadaveric distal radius volar plate model. Methodology A total of 20 wrists from 10 fresh frozen cadavers were included. A 2.5 mm titanium alloy distal radius anatomical plate was placed to the distal radii in full anatomical position, just proximal to the watershed line. Three bi-cortical screws to the shaft of the radius, followed by uni-cortical drilling for distal screwing were placed. Measurement by pulling the drill once it reached the opposite cortex was applied. We selected the screw lengths such that they corresponded to the SL75UCS. In the same configuration for each of the cadavers, we delivered six screws from distal radius holes of the anatomical plate. An oscillating handsaw was used to create an extra-articular distal radius fracture model (AO 23-A3.2). We created a dorsal AP model by performing a 1-cm wedge osteotomy from the dorsal aspect. Complete separation of the volar cortex was achieved. Potting was performed by embedding the shaft of the prepared radius into the polyurethane medium. We placed aluminum apparatus into the distal end to ensure applying of AXC and TRC in bio-mechanistic tests. Results No statistically significant difference of stiffness between the SL75UCS and FL100S both under AXC (p=0.88) and TRC (p=0.82). SL75UCS and FL100S groups did not differ in elastic limit under AXC (p=0.71) and TRC (p=0.71). Maximal force on SL75UCS and FL100S groups were also similar under both AXC (p=0.71) and TRC (p=0.50). Conclusions Our study findings suggest that drilling the dorsal cortex may not be necessary in the management of distal radius fractures. Instead, utilizing SL75UCS could serve as a viable alternative. This approach offers potential advantages in reducing the risk of extensor tendon complications associated with drilling or screw protrusion. It is a safe method under torsional load to avoid drilling of the dorsal cortex and SL75UCS could be performed in order to prevent from extensor tendon complications secondary to drilling or screw protrusion.

Computed Tomography Evaluation of Distal Screw Penetration in Volar Locking Plate Fixation for Intra-Articular Distal Radius Fractures

PURPOSE

Volar locking plate fixation for distal radius fractures (DRFs) is a technically demanding procedure with a risk of distal screw penetration through the dorsal cortex or the articular surface. This study aimed to investigate the incidence and details of distal screw penetration after volar locking plate fixation for intra-articular DRFs using a CT scan and to evaluate the relationship between the incidence of screw penetration and fracture comminution severity and the clinical complications of screw penetration.

METHODS

This was a retrospective case series of 91 adult patients (mean age, 63 years; 27 men) who underwent volar locking plate fixation for intra-articular DRFs from 2015 to 2018. The positioning of the distal screws was evaluated using a postoperative CT scan, and radiological outcomes were compared between the AO C1 and C3 groups. At the final follow-up, tendon rupture and arthritis severity were assessed as clinical complications of dorsal and intra-articular screw penetration.

RESULTS

Distal screw penetration was observed in 44 wrists (48%), dorsal cortex screw penetration in 34, intra-articular screw penetration in 13, and both dorsal cortex and intra-articular screw penetration in three. The incidence of intra-articular screw penetration was significantly higher in the C3 group than in the C1 group. No tendon rupture was observed. Multivariable analysis revealed that intra-articular screw penetration was significantly related to high severity of arthritis.

CONCLUSIONS

Approximately half of the study patients with intra-articular DRFs had distal screw penetration. The incidence of intra-articular screw penetration was associated with the severity of fracture comminution, and the intra-articular screw penetration was associated with the incidence of early radiocarpal arthritis. Intra-articularly penetrating screws should be replaced as soon as they are discovered, regardless of the length of penetrated screw or absence of patients' subjective symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Extensor Tendon Injury After Volar Locking Plating for Distal Radius Fractures: A Systematic Review

