The Arthrex Titanium Volar Distal Radius Plating System provides a comprehensive solution for distal radius fracture management. A comprehensive offering of Volar Plates are available in narrow, standard, and wide as well as multiple shaft lengths. A variety of screw fixation options, Aiming Guides, and instrumentation allows for customization according to the surgeons needs and the complexity of the fracture. The Arthrex Wrist Plating System is developed to provide the solution to your distal radius fixation needs. 

 
Advantages
 
Anatomic: Plates are developed to fit the anatomy and contours of the distal radius for a low profile repair and anatomic reduction of the fracture. 

 
Comprehensive: In addition to a comprehensive plate selection, multiple screw options are available including fixed angle locking, variable angle locking, and non-locking options. 

 
Options: Fracture patterns pose unique challenges and the variety of fixation options included allow multiple solutions for even the more complex fracture patterns. 

 
Straightforward instrumentation: The modular set layout allows for easy identification of appropriate instruments and reduces confusion in the OR. Proper screw length is verified at a glance with the graduated screw caddy, reducing the time needed to measure screws by hand.

Trauma Upper Extremities

Product

The Titanium Volar Distal Radius Plating System provides a comprehensive solution for distal radius fracture management. Volar plates are available in narrow, standard, and wide, as well as in multiple shaft lengths. The volar plates are now offered with two different screw shaft options, 2.4 mm and 3.5 mm. A variety of aiming guides and instrumentation also allows for customization, based on surgeon preference. The Wrist Plating System, which includes both the volar and fragment specific plates, is developed to provide the solution to your distal radius fixation needs.
&nbsp;
Advantages
 
Anatomic: Plates are developed to fit the anatomy and contours of the distal radius for a low-profile repair and anatomic reduction of the fracture. Comprehensive In addition to a comprehensive plate selection, multiple screw options are available, including KreuLock™ Locking Compression Screws, fixed-angle locking, variable-angle locking (VAL), and nonlocking screw options. The plate is available with either 3.5 mm or 2.4 mm shaft screws to accommodate surgeon preference.
&nbsp;
Options: Fracture patterns create unique challenges and the variety of fragment specific plating options included allow multiple solutions for even the more complex fracture patterns.

Hand and Wrist

Steven J. Lee, MD, (New York, NY) presents the Arthrex® Volar Distal Radius Plate technique. A comprehensive offering of Volar Plates are available in narrow, standard, and wide as well as multiple shaft lengths. A variety of screw fixation options, aiming guides and instrumentation allows for customization according to the surgeons needs and the complexity of the fracture.

