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Distal Radius Fractures-Volar Plating for All

Francisco Rubio, M.D. Miami Hand and Upper Extremity Institute

Miami, FL

Frontiers in Upper Extremity Surgery 2017

Disclosure

Skeletal Dynamics- Consultant

• 85% Dorsal

• 15% Volar

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• Anatomical Reduction

• Early Function

• Stable Fixation

1970 - AO

Dorsal Plate Fixation

Extensor Tendon Disturbance

• Limited Motion

• Plate Removal

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Fragment Specific Fixation

1994

- Distal fragment does not toggle

- Provides stable distal fixation in comminuted or osteoporotic bone

1995 - Distal Radius Locking Plate Fixation

“π - Plate”

Extensor Tendon Ruptures

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- Plate redesign

The Dogma

Dorsal Fracture – Dorsal Plate

Palmar Fracture – Palmar Plate

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PQ

PQ

The volar approach seldom presents flexor tendon problems

Operative Treatment of Volar Intra-Articular Fractures of the Distal End of the Radius. - Jupiter JB, Fernandez DL, Toh CL, Fellmann T, Ring D. J Bone and Joint Surg. 78A: 1817-1828 1996

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A new method of treatment

Volar management of

the dorsal fracture

1997

Ineffective for Dorsal Fractures

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First PlateDesigned for

Volar Fixation of Dorsal Fractures

1998H-Plate

2002Volar Fixation for Dorsally Displaced Fractures of the Distal Radius:

A Preliminary Report.

JL Orbay, DL Fernandez; J Hand Surg 2002;27A:205–215

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4-6 weeks post-op

1998 - 2013Volar Plate Evolution

Fixed Angle FixationStrongest Possible Interface

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Plate acts as template and drill guide

Subchondral Support Scaffold

Ligament Contribution to Patterns of ArticularFractures of the Distal Radius

Daniel G. Mandziak, MBBS, Adam C. Watts, MBBS, Gregory I. Bain, PhD, MBBS

Journal of Hand Surgery. 2011.07.014

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LRL

RSCVRU

DRU

DRC

AMF

LFPMF

SRL

Load Transmission Through the Wrist in the Extended Position

Masataka Majima, MD, Emiko Horii, MD, Hiroshi Matsuki, MD, Hitoshi Hirata, MD, Eiichi Genda, MD

( J Hand Surg 2008;33A:182 – 188.)

Fracture fixation methods

• Pins/wires

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Hand (NY). 2014 Jun; 9(2) 230-236

Fracture fixation methods

• Pins/plates

Fracture fixation methods

• Plates and extenders

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Scaphoid Fossa Fixation

Lunate Fossa Fixation

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Lunate Fossa

Watershed Line

Watershed Line

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3 mm

Watershed Line

2 mm

Watershed Line

Watershed Line to Plate Distance

5 mmVolar Marginal Fragment

Volar Lunate Fragment

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Plate extenders

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Plate extenders

Radiographic Evaluation of Dorsal Screw Penetration After Volar Fixed-Angle Plating of the Distal

Radius: A Cadaveric Study  

 

Steven D. Maschke & Peter J. Evans & David Schub &

Richard Drake & Jeffrey N. Lawton

Hand. 2007 Sep; 2(3): 144–150

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Extended Tangential View“Carpal shoot through”

Marsland et al. Hand ( 2014) 9: 516-521

Extended Tangential View

MWFlexor Tendon Injury

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FDP IIFPL

Most Frequently Ruptured Tendons

#1 #2

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--------Volar Rim Lunate Fossa

Volar Radial -------Tubercle

Inter Fossa Sulcus

Tendon Center to Bone 4.5mmPlate to Tendon Surface ≈ 0mm

FPL

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0 1 2

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

“The Critical Line”

168 DRFs treated with volar plating

• Grade 0 0 Ruptures

• Grade 1 1 Rupture

• Grade 2 2 Ruptures

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

Group 1 (Acu-Loc) Group 2 (DVR) P Value

No. of patients 72 93

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

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Group 1 (Acu-Loc) Group 2 (DVR) P Value

No. of patients 72 93

No. of prominent plates, volar

Grade 0 19% 49% <0.0001†

Grade 1 18% 51% <0.0001†

Grade 2 63% 0% <0.0001†

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

Group 1 (Acu-Loc) Group 2 (DVR) P Value

No. of patients 72 93

No. of prominent plates, volar

Grade 0 19% 49% <0.0001†

Grade 1 18% 51% <0.0001†

Grade 2 63% 0% <0.0001†

No. of cases with

flexor tendon rupture(s)4% 4 4 4 4 0% 0.08

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and OlderRohit Arora,MD,Martin Lutz, MD, Christian Deml,MD, Dietmar Krappinger,MD, PhD, Luzian Haug, MD, and Markus Gabl,MD

J Bone Joint Surg Am. 2011;93:32146-93

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• Randomized: VLP vs Casting.

• “Simple volar approach” @ 1-2 weeks

• Operative group did better first 6 months.

• At one year both groups were almost equal.

• 36% vs 14% complication rate

• Total: 13 5

• Flexor 4 (plate prom) 0

• Extensor 6 (long screws) 0

• CTS 1 0

• CRPS 2 5

Operative Non Operative

• Total: 3 5

• CTS 1 0

• CRPS 2 5

Operative Non Operative

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Standard Fixation Technique

Complication rate and patient satisfaction after volar plating of distal radius fractures

J. L. Orbay, F. Rubio, E. J. Balaguer, L. Vernon

Unpublished data

- 808 consecutive patients

- 443 evaluated thus far (54.8%)

- 9.2% overall complication rate

- 4.3% required a second operation

- <0.5% infection rate

Complication rate and patient satisfaction after volar plating of distal radius fractures

J. L. Orbay, F. Rubio, E. J. Balaguer, L. Vernon

Unpublished data

- Overall satisfaction 91.4%

- 90.1% would have the same procedure again

- 92.6% would recommend their surgeon

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Volar Approach for Dorsal Fracture Not Trivial

Anatomical Plates

RequireAnatomical Reduction

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Using the Extended FCR Approach

• Release the radial septum

• Intrafocal Exposure

• Pronate the proximal fragment

• Release FCR tendon sheath

Standard Fixation Technique

Standard Fixation Technique

Removing dorsal hematoma allows reduction

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Dorsal rim fracture

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Bone Graft Support

2 mm Rule

2 mm

2 mm

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1- Reduce and Pin Lunate Fossa

2- Reduce and Pin the Scaphoid Fossa

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Volar rim fracture

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Prevent Collapse and Salvage Failures of theVolar Rim of the Distal Radius

J. L. Orbay, F. Rubio, L. Vernon

Journal of Wrist Surgery 2016;00:1–5.

21 patients

- 17 had volar marginal fixation at primary surgery

- 4 had volar marginal fixation as a revision

- No failures in primary VMF fixation group

- 2/4 had failure after revision

- 91% successful overall VMF fixation

- failure associated with revision fixation

Prevent Collapse and Salvage Failures of theVolar Rim of the Distal Radius

J. L. Orbay, F. Rubio, L. Vernon

Journal of Wrist Surgery 2016;00:1–5.

- For failed VMF fixation, opening wedge osteotomy

- Correct volar tilt to 5 degrees dorsal

- Restores supination loss seen after failed VMF fixation

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A combination

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Is there any role for a dorsal approach?

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Thank You!