Distal radius fractures are common orthopedic injuries. Treatment has varied historically, but volar locking plating currently predominates. Although flexor tendon injury is a well-studied complication of this operation, extensor tendon injury is less well studied. The purpose of this review is to search the literature and present the epidemiology, presentation, and treatment of this complication. The Cochrane, EMBASE, PubMed, and SCOPUS databases were searched for the terms "volar" + "radius" + ("plate" OR "plating") + "extensor." Ninety final studies were included for analysis in this review. The incidence of extensor tendon rupture varies from 0% to 12.5%; the extensor pollicis longus is most commonly ruptured. The presentation and management of extensor tendon injury after injury, intraoperatively, and postoperatively are summarized. Radiographic views are described to detect screw prominence and minimize intraoperative risk. Extensor tendon injury after volar locking plate for distal radius fractures is an uncommon injury with several risk factors including dorsal screw prominence and fracture fragments. Removal of hardware and tendon transfers or reconstruction may be necessary to prevent loss of extensor mechanism.

Optimal screw length in volar locking plate osteosynthesis for distal radius fractures: a systematic review

BACKGROUND

Fractures of the distal radius represent the most common fracture of the upper limb, and can be managed surgically with volar locking plate osteosynthesis (VLPO). Uncertainty remains regarding the optimal length of the distal locking screws. The aim of this study was to determine the optimal VLPO screw length which provided adequate stability while minimizing complications.

METHODS

A systematic review of relevant literature published within Cochrane, PubMed, MEDLINE and Embase, including studies up to April 2020, was performed using the Preferred Reporting Items for Systemic Reviews and Meta-analysis (PRISMA) guidelines. Studies were included if they investigated distal radius fracture fixation with VLPO, screw lengths, complications, and associated imaging.

RESULTS

Search results identified 664 relevant studies, of which 14 studies examining 926 radii were included for review. Synthesis revealed that unicortical locking fixation with screws ~75% the depth of the radius, or 2 mm short of the dorsal cortex, provided equivalent stability to bicortical fixation. The lunate may be used as a proxy to determine radial depth at each quartile column. Inadvertent screw protrusion can be assessed by taking four images intra-operatively; anteroposterior (AP), lateral, 45° supinated and dorsal tangential views (DTVs). Radial shaft screws can have up to 2 mm prominence with no clinical significance.

CONCLUSION

Unicortical locking fixation at least 75% the depth of the distal radius provides equivalent stability to bicortical fixation in extra-articular fractures with lower complication rates. Imaging should be used to confirm that penetration of the dorsal cortex has not occurred.

Systematic use of short unicortical epiphyseal locking screws versus full-length unicortical locking screws in distal radius fracture volar plating: A prospective and comparative study

PURPOSE

Volar locking plates, used in distal radius fracture (DRF), present a risk of injuring extensor tendons with screws penetrating the dorsal cortex of the radius. Actually, even when aiming to use maximum-length unicortical locking screws, some still could be bicortical. We hypothesize the use of only short unicortical screws would allow a proper stabilization of the radial epiphysis without the risk of dorsal cortex penetration.

MATERIALS AND METHODS

A prospective monocentric non-randomized study was conducted. Patients with DRF (excepted for partial dorsal joint fractures) were treated in group A with short locking epiphyseal screws (16 mm for females, 18 mm for males) and in group B with full-length unicortical locking screws. Ultrasound was done 3 months postoperatively to evaluate the number and length of prominent dorsal screws. X-rays were performed after 6 weeks to assess stability according to volar tilt and radial inclination variations.

RESULTS

There were 37 patients in group A and 39 in group B with 148 and 156 epiphyseal screws, respectively. In group A, there were 0% of dorsal penetrating screws against 6.5% (10 screws from 8 patients) in group B (p < 0.05). There was no significant difference for the stability between the groups: mean volar tilt variation ( - 0.6° vs. - 0.7°) and mean radial inclination variation ( - 0.4° vs. - 0.4°).