Not Hidden

English  - en

video

Human

Arthrex® Distal Radius Plate Surgical Technique

So here we have a left wrist. Our incision is usually based off the CRx tendon, which I think you can see there. So we're going to make an incision directly over the CRx tendon. So you could do a couple of things with the approach. I usually like to go right through the CRx tendon sheet. So here's our CRx tendon. I'm going to go ahead and split the tendon sheath and split it open. Okay. I like to take the tendon radially and go ahead and protect me off the radial artery. I'm going to push that over. [00:00:38] To the side for good. We can take our knife and go right through the sheath of this CRx tendon. So once we're through the CRx tendon, we'll go ahead and see the FPL tendon and move that. We should take a freer you can go ahead and sweep the FPL tendon away. And we see a nice good look at the pronator quadratus. It's important to spend a little extra time on the distal part of the wound so you can go ahead. And because that's where you're going to have issues with putting your plate on. So now we can see the pronator quadratus very nicely. We'll go ahead and incise it longitudinally, leave a little cuff of pronator on the radial side to repair at the end. We normally take down the insertion for the brachioradialis as well as the, which is right over here, as well as the floor of the first dorsal compartment tendon. So you can start seeing the tendons right here. So now I have great exposure of the entire radial side of the distal radius. And I'll go ahead and continue dissecting the pronator quadratus off on the ulnar side. And hopefully we get a nice little layer of tissue here that we can close over the tendon at the end of the case. You can use a wide elevator if you'd like to do the same thing, and just get yourself a nice view of the distal radius. So at this point, I also like to put in a lobster claw clamp at the proximal aspect of the distal radius, and I'll angle it Angle approximately. This does two things. I get to grab the lobster claw and keep my hands out of the x ray machine. But more importantly, if I put a plate on here, I know that if my proximal aspect of my plate is within my lobster claw, especially in some of our incisions, or trying to make smaller and smaller, that it will be centered on the on the shaft of the radius. So one of the nice features of this plate is that it does has the variable angle screws for the locking screws, and it has the ability to be placed either in a standard fashion which is just proximal to the watershed line, or in those very comminuted distal fractures. It can be placed a lot more distally than most plates out on the market, and you can put it distally, and then you could angle your distal locking screws approximately with the variable angle guide, which gives you about a 20 degree cone to make sure that the screws are not into the joint. Another great feature about this plate is that if you go ahead and put it distally, we're all worried a little bit about the tendons rupturing or getting irritated by the edge of the plate. And you can see this plate is well contoured distally and there's minimal plate that is sticking out. And almost no chance for that tendon to get irritated or to rupture. So depending on what you're used to, there's different options on your guides for your distal locking screws. This is the one I like the most, which is a pcgaming guide. The fact that its peak doesn't show up on your x rays, which is kind of nice. You just click it on there and go ahead and screw this on, and that screw can come out later on so that you can fill that in with a regular locking screw if you'd like. Your other options for surgeons who are used to having the nubbins pre-placed, you have that as well. And it shows pretty well the the positions of the two radial styloid screws, which is a nice option for this plate. Your other option is to go ahead and use an individual locking sleeve like that. And then your last option is the variable angle guide which you put in each hole. And this gives you about a 20 degree cone to put in your distal locking screws. And there's a very positive end point. So there's no mystery as to as to how far you can bring this guy, that you can feel it end and stop very abruptly. So the different sized plates that are available, there's a this is the narrow, there's a standard and there's a wide. In general, I'll probably go with a plate that might be a little bit more narrow unless it's a very common fracture. The narrow one gives you a little bit more options to play with and positioning. Another option are these attacks which are nice and which you can. These can be drilled into one of these holes very quickly with a K-wires driver. And it will provisionally hold your plate to the bone. So I think we're going to go ahead and start with the sliding screw. This is a 2.5 drill right in the middle of the sleeve, so you can give us some room to move the plate back and forth. There's a standard two cortices for this. Okay. Depth gauge. This is going to be A35 screw. Let's see. That looks pretty good there. Okay. Let's see what that looks on x ray. So this part is optional. We can go ahead and put in a 0.05 4K we are into the distal K-wires hole. And if this is not in the joint then the screw shouldn't be in the joint. That's great okay. So this is our drop in guide which has a nice ruler on it for just locking screw. This holds a 1.7mm drill. And there's a laser mark on the drill. So we can drill, bounce back and forth, feel the other side or the cortex, which feels like right about there. And then maybe go through the cortex in case in patients who have very comminuted bone or you're not sure you felt the cortex, well, you can use a dip stick and they can feel that says about 22, I'm going to probably put in a 20 screw. Usually you put a screw in two millimeters short just in case, to minimize chances that the extensor tendons can get irritated and rupture. Okay, after the first screw, you should get a quick little x ray. Make sure this looks good. If this looks good, the rest of the screw screws should look really good. So far, so good. Okay. Another 20. This is a locking peg. And put that in. It will speed up our surgery. You don't have to screw it in. And I have on here a torque limiting handle. So we can go ahead and. To the right until it ratchets. And then that's all we need to do. Okay. Good. This plate has options for two different styloid screws. It's kind of nice about an 18. Maybe another 18. We can fill this screw with locking screws as well. You can drill right through this. Okay, so there's two locking screws proximally. I usually just use the most proximal one if you need to. You have an additional proximal locking screw if you need to. These are 3.5 guide screws right in. So this measures a 12 you could see on the far cortex. So go ahead and put a 12 screw in there. Okay. So for those of you who like the nubbins we'll go ahead and use nubbins either for approximately and or distally. Also with two five drill. Let's put a 16 in there. Okay. Let's see how that looks. That looks great. So you can see how distal you can put these screws in and not be in the joint. Okay. So this plate also provides for a little kickstand which is nice for those of you who like to fix it distally first and then bring it down to the plate proximally and or for corrective osteotomies to get yourself the exact amount of angle correction. So you can see the numbers here correspond to the angle that your kickstand will give you. So I'm going to screw that into the proximal hole. So this is set around 10 or 11 degrees. And this will sit on the bone. So once you go ahead and fix it proximally when we get rid of the kickstand, that'll go ahead and give me my 11 degrees of Volar Tilt.

