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VID1-00975-EN | A | Radial Styloid Plate

Sanj Kakar

Human

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Radial Styloid Plate

Okay. So now we're going to talk about radial column fixation. Essentially two approaches for the radial column you can do an extended CRx approach. Remember that goes from the distal pole of the scaphoid to the distal wrist crease to the proximal wrist crease along the CRx and becoming radial. You can raise the subcutaneous envelope and retract the skin to give you the radial column exposure. Alternatively, you can do a radial column direct exposure, and what I like to do is here, as you can see, the styloid and we're basically going between the first and second dorsal extensor compartments. You want to be very wary and respectful of the anatomical structures here. And essentially that's the dorsal sensory branch of the radial nerve and a branch of the lateral antebrachial cutaneous nerve. So once you're through the skin we'll then use dissection scissors. And essentially here we're raising full thickness skin flaps. And in doing so we're trying to keep the dorsal sensory nerves. You can see there's a branch just running right here with the skin flap. So this actually wants to stay volar. So you can see I've released this now. And so the nerve is staying with the volar skin. So what you can see now is that we have the first and we have the second extensor compartment tendons. And we're just going to incise the first extensor compartment. But cheating dorsally thereby giving you a shelf to prevent subluxation of your tendons. Now you have two options here. You can either leave the distal centimeter of the extensor retinaculum intact so these tendons do not subluxated, or you can release it, but then you'll need to repair it afterwards. So we're basically going to leave it within its envelope distally. So you can see here I've released the extensor compartment but distally I've left it intact. So this will prevent subluxation. I've also cheated the incision dorsal. That gives us this nice volar leaflet to prevent volar subluxation of the tendons. And now we're directly on the radial column. And here's the second extensor Compartment and we can release that again. Release it proximally, but leave it attached distally so you're not getting instability. So now you can see here it's like a cloverleaf design of the radial column plate. This is a five hole plate. And what you'll notice is that there's an oblong hole here to allow for the plate to cheat proximally or distally. And you also have this cloverleaf. And all of these are variable angle locking screws. And they're designed such that this most distal screw runs parallel to the subchondral bone of the distal radius. So now I'm putting my transradial Styloid K-wires. There's a couple of ways of doing this. If there is not intra-articular fracture and you want to get the reduction, you can either do it indirectly, whereby you reduce the fracture and take a fluoroscopic image, or you can make a dorsal approach while you're looking directly at the joint and levering the fracture over. I like to put a bump underneath the wrist, and in that way I can only deviate the wrist and it pulls the fragment distally to get it to its appropriate alignment. And remember that the that the radial styloid is a lot more dorsal than you think. A lot of the times people think the styloid is a volar structure, it's actually more dorsal. It's more of a midline structure. So here we have a bump underneath the radius. We're only deviating it. And that now is helping to pull the radial styloid back into its anatomical footprint. So you can see now on the lateral view we're perfectly centered within the styloid holding our fragment in place. So now what we're going to do is we're going to slide the plate over the distal hole of the K-wires. Slide it underneath the first extensor compartment. Tendons. You can see the first and second are retracted out of harm's way. And you can see that the contour of that cloverleaf that I was mentioning fits perfectly to the contour of the radial styloid. Now, to help secure the plate to the bone, you can either put a non-locking screw or what we're going to do is put one of these tags, which essentially sucks the plate down to the bone. And the beauty of these is that you're not married to its position. You can always tweak this and move it out of harm's way. So you can see there's the BB-Tak essentially locking the plate down. And now we'll check its position. And if we don't like this, we can simply take it out. It's essentially the whole of a k wire. And you can move the plate proximally or distally. So now you can see the position of that plate has contoured perfectly to the styloid. The BB-Tak has held it down. And if you don't like it, simply take the BB-Tak out. If you like it like we like it here, we can now start our fixation here on the lateral view, you can see how the plate sits, and you can see that it sits much more dorsal than you would think initially, but that is the correct position of the plate. So now we're looking at the AP radiograph of the radius. You can see there's the distal styloid K-wires and the plate placed on top of this hugging the radial styloid and the radial column. Now we're putting in the non-locking screw. That will also enhance its the plates reduction to the plate. And it's a transradial drill hole through to the other side. You can alternatively put a locking screw in here because the tack is also functioning as a non-locking screw. So now we're placing the rest of the screws. We're doing hybrid fixation which is a combination of locking and unlocking fixation. We are placing these screws transradial. They don't have to be. Especially the most proximal screws can be a little bit shorter and can be uni cortical to decrease her stress rising. So now we're moving on to fixing the styloid. The styloid is currently being TransFix with this K-wires, but now we can place screws proximal to this if the fragment is large enough to capture that distal fragment. One of the keys in putting in the distal screws is. Remember, the druj is just opposite you, so you do not have to be bicortical here. And because we have locking screw technology, it locks into the plates. Okay. Now we're going to remove this trans radial styloid K-wires. We have excellent purchase of our distal fragment. And this is essentially a home run screw just hugging the subchondral support of the radius. So here now you can see on the AP view how we've got subchondral support of that radial Styloid fragment. Now remember on the ulnar side you may have a volar ulnar hook plate. You can make those screws longer if you want. But the key thing here is to get subchondral support of the radial column, which we've achieved nicely with this plate. So you can see that the configuration of that hole is parallel to the articular surface. So if you want to you can run a screw that is subchondral to the articular surface. Also note the most distal shaft screw is short of the drug. So you want to be careful there. You don't inadvertently injure the drug by going completely through the radius into the drug. So here you can see on the lateral radiograph how the plate is placed. You can see its distal covering the radial styloid giving us fixation of that column. So now just a word on the closure. You can see that I've left the distal aspect of the retinaculum of the second and the first extensor compartment intact. And that's enough to prevent volar subluxation of your tendons. In addition remember we incise the first auto compartment cheating dorsal. So now you have this nice volar sheath to prevent subluxation of these tendons. If you want to you can also put a suture across here. Note that there will be a little bit of a gap, but that's okay because we're simply holding the tendons in their respective anatomical location. Proximally you can see you can cover the plate if needed.

Radial Styloid Plate

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