A new single volar approach for epiphyseal ulnar and radial-sided comminutive fracture of the distal radius: the mediolateral windows approach

Treatment of the Distal Forearm Fracture by Volar Dual Window Approach

BACKGROUND

Distal forearm fractures were defined as distal radius fractures with concomitant distal ulna fractures, except ulna styloid fractures. Distal forearm fractures are common among geriatric populations, particularly those with osteoporosis. Conventionally, distal forearm fractures are reduced by a double incision approach; however, malreduction and instability of the distal radioulnar joint were not uncommon. We introduced a modified volar dual window approach to treat the distal forearm fracture and evaluate the functional outcomes and complications.

METHODS

From January 2020 to June 2023, 13 patients with distal forearm fractures underwent open reduction by the modified dual window approach with locking plate fixation. After surgery, splints were applied for two weeks, and the patients underwent postoperative hand therapy for three months. The mean Quick Disabilities of the Arm, Shoulder, and Hand scores, range of motions, grip strength, postoperative radiographic parameters, and complications data were collected.

RESULTS

The mean follow-up period was 12.1 months, and the mean age was 52.3 years. Average wrist flexion was 67°, extension 69°, pronation 81°, and supination 79°. Grip strength was 28.3 ± 11.5 kg, which was 88% of the uninjured opposite side. The Visual Analog Scale score during activities was recorded as 0.5 ± 0.9. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14 ± 11.5. The postoperative radiographic parameters were as follows: radial height: 10.8 ± 1.7 mm, radial inclination: 22.6 ± 3.7°, volar tilting: 4.0 ± 3.9°, and ulnar variance: -0.4 ± 1.4 mm. All the patients achieved bone union at the final follow-up. Two patients underwent ulnar implant removal due to irritation symptoms. Neither infection, nor neurovascular injury, nor malreduction developed in these patients.

CONCLUSIONS

The modified volar dual window approach can achieve good wrist function and distal forearm fracture reduction without increasing neurovascular or wound healing complications. This method is an alternative approach for distal forearm fracture, especially in comminuted distal ulna fracture or distal radioulnar joint incongruity.

Arthroscopically Assisted Treatment of Volar Rim Fractures

Background  Arthroscopically-assisted reduction and internal fixation (AARIF) for distal radius fractures (DRF) has been extensively described. Little information is available about AARIF in AO "B3" and "C" DRF with displaced lunate facet volar rim fragment (VRF) and volar carpal subluxation. However, lunate volar rim fragment (LVRF) may be very difficult to reduce and fix under arthroscopic control using the flexor carpi radialis (FCR) or FCR extended approaches while traction is applied. Purposes  The aims were to describe our surgical technique of AARIF of partial or complete DRF with VRF and provide information about how often this technique may be necessary, based on a large DRF database. Methods  The dual-window volar approach for complete articular AO C DRF with volar medial fragment was described in 2012 for performing open reduction internal fixation (ORIF). Since 2015, we have used the dual-window approach for AARIF of "B3" or "C" DRF with volar carpal subluxation. We analyzed our PAF database, searching for patients treated with AARIF in "B3" and "C" fractures. Results  The dual-window volar approach is very useful when using AARIF for AO "B3" and "C" DRF with displaced VRF and volar carpal subluxation. The anteromedial part of the exposure allows a direct access to reduction and fixation of the LVRF under traction and arthroscopic control. Overall, 1% of all articular DRF in this series showed a displaced LVRF amenable to the dual-window volar approach. Conclusion  It is almost impossible to access and properly fix a VRF using traction and arthroscopic control through the FCR or FCR extended FCR approach because of the stretched flexor tendon mass. The use of the dual-window approach during AARIF of AO "B3" or "C" DRF has not previously been reported. Displaced VRF are rare whether they were part of "B3" or "C" fractures. If AARIF is chosen, we strongly recommend the use of the dual-window volar approach for AO "B3" and "C" fractures with VRF. A single anteromedial approach can also be used for isolated "B3" anteromedial DRF.

Single Incision, Dual Window Approach for a Comminuted Distal Radius Fracture

Introduction  Complex distal radius fractures often involve a fragment of the volar-ulnar articular surface and the radial styloid. The volar ulnar corner of the distal radius is an important constraint to volar translation of the carpus and thus requires stable fixation to prevent wrist displacement. The traditional volar Henry approach often requires undue tension on the median nerve while retracting for access to the ulnar aspect of the radius. To protect the median nerve from iatrogenic injury and to improve exposure of the surgical site, we propose a single incision, dual window approach to the distal radius for complex bi-columnar fractures. Methods  This technique combines the trans-Flexor Carpi Radialis (FCR) approach with a subcutaneous dissection to the ulnar aspect of the wrist. This window utilizes the interval between the ulnar neurovascular bundle and the carpal tunnel contents. Results  This technique allows the surgeon to work through either window and thus visualize and directly fixate the various fracture fragments. We have treated complex articular distal radius fractures associated with ulnar communition with this novel technique and it has provided direct reduction with improved fragment access. The surgical technique, a case presentation and results are detailed in this report. Conclusion  This case report has demonstrated that complex bi-columnar fractures of the distal radius can be effectively approached and fixated with a single incision dual window approach.

