Name: Volar Hook Plate
Uploaded: 2017-03-10T00:00:00Z
Channel: Arthrex
Description: Sanj Kakar, MD, FAOA, (Rochester, MN) demonstrates the Volar Hook Plate. The volar hook plate allows very distal fixation of fracture fragments using a low profile and easy-to-use design.

<p>Sanj Kakar, MD, FAOA, (Rochester, MN) demonstrates the Volar Hook Plate. The volar hook plate allows very distal fixation of fracture fragments using a low profile and easy-to-use design.</p>

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VID1-00972-EN | A | Volar Hook Plate

Sanj Kakar

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Volar Hook Plate

Okay, so for the hook plate, I like to do the extended FCR approach. And so the reason for that is because usually when we're doing the FCR approach, we stop about here and it's very difficult to get distal. And this allows us nice coverage to look at the distal aspect of the fracture. So I find the distal pole of the scaphoid. And I flex the, the wrist to see the distal wrist crease, flex it back to see the proximal wrist crease which is about here. And then we're overlaying the FCR tendon. And so that will be our incision. And usually it's about eight centimeters in length. So if we just take a minute to see where that extra inch of an incision distally gives us, usually with the distal radius fracture with standard FCR approach you're down to here. But now we can see all the way distal and we can get as distal as we want because this is usually where that volar ulna corner fracture is. So now we have a nice exposure to put our plate on. So now we need to release the pronator quadratus. And now the pronator quadratus is lifted as a only base flap is being perfused proximally. And now here you're getting up to the the watershed line. And so this right here is where that volar ulnar corner fracture is. You don't want to go any more distal to this because you can see this is where the carpal ligaments will insert into. But now we have a nice exposure of the distal aspect of the distal radius. And I use this approach even for for standard distal radius fractures. Now remember the deforming force is the brachioradialis tendon. So you can find it here proximally. And you can see it right here. So with these protected out of harm's way you can do a step cut to Notomi. Or I usually just release it. And there it's released. So now with the volar ulnar corner reduced I usually use a dental pick just to hold the fracture reduced. I'll now temporarily stabilize this with a k wire. And again you can see the advantage of this extended FCR approach. You can see everything right in front of you. So now with this stabilized, I would take a Fluro scan just to ensure that we've got adequate fixation of that. And so there you can see the teardrop angle fixed. And look how distal we are with that k wire. So it'd be very difficult to fix a fracture there with a standard distal radius plate. So this is now the guide. And this guide is perfect in that you can see that there are two cannulations which match the tines of the volar hook plate. In the future what we will have is we'll have a K-wires hole here where you can simply put that over the key that's placed in situ. So what will happen is that this guide now is designed, you can see how it's designed to match the contour of the volar aspect of the radius. And it rides up. And in future, as I said, that there will be an extra hole here which will slip over the K wire. So you can then put your drill holes in. But for purposes of today we will use this as is. The purpose of this guide is twofold. You can see here there's a nice little handle which will allow you to place the guide as distal as possible. If you want to hold it you can put a key through here. So that will give you fixation. Or you can hold it as a little lever as a handle and then drill the holes. And these cannulations are parallel and they match the tines on the volar hook plate. Now one of the key things now is to take your marking pen so you don't lose the holes. And just put a little mark right there. Because when there's a lot of blood around, it's very easy to lose those holes. Here we have the the volar hook plate. And you can see that the contour of this plate, if you look at the side view, is designed at 70 degrees to match the volar lip of the radius. You can see how the tines match the drill guide. Here you can see their parallel. And in addition the tines are long and so you don't have to keep them this long. What you can do to help for placement is cut one of the tines a little bit shorter. So in that way you'll place the long tine in. And then the shorter time will find its path in these holes. The other key differential of this is the fact that we've already got provisional stability of the volar ulnar corner. And we're not tamping in these times because this piece can be rather small. And one of the concerns when you're tamping it in is that you can cause iatrogenic fracture. So with the fracture reduced we simply just place this into the holes. And you can see I'm not tamping it in I'm just pushing it in with my fingers. And we've got provisional capture of that fragment. Because these fragments, as you know, are very small indeed. And now what we can do is we can place a screw here just to hold this in situ. So we have an option here of capturing the plate proximally. We can either put a Definitiv screw or you can use a tack. It's your choice. But we'll put we'll put a screw in right now. So this is a 1.7 drill guide for a 2.4 screw. Okay. So you can see that's nicely held down the plate. Now with that fragment captured we can take out our K-wires. So now you can see we've captured that fragment. And let's take a quick fluoro scan of this. So you can see there how distal the tines are. And we've hugged the ulnar aspect of the radius. And we've placed it in that way such that you can always put a second one of these next to that if you want, and just fix these fragments from a volar approach just using a couple of hook plates. So here you can see on the lateral view how that plate has contoured nicely to the volar aspect of the distal radius. You can see that the tines are long so it gives you that buttress. Now you can always cut those if you want. But basically that is as distal as you can get with that hook plate. And you can see you're not really worried there about the flexor tendons given its profile. You can see now with the dimensions of this plate how we have the whole radial column still exposed. And so sometimes you'll have a fracture which is also distal on the radial side. So you can simply put another one of these next to this. And that's your fixation. One of the advantages also of this system is that it has this locking tower. And so you can basically place now locking screws. You have hybrid fixation. You have non locking and locking fixation. And this will give you just a vertical perpendicular screw. Or we can do a variable angle screw to try and give us extra support of the articular surface. So all of these are variable angles. So what I like to do is use this screw here. And this will give me an angle that I'm trying to approximate to get a subchondral support of that fracture. So you can see the angle of this screw. Now is in such a way to give us subchondral support of the articular surface. And this locks into the plate like so. So here you can see on the on the fluoroscopic view how that screw has been placed to basically parallel the subchondral bone. And on a more distal fracture, you can simply drop your hand using the variable angle capabilities to get the screw much more subchondral. But you can see here with this fixed angle construct how you can put two of these in. And that can obviate the need of putting additional fixation. Once this column is now fixed, you can then go on to addressing the dorsal aspect if you need, or the radial column through this same approach if needed.

Volar Hook Plate

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