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VID1-00974-EN | A | Spanning Plate for Distal Radius Fractures

Sanj Kakar

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Spanning Plate for Distal Radius Fractures

Now we're going to talk about spanning plating of distal radius fractures. Here you'll see the plate how it's designed. It's designed as it comes distally. It's tapered to allow us to place a 2.4mm screw. And more proximally you can see that the screws are larger, which will be a 3.5mm screw. In addition, please note that there are also screws in the central aspect, which will allow you to fix fractures if you need to and give subchondral support. It's dealer's choice as to your preference. You can either go to the index or long finger metacarpals. I tend to like to go to the index finger metacarpal. It's a straighter line of application. And also note that there was a recent article in the Journal of Hand Surgery showing that if you're going to put it under the long finger, you need to watch out for the EPL as you can inadvertently trap the EPL. So what I like to do is first put the plate on on the wrist and then mark your incision. So now we're going to make our incision over the index finger metacarpal. It's the same type of incision. For example if you're putting a TightRope in or an external fixator. Key thing here is to watch out for the dorsal sensory branch of the radial nerve. It's always there. One needs to protect that and respect it. So here you can see right underneath the skin there's the nerve. So raise full thickness skin flaps. And basically the most important thing here is to protect and respect that nerve and move it out of harm's way. You can see here it wants to go ulnar. And that's where we're going to take it. Now you can see here's a branch of the on the radial side. So we'll respect that. And you're down right onto index finger metacarpal. And the key thing here now is to dissect straight down onto it. And you want to come underneath the fascia. Remember the ecrb attaches on the base of the index finger metacarpal. And we want to slide the plate underneath that going from I personally like distal to proximal but you can go proximal to distal. So here you'll see the fascia. We're going to basically come underneath this fascia because the plate is going to slide underneath this. And what I like to do is essentially you're now dorsal to the To the capsule, and you push the freer and you'll see with with relative ease how the freer elevator now has gone underneath the skin. And this is where the plate will be going. And so use the freer here. And it's creating that tunnel that you're going to do later on to slide the plate. So now we're making our approach to the radius key thing here is remember you're placing this plate underneath the ecrl and ecrb. So the dorsal sensory branch of the radial nerve will be in play here. And here's the the fascia overlying the musculature. And you'll see now there are the tendons there of the ecrl and ecrb. And as we come right underneath, I'm looking out for the nerve. And there's the radius right here. And this is where our plate will be fixed proximally. So now you can see here we're passing the freer elevator underneath the tendons. That's key. It has to be underneath the tendons. And we're on to the radius. So now we've created a nice passage to pass the spanning plate. So now what we've done here we've placed the 3.5mm millimeter locking tower into the plate. And this essentially acts as twofold. Number one, you can drill through this. But for this stage I like to use this as a handle. And we're passing the plate here from proximal to distal. You can do distal to proximal. It doesn't really matter. Obviously if you're going to go from distal to proximal you'll put the 2.4mm locking tower in the distal aspect of the plate. So here now you can see I'm underneath the cell and I'm hugging the radius. And I'm just using the tower as a handle to push. And as you can see it comes out distally. So now what I've done is I've put the 2.4mm tower into the distal screw. And I do this because now I can use it as a handle to tweak the plate into the position that I like. We'll now check its position on the Flora scan. And then we can place non locking screws proximally and distally to hold this down to the bone. So now here you can see I'm using the locking tower to position the plate over the second metacarpal. And more proximally you can see again how I'm using that tower to capture that onto the radius. And I think that looks pretty good. Now, the key part of this is to make sure that the screw is placed bicortical through the metacarpal. And what you can see here is I've positioned the plate such that the other screws should be bicortical two. And with the locking guide I can move the plate proximal to distal to my fancy. And then through the oblong screw hole this is where we're going to place the non-locking screw. If you look here at the distal aspect of the plate there's a key wire hole. And that's for two reasons. Number one, you saw when I placed the plate, I used a freer elevator to create a passage. But sometimes what you can do is, is place a heavy duty wire through this and pull the plate through. The second advantage of having this key hole is rather than using, for example, a tack, if you didn't want to put it into this shaft, you can put a key here to provisionally stabilize the plate and get an idea of the length that you can move it proximally to distally on the metacarpal. Now, with the locking screw, I haven't bought my screw distally. I haven't tightened it down. I can now adjust the plate. And this is now where you do your traction and carpal Possible relocation maneuver to reduce the fracture and get provisional restoration of length of your radius fracture. Now, I've deliberately placed a screw through the tower here because I know we've got good restoration of radial length. If I wasn't confident on that, I would put it through the oblong screw here. And that will give me. You can see the length of this oblong screw to either compress or distract. So there you can see our screw is placed into the oblong screw holes. It's bicortical. And then we can place screws proximal and distal to that. So there you can see the placement of the shaft screws. And we've cheated this deliberately radial. Because remember these patients often have for example a ulna corner fragment. And that can be fixed with a ulna corner plate. But you can see all our screws now will be bicortical. And we also have screws in the shaft of the plate which will allow us to place screws either subchondral or, if you if you wanted extra fixation within the carpus generally not needed. Generally, place those screws within the shaft of the radius. So now we've fixed distally. We're now going to do hybrid fixation. Approximately the screw is sucked the plate down nicely. So now I'm going to put locking screws into the shaft. So here you can see we have three screws I think at a minimum you want to have three screws in the shaft and three screws in the second metacarpal. At a minimum this screw hole has been left open. But you can put another non-locking screw in there if you desire. So there you can see the fixation in the index finger metacarpal. There you can see the stabilization of the plate at the shaft of the radius, cheating radially because it's over the index finger metacarpal as well. If you had it on the long finger metacarpal the plate would sit a little bit more centrally. So now you can see the tilt lateral radiograph. You can see how the plate is sucked down nicely overlying the fracture giving us that dorsal buttress as you need. And don't forget there are screw holes in the central aspect of the plate. If you wanted to put them subchondral on the radius if needed. What we've done here is we've made a small incision, because I want to place a screw underneath the subchondral bone. So you can see on the flora scan, we marked out the incision. It's a small incision. Spread the tendons medially and laterally as needed. And now we're going to use the variable angle guide to give us our desired trajectory of the screw. Okay. Let's take a look. So there you can see the screw is placed on the AP plane. And on the lateral radiograph you can see it's giving some subchondral support. If I needed to have that I would move the plate proximally and distally. But I would have factored that in my initial decision before I'd locked the plate proximally and distally. But you can see the advantage here is that there are screw holes and a position if you need them to give you subchondral support.

Spanning Plate for Distal Radius Fractures

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