John Riehl, MD, (Gulf Breeze, FL) reviews 2 case presentations highlighting applications for volar and dorsal approaches to distal radius fractures.

Distal Radius Surgical Stabilization with the Wrist Plating System

Hi, my name is John Riel. I'm an orthopedic trauma surgeon practicing on the Gulf Coast, and I have a couple of cases on distal radius fractures that I'd like to share. First case, 75 year old female was playing baseball with her grandson and had a fall on an outstretched hand onto her right wrist. She had immediate pain and deformity, was seen in the emergency department and referred to my clinic the next day. His right hand dominant, had no significant past medical history and does not use tobacco. These are x rays that she presented with with dorsal displacement of the distal radius fracture. She was found to be neurovascular intact on presentation. And she happened to be MPO that day, and so ended up taking her to the operating room that afternoon with this displaced fracture. She had a volar approach performed and a standard three hole Arthrex volar plate was placed. These are her x rays at two weeks postoperatively, and you can see the realignment of the distal radius here and the plate placed early. She was splinted after surgery and the splint was removed at two weeks, along with removal of her staples. She was on vitamin C and off of all narcotic pain medicine at her first follow up. I ordered a Dexa scan on her due to her low energy osteoporotic fracture, and her wound was healed at two weeks. She had no pain and was off of narcotic pain medication as stated above. Placed her into a wrist brace just for comfort, but allowed range of motion is tolerated. And these are her six week X-rays showing a healed fracture with restoration of alignment following the injury. The rest of her clinical course, she had full range of motion at six weeks. Fracture was healed. She had no pain at that point. Her three month x rays are seen here on the bottom of the screen, and at six months, she remained pain free. These x rays on the right are another example of the Arthrex plate. This is a narrow plate. And put this in here to note the screw spread that you can achieve with both the narrow and the standard plates. The second case, this one is a 54 year old male had a fall from standing on an outstretched hand, closed injury. He's a right hand dominant person and works as an accountant. These are his initial injury films and you can note here on the lateral view. Dorsal displacement and comminution. This is an intra-articular fracture primarily with dorsal displacement. And there's a gap in the articular surface which is also wide on the lateral view. So my plan here was for a dorsal approach with direct visualization of the articular surface and direct reduction and dorsal plating here on lateral view. We can take a little bit closer look at these x rays. And you see primarily dorsal comminution. And you see this gap in the articular surface. The articular surface is also widened from normal. And if you compare the width of the lunate versus the width of the distal radius with this fracture that can be seen here with these lines. So Intraoperatively I did a dorsal approach and had direct visualization of the articular surface here. This is the scaphoid for orientation. And these are your distal radius fracture lines. Once the fracture site was reduced and pinned again you can see the distal radius fracture fractured now, reduced back. And I placed a dorsal buttress plate here. You can see on the view here the plate in place with screws and the articular surface reduced. This is another view of the plate. And you can see the EPL tendon coming over the plate there. And these are intraoperative x rays. And so this is showing the overall alignment that was achieved with the use of the dorsal plate. This is a comparison of our pre-op views versus our post-operative views. And the difference in the articular width on the lateral view. Post-operative x rays are shown here with reduction of the displacement and overall restoration alignment of the distal radius. So some of my indications for when I go dorsal I would say the vast majority of my distal radius fractures I fix with the volar plate. But there are a few indications where going dorsal I find to be very helpful in treating these fractures. So isolated dorsal fractures. Dorsal Barton's fracture A shearing type fracture dislocation when there is primarily dorsal displacement, especially with an AP or with an apex. Volar type of fracture. If I need intra-articular visualization, going dorsal can be very helpful if I if I have traumatic wounds that preclude another approach or lead me towards a dorsal approach, that may be another indication for me to go dorsal. And if I have concurrent distal radioulnar joint and or SL injury, then I may choose to go dorsal. My primary two indications are with these isolated dorsal fractures though. And when I need to visualize intra-articular some potential advantages to dorsal plating it. Dorsal plating provides a buttress to the most common distal radius fracture pattern type, and is the more biomechanically advantageous place to place a plate, and it avoids the neurovascular structures that are encountered anteriorly. Some of the previous criticism of dorsal plating is now resolved with newer plates as far as tendon irritation and rupture, and newer low profile plates have been shown in several studies to have lower incidence of tendon rupture.

