Sterile Distal Radius Kit

Transcription

1 For Fragment-Specific Fracture Fixation Using the Variable Angle LCP Two-Column Volar Distal Radius Plate 2.4 With Variable Angle Locking Technology Sterile Distal Radius Kit Surgical Technique

2 Image intensifier control Warning This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended. Processing, Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to: For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to:

3 Table of Contents Introduction Indications 3 Sterile Kit Variations and Added Instruments 4 Distal Radius Sterile Kit Key Steps 6 Sterile Tube Packaging 7 AO Principles 8 Clinical Cases 9 Surgical Technique Approach 10 Implantation Steps 11 Postoperative Treatment and Implant Removal 21 Product Information 22 MRI Information 28 Bibliography 29 Sterile Distal Radius Kit Surgical Technique DePuy Synthes 1

4 2 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

5 Indications Variable Angle LCP Two-Column Volar Distal Radius Plates 2.4 are indicated for the fixation of intra- and extra-articular fractures and osteotomies of the distal radius. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 2

6 Sterile Kit Variations and Added Instruments Variable Angle LCP Volar and Dorsal Distal Radius Plates 2.4. Sterile Instruments and Implants for multi-fragment fracture fixation with variable angle locking technology. Core sterile kits Core sterile kits contain both the implants and instruments to perform one distal radius surgery with a 3-shaft hole VA-LCP Two-Column Distal Radius Plate 2.4. All implants are available in both Stainless Steel and Titanium. Extra screws are provided single-packed in sterile packaging. 4 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

7 Sterile Kit Variations and Added Instruments Sterile instrument kits with individually packed sterile plates and screws Instrument kits are part of a modular system with individually packed sterile plates and screws. They contain only the instruments needed to perform one distal radius surgery with the following DePuy Synthes Variable Angle radius plates: VA-LCP Two-Column Distal Radius Plates 2.4 VA-LCP Two-Column Distal Radius Plates, 2.4/2.7, Extra-Long VA-LCP Extra-articular Distal Radius Plates 2.4 VA-LCP Dorsal Distal Radius Plates 2.4 Plates and screws are available single-packed in sterile packaging. Trial implants In addition, sterile trial implants are available separately to determine the correct plate length and width of VA-LCP Two-Column Distal Radius Plates. Implant removal screwdriver The single-use T8 screwdriver is designed to facilitate implant removal without the need for a sterile instrument kit. Note that the screwdriver tip is non-retaining to facilitate maximum torque transmission. Note: All implants and instruments of the Sterile Distal Radius Kit are single use. Do not resterilize. Dispose of all unused items after surgery. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 2

8 Distal Radius Sterile Kit Key Steps Note: Please refer to the corresponding IFU ( and this surgical technique for full usage information. 1 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

9 Sterile Tube Packaging The amount and lengths of screws contained in the Distal Radius Single Use Kit has been identified both scientifically to fit various anatomies and through historical sales data. For most cases, the kit will contain screws of sufficient length. It is recommended to measure each hole s depth to determine the correct screw length based on the current recommendation of the literature. 3,10 Extra screws that are not contained in the kit are available individually packed in sterile tubes. Step 3: Circulating Nurse (non-sterile field): Hold the outer cap and point the inner tube towards the sterile field. Scrub Nurse (sterile field): Remove the inner tube by pulling and if necessary slightly twisting the inner tube back and forth to release it from the outer cap. When twisting the tube, hold on to the tube and not the cap. Leading the Way to Sterile Implants The Sterile Tube concept consists of a solution that uses 2 tubes where one fits into the other to allow a streamlined and secure transfer of sterile implants into the sterile field. sterile field non-sterile field Step 4: Open the inner tube by unscrewing the inner cap from the inner tube and remove the holder with the screw. Follow the following steps to access a sterile screw: Step 1: Tear the pull-strip open to remove the sleeve. sterile field Step 5: Engage the screwdriver in the screw recess and if necessary secure with finger. Remove the screw from the holder by tilting it out of the holder/tilting the holder away at the opening. non-sterile field Step 2: Open the outer tube by unscrewing the outer cap from the outer tube. Do not touch the inner tube to maintain sterility. sterile field non-sterile field Sterile Distal Radius Kit Surgical Technique DePuy Synthes 1

10 4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique AO Principles AO PRINCIPLES In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation. 1,2 In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation 1, 2. 4_Priciples_03.pdf :08 Anatomic Anatomic reduction reduction Fracture Fracture reduction reduction and and fixation fixation to to restore restore anatomical anatomical relationships. relationships. 1 2 Stable Stable fixation fixation Fracture Fracture fixation fixation providing providing absolute absolute or relative or relative stability, stability, as