Disclosure. 85% Dorsal. 15% Volar. Distal Radius Fractures- Volar Plating for All. Skeletal Dynamics- Consultant

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1 Distal Radius Fractures- Volar Plating for All Frontiers in Upper Extremity Surgery 2017 Francisco Rubio, M.D. Miami Hand and Upper Extremity Institute Miami, FL Disclosure Skeletal Dynamics- Consultant 85% Dorsal 15% Volar 1

2 AO Anatomical Reduction Stable Fixation Early Function Dorsal Plate Fixation Extensor Tendon Disturbance Limited Motion Plate Removal 2

3 1994 Fragment Specific Fixation Distal Radius Locking Plate Fixation π-plate - Distal fragment does not toggle - Provides stable distal fixation in comminuted or osteoporotic bone Extensor Tendon Ruptures 3

4 - Plate redesign The Dogma Dorsal Fracture Dorsal Plate Palmar Fracture Palmar Plate 4

5 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:

6 A new method of treatment Volar management of the dorsal fracture 1997 Ineffective for Dorsal Fractures 6

7 1998 H-Plate First Plate Designed for Volar Fixation of Dorsal Fractures 2002 Volar Fixation for Dorsally Displaced Fractures of the Distal Radius: A Preliminary Report. JL Orbay, DL Fernandez; J Hand Surg 2002;27A:

8 4-6 weeks post-op Volar Plate Evolution Strongest Fixed Angle Possible Fixation Interface 8

9 Plate acts as template and drill guide Subchondral Support Scaffold Ligament Contribution to Patterns of Articular Fractures of the Distal Radius Daniel G. Mandziak, MBBS, Adam C. Watts, MBBS, Gregory I. Bain, PhD, MBBS Journal of Hand Surgery

10 DRC DRU PMF LF VRU AMF SRL LRL RSC 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: ) Pins/wires Fracture fixation methods 10

11 Hand (NY) Jun; 9(2) Fracture fixation methods Pins/plates Fracture fixation methods Plates and extenders 11

12 Scaphoid Fossa Fixation Lunate Fossa Fixation 12

13 Lunate Fossa Watershed Line Watershed Line 13

14 Watershed Line 3 mm Watershed Line 2 mm Watershed Line to Plate Distance Volar Lunate Fragment Volar Marginal 5 mmfragment 14

15 Plate extenders 15

16 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 Sep; 2(3):

17 17

18 Extended Tangential View Carpal shoot through Marsland et al. Hand ( 2014) 9: Extended Tangential View MW Flexor Tendon Injury 18

19 Most Frequently Ruptured Tendons #1 #2 FPL FDP II 19

20 Volar Radial Tubercle Volar Rim Lunate Fossa Inter Fossa Sulcus FPL Tendon Center to Bone Plate to Tendon Surface 4.5mm 0mm 20

21 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 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 168 DRFs treated with volar plating Grade 0 Grade 1 Grade 2 0 Ruptures 1 Rupture 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

22 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 No. of prominent plates, volar Grade 0 19% 49% < Grade 1 18% 51% < Grade 2 63% 0% < 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 No. of prominent plates, volar Grade 0 19% 49% < Grade 1 18% 51% < Grade 2 63% 0% < No. of cases with flexor tendon rupture(s) 4% % 0.08 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 Older Rohit 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:

23 Randomized: VLP vs Casting. Simple volar 1-2 weeks Operative group did better first 6 months. At one year both groups were almost equal. 36% vs 14% complication rate Operative Non Operative 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

24 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 consecutive patients 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% % would have the same procedure again % would recommend their surgeon 24

25 Volar Approach Not Trivial for Dorsal Fracture Anatomical Plates Require Anatomical Reduction 25

26 Using the Extended FCR Approach Release FCR tendon sheath Release the radial septum Pronate the proximal fragment Intrafocal Exposure Standard Fixation Technique Standard Fixation Technique Removing dorsal hematoma allows reduction 26

27 Dorsal rim fracture 27

28 28

29 29

30 Bone Graft Support 2 mm 2 mm 2 mm Rule 30

31 1- Reduce and Pin Lunate Fossa 2- Reduce and Pin the Scaphoid Fossa 31

32 Volar rim fracture 32

33 33

34 Prevent Collapse and Salvage Failures of the Volar Rim of the Distal Radius J. L. Orbay, F. Rubio, L. Vernon Journal of Wrist Surgery 2016;00: 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 the Volar Rim of the Distal Radius J. L. Orbay, F. Rubio, L. Vernon Journal of Wrist Surgery 2016;00: For failed VMF fixation, opening wedge osteotomy - Correct volar tilt to 5 degrees dorsal - Restores supination loss seen after failed VMF fixation 34

35 35

36 36

37 A combination 37

38 38

39 39

40 Is there any role for a dorsal approach? 40

41 41

42 42

43 Thank You! 43

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