Chris Martin, MD, (Salt Lake City, UT) demonstrates the surgical technique for fixing a distal radius fracture with the Arthrex® Dorsal Distal Radius plate. The Dorsal Plate is designed to be a low-profile option for fractures that require dorsal buttressing and reduction. The plate allows for variable angle locking and is available in narrow and standard widths. In addition to a volar and dorsal plate, the Wrist Plating System also includes radial styloid plates, periarticular hook plates, dorsal L‐plates and a spanning plate.

Dorsal Distal Radius Plating

So we're going to do a dorsal approach to the distal radius. The first landmark use is generally the styloid and Lister's tubercle. And we're going to come in straight over the carpus and just right down the center of the radius. And then dissection goes down to the retinaculum. This reeler tissue is used to elevate and expose the retinaculum widely. And taking care looking for the superficial radial nerve on this side. And the extensor pollicis longus is a useful landmark, as that exits the retinaculum and then bring an incision straight over the retinaculum out the extensor pollicis longus, and then portion of this flap can be elevated depending on the fracture. If one needs wide exposure to the joint, this can be elevated off of the fourth dorsal extensor compartment, or sometimes left on for an extra articular fracture, and the proximal retinaculum is taken all the way over to the fifth dorsal extensor compartment. As we get a nice wide piece, and there's the tendon of the fifth showing up, and then brought back as a large flap off the fourth, and then back to the third and on to Lister's tubercle. So with the EPL is the landmark will release this retinaculum from the EPL preserving this. And once the EPL is exposed that gives us access to Lister's tubercle. And then we want to stay as subperiosteal as you can. The retinaculum can thin out in this region, especially proximally. So take in some of this periosteum between the third and the second compartments is often useful. There's our periosteum and the second compartment just a little more off the second compartment. And now we're exposed. So I have this large capsular retinacular flap that we'll use later in closure. I'm going to put this retractor between the third and fourth dorsal extensor compartments. Generally release a little more fascia there. At this point I'll identify and excise just part of the interosseous nerve. And periosteum on both these sides is useful especially ulnar. So I will elevate off of the fracture site out distally, trying to preserve any tissue I can to sew into that will be helpful during the retinacular closure later. And then the joint line can be felt and to allow access to the joint, the capsule is reflected off of the dorsal lip of the distal radius. So in a specimen here we don't have traction in that advantage. But this can be pressed down I can see into the joint visualize this fairly well. So the access to the joint. Here's my scaphoid facet. I'm working over to the lunate facet. A little tougher to see but can be seen especially under traction. Very frequently the fracture line in the joint is going to be extending up here. And if a knife or elevator is placed first into the fracture line, then the soft tissue at the dorsal lip of the radius can be released, and these frequently scaphoid facet and lunate facet fragments can be booked open for in access, even down deep and vulgar. And now we need a roger. Lister's tubercle is frequently comminuted separate fragment in this specimen. We're just going to simply remove it. And if there is reasonable bone, it can be just placed in the fracture site and used as graft. Now this central tissue and periosteum back in this region is exposed. Here's our first dorsal extensor compartment back here. The plate's going to slide under that. So I'm going to use some type of elevator. Simply create a pouch underneath the first dorsal extensor compartment. And now we're ready for some type of plate. Here's a narrow plate. We have a fairly small specimen. So that looks like the best fit. So this plate slid back under the pouch. And then with a drill guide one of the oblong drill holes will be selected first, depending on our degree of comminution, either here or even back here onto the shaft. And then before tightening this, we want to make sure that we've got the distal portion of the plate where we want it in relation to the joint. So again we can inspect our fracture site. Remember the articular surface is always curving away from us just a little bit away from this ridge. And I want these screws to be able to come down right in the subchondral bone. So something in that neighborhood looks pretty good. So once I'm happy with the position distally relative to the articular surface, I'm going to buy that position and secure that screw. And let's go distally now. And all these screws are designed to go down roughly parallel. So in effect this is going to give us a platform made of screws directly in the subchondral bone. So with several ways to put these in. So second we'll stay on the skateboard for set. Use this drill. Good. Drill is also calibrated. You can use a regular depth gauge or the drill guide or polar vortex. Measures 19 and we'll put in a 20 screw. Here we're going essentially