CONCLUSION

For a same stability with volar locking plates for DRF, short epiphyseal locking screws should be preferred to full-length unicortical screws in order to prevent extensor tendon injuries. Based on 75% of distal radial average anteroposterior width for each sex, screw lengths of 16 mm for females and 18 mm for males seem to be the length to use. LEVEL OF EVIDENCE 2: Prospective, Comparisons made, non-randomized.

A Prospective Cohort Study on Accuracy of Dorsal Tangential Views to Avoid Screw Penetration With Volar Plating of Distal Radius Fractures

OBJECTIVE

To assess diagnostic performance of dorsal tangential views (DTVs) to detect dorsal screw protrusion in clinical practice.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Fifty consecutive patients undergoing volar plating for 50 distal radius fractures were prospectively included.

INTERVENTION

Fluoroscopic DTVs were routinely obtained, and screw revision was documented. Multiplanar reconstructions of postoperative CTs allowed for detection and quantification of dorsal screw penetration using reproducible measuring techniques.

MAIN OUTCOME MEASUREMENTS

Diagnostic performance (sensitivity, negative predictive value, positive predictive value, and accuracy) of DTV.

RESULTS

Intraoperatively, in 16 of 50 patients (32%), screws were revised based on DTV, with 13 of 218 screws (6.0%) being revised due to dorsal prominence. One screw was changed because DTV showed it was in the distal radioulnar joint. Postoperatively, in 10 patients (20%), the computed tomography revealed 12 additional screws penetrating ≥1 mm with an average of 1.8 mm (range 1.0-4.5 mm). DTV had a sensitivity of 52%, a negative predictive value of 95%, and accuracy of 95%. No ≥1-mm protruding screw remained in the third compartment.

CONCLUSIONS

In one-third of our patients, the incidence of protruding screws that can cause iatrogenic extensor tendon rupture was reduced by obtaining additional DTVs. Although DTV reduces the incidence of dorsal screw penetration considerably, this study reveals limited sensitivity. Therefore, one should keep in mind that dorsal screw penetration may go unnoticed on DTVs, and proper surgical technique remains paramount of DTV.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Radiocarpal joint stiffness following surgical treatment for distal radius fractures: the incidence and associated factors

Background

Postoperative radiocarpal joint stiffness (RJS) is common in patients with distal radius fractures (DRFs). The purpose of this study was to record the incidence of RJS and to determine potential risk factors that may be associated with it.

Methods

We retrospectively included a series of patients who suffered from DRFs and underwent volar plate fixation. Patients’ basic data, radiographic data, and postoperative data were collected. The incidence of RJS during follow-up was recorded, and both univariate analyses and multivariate logistic regression were used to determine factors associated with it.

Results

A total of 119 patients were included in this study. After surgical procedures, there were 42 (35.3%) patients with RJS and 77 (64.7%) patients without. The incidence of RJS after surgical treatment is 35.3%. Multivariate analysis showed that intra-articular fracture (OR, 1.43; 95% CI, 1.13–1.81), pre-operative severe swelling (OR, 1.35; 95% CI, 1.05–1.74), post-operative unsatisfied volar tile (OR, 1.38; 95% CI, 1.01–1.89), and improper rehabilitation exercise (OR, 1.72; 95% CI, 1.18–2.51) were correlated with the incidence of RJS during follow-up.

Conclusions

Patients with intra-articular fracture, pre-operative severe swelling, post-operative unsatisfied volar tile, and improper rehabilitation exercise were factors associated with the incidence of wrist stiffness. Preoperative risk notification and postoperative precautions are necessary for relevant patients.

Fixation of distal radius fracture with volar locking palmar plates while preserving pronator quadratus through the minimally invasive approach

BACKGROUND

The volar locking plate technique with an L-shaped incision of the PQ muscle through the classic volar Henry approach is a popular method for treating distal radius fractures. Recently we revised and improved this traditional technique by performing mini-invasive surgery.

OBJECTIVE

The purpose of this study was to evaluate the clinical effects after fixation of distal radius fracture with volar locking palmar plates while preserving the pronator quadratus through minimally invasive approach.