Plate coverage predicts failure for volarly unstable distal radius fractures with volar lunate facet fragments

INTRODUCTION

Loss of reduction after operative fixation of volarly unstable distal radius fractures with a volar lunate facet fragment (VLF) is considered problematic because it results in carpal subluxation or dislocation and subsequent impaired function. We hypothesized that the indicator of loss of reduction of the VLF after fixation is plate coverage of the bony fragment. We investigated the relationship between the plate coverage of the VLF and loss of reduction after fixation, and calculated the plate coverage that was associated with failure of fixation of the VLF.

MATERIALS AND METHODS

We conducted a retrospective review. We included patients with surgically treated volarly unstable distal radius fractures with VLF with a volar locking plate who had a minimum follow-up of 6 months. A total of 33 patients (35 wrists) met criteria for inclusion into the study. The patients were divided into a displacement group and a non-displacement group. We calculated and compared longitudinal dimension and plate coverage of the VLF between the two groups to reveal the risk factors for loss of reduction.

RESULTS

At final follow-up, 25 fractures maintained radiographic alignment and 10 (28.6%) lost reduction. Univariate analysis between the two groups showed that plate coverage against the transverse and longitudinal dimension of the VLF was correlated with loss of reduction after operative fixation. In multivariate logistic regression analysis, only plate coverage against the longitudinal dimension of the VLF remained a significant predictor of failure. With 64.7% as the cut-off point for plate coverage against the longitudinal dimension of the VLF, the sensitivity and specificity of the prediction were 96% and 80%, respectively.

CONCLUSION

The predictor of loss of reduction after fixation of volarly unstable distal radius fractures with a VLF was plate coverage against the longitudinal dimension of the VLF.

A New Single Volar Approach for Both-Bone Fractures of the Forearm: The Mediolateral Windows Approach Extended

Fractures of the forearm are common injuries in adults. Particularly, both-bone fractures of the radius and ulna are frequently encountered by orthopedic surgeons. To date, these fractures are typically treated with open reduction and internal fixation, because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. We propose a modification of the classic double approach for both-bone fractures of the distal radius and ulna. Indeed, we described a minimal and anatomic approach to prevent complications such as the heterotopic ossification of the interosseus membrane and vascular-nervous lesions. By a single anterior incision, we utilize 2 windows to expose the medial and lateral compartments of the forearm. In this way, we avoid the handling of the interosseous membrane, and we protect the ulnar, median, and radial nerves from the surgical approach. This technique is indicated for complex distal radius and ulna fractures. We exclude open fractures, and Monteggia, Galeazzi, or Essex-Lopresti lesions. In this report, we describe the surgical anatomy, surgical approach, and complications regarding this approach.

A Brachioradialis Splitting Approach Sparing the Pronator Quadratus for Volar Plating of the Distal Radius

Fractures of the distal radius account for up to 15% of all extremity fractures. Volar plating has become more popular, as it allows locking plate technology to be applied. Traditionally, access to the volar radius has been achieved through the approach of Henry using the interval between flexor carpi radialis and the radial artery, involving incising the radial border of the pronator quadratus (PQ). With this approach, PQ repair is difficult, and when attempted is often incomplete or tenuous, as it is a direct muscle-to-muscle repair. Theoretical advantages of repairing the PQ include the provision of plate coverage, a protective gliding layer, a well-vascularized coverage of the fracture fragments, and a protective barrier against deep infection in the case of superficial infection. Techniques have been developed to try and improve on the Henry approach. We have developed a surgical approach to volar plating that utilizes the anatomic relationship between brachioradialis and PQ in a way that allows simple and stable reattachment of the PQ muscle. We have termed the technique the "Brachioradialis splitting" approach. We present it here.

Anterolateral surgical approach to the malunited distal radius fracture for corrective osteotomy and bone-graft harvest

The most common complication after distal radius fractures is union with deformity. When symptomatic, distal radial malunions may require operative intervention. Numerous approaches to the distal radius have been described. Most volar approaches involve sectioning the brachioradialis and opening the first extensor compartment to permit adequate exposure. When bone graft is required, this may necessitate a separate incision and further add to the morbidity. We present an alternative anterolateral surgical approach to the distal radius, which allows for excellent exposure, and minimal trauma to the tendons while permitting harvest of local bone graft through the same incision.