frequently in intra-articular fractures. The central screw between the scaphoid and the lunate facets is not as useful as frequently in the area of comminution. So I can feel bone all the way down onto the volar cortex. And. 24. That will lock down. And then the beauty of the dorsal approach. I don't need CRM at all at this point, and if I'm worried about the joint surface or my comminuted fracture, I can always check it directly and I've got no penetration. So looking good. We're going to move ulnar and now use the variable angle type drill guide. And this drill guide is designed to seat within the plate. And inspecting that I can look at the joint surface and know where I want to go and aim this plate accordingly. So this one we're going to go just a little bit ulnar. Even the screw is not in the joints. And we'll fill one last articular screw hole. This is cinched up and locked. And now remaining. We're just going to switch around and secure the rest of the plate on the shaft here. 14. So given two elongated holes, it gives us more flexibility to be able to choose the length where to put this distal portion. And very frequently this whole area is too comminuted to allow sufficient purchase in that screw. So having the second elongated hole approximately gives us a lot of freedom in that regard. So now we'll do two locking screws proximally. And another 14. Then our choice here is either one more slight pull that's going to give us access there. And on occasion we do split between the two muscles of the first dorsal extensor compartment. Now we're between and get back approximately to this last screw hole. All right. So after our fixation I'm going to directly inspect this joint. And here I've got no screw penetration. I know I've got a good reduction. I can see it both directly. And then we'll confirm this on C-arm as well. But I know that inspecting it directly is more accurate. Now that we're happy, we're going to go to closure. I'm going to take a little bit of tension off of this EPL. Just mobilize it. Just a touch. Much really some of the fascia. So first is our capsular repair. Sometimes we can leave a cuff of tissue here. And if we haven't been able to do that this plate provides two areas to fix the capsule back to the dorsal lip of the radius. One more again and did not save much tissue there. So the plate is going to bail us out. And then we'll lay the retinaculum over. So the retinaculum. We save this as a wide flat, because I'm going to use the distal portion of the flap to help with my plate and try and minimize our risk of tendon irritation. So I'm going to divide this all the way down to the four between the first and the second compartments. And the tendons of the second are raised up. Just retinacular flap is passed through, and now these tendons can retract out of the way. And we'll proceed with closure over here. Here's where this ulnar periosteum was useful to save. Sometimes it can be used to cover the plate. Sometimes it can just be used to help approximate the retinaculum. And here I can go to the periosteum or reinforce the capsular repair. I'll add one more centrally. So the remainder of the retinaculum I'm going to pass over the tendons of the second and fourth. The EPL is going to stay superficial. And now we're going to move up here and grab our distal retinaculum. Him. And we know that we need roughly a centimeter of retinaculum for this to remain functional. And here we'll have no problem achieving that. So the EPL will be left superficial and the rest of this will simply be closed up. And there we are. And the remainder of the wound is closed in layers as usual. So the first thing about dorsal plating we know is we are so much closer to the joint than we're used to with volar plating that sometimes these plates will look like they are above and into the joint. But we need to remember that the dorsal lip comes out distally a fair amount. And surgically we were right here looking at this bone. So we know this plate is not prominent and not riding over the joint. The same is true for the ulnar screws. We put these in under variable angle and we know they're directly beneath the subchondral bone x ray wise it gives us a good angle. And we've even got this ulnar screw aimed more into the volar ulnar corner, which is generally a difficult place to get to with plating. And then we have our capsular reattachment back here. So position wise everything looks good with that plate. Laterally we can see these screws come down and form a scaffolding right below the subchondral bone. We've got a good idea of this bone coming in there. Same thing as volar. We've got our more radial screws or slightly distal ulnar screws are slightly back to make up for the inclination of the radius. So lateral wise we look good. This is an unusual view looking end on, but it demonstrates some of the versatility of this plate. This allows us to form a scaffolding of parallel screws directly beneath the articular surface. And with these ulnar most screws, we can get near the sigmoid notch down into that volar portion of the lunate facet, which is a notoriously difficult place to get from volar.

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.

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.

Titanium Distal Radius Plates and Screws

Titanium Wrist Plating System