METHODS

From May 2014 to March 2017, 58 patients (38 males and 21 females) with an age range of 22-72 years (mean age 44.6 years) and with distal radius fractures underwent open reduction and internal fixation with volar locking palmar plates. The patients were classified as 23A-2 through 23C-2 according to the Orthopedic Trauma Association fracture classification system. All surgeries were completed by one trained team. The group that received volar locking palmar plates of distal radius performed with the traditional method through Henry approach involved 33 patients (21 males and 12 females) and the group that received PQ through minimally invasive approach group involved 25 patients (16 males and 9 females). We compared the two groups for wrist pain, forearm range of motion, grip strength, preoperative complications and wrist functional recovery score.

RESULTS

The minimum follow-up for the whole cohort was one year. The differences between the two groups were significant in terms of wrist pain, forearm range of motion, grip strength and wrist function at 1, 2, 6 weeks postoperatively, but insignificant at 3 and 12 months postoperatively. In the minimally invasive group a case of limited extension of the forefinger 3 months postoperatively was found. No significant differences were found for preoperative complications and radiographs postoperatively.

CONCLUSION

Fixation with volar locking palmar plates through minimally invasive approach is a satisfactory and optional method in the treatment of distal radius fractures. This technique yields better early wrist function, shortens rehabilitation time and gets high psychological satisfaction.

Predicting epiphyseal screw length in anterior plating of distal radial fractures

The purpose of this study was to determine whether optimal epiphyseal screw length could be predicted with reference to a given diaphyseal screw length when fixating a plate to the anterior surface of the distal radius. Computerized tomography scans of 40 wrists of 28 men and 12 women were semi-automatically segmented. A virtual anterior plate model was fixed to the distal radius. The mean maximal appropriate length of one diaphyseal screw and of the four distal epiphyseal screws were measured and linear regression analyses were performed. We found that the epiphyseal screw lengths were highly correlated to the diaphyseal screw length. Based on the data derived from measurements, we recommend epiphyseal screw lengths from ulnar to radial of 18, 18, 20 and 16 mm, respectively, if the diaphyseal screw is 14 mm or less. For diaphyseal screws longer than 14 mm we recommend epiphyseal screws of 20, 20, 22 and 18 mm. Using these recommended screw lengths as general guidelines may reduce the risk of intra-operative and postoperative extensor tendon injury.

Distal locking screw length for volar locking plate fixation of distal radius fractures: Postoperative stability of full-length unicortical versus shorter screws

We compared post-operative distal radius fracture (DRF) displacement after volar locking plate fixation using full-length unicortical and shorter-length distal locking screws. In this non-inferiority, retrospective cohort study, DRFs treated with volar locking plate fixation were evaluated on X-rays. In the full-length group, volar locking plate fixation was performed with full-length unicortical distal locking screws. In the shorter-length group, the distal locking screws were planned pre-operatively to be approximately 75% of the distal radius depth based on the lunate depth, and the same depth was drilled. Three radiographic parameters - ulnar variance, volar tilt, and radial inclination - were measured intra-operatively and at the final follow-up. The displacements were compared between the two groups. Each group contained 34 fractures. The mean ulnar variance between the two periods increased 1.1 mm in the full-length group and 1.3 mm in the shorter group (mean difference, 0.2 mm; 90% confidence interval, -0.3 to 0.6). The shorter group was not significantly inferior to the full-length one. Volar tilt increased 0.6° in the full-length group and -0.1° in the shorter group, while the radial inclination increased 0.1° in the full-length group and 0.2° in the shorter one. The differences in the increases were not significant. The post-operative DRF stability of 75%-length distal locking screws was not inferior to that of full-length unicortical screws. To prevent extensor pollicis longus tendon rupture, shorter distal locking screws and the same drilling depth may be preferable for volar locking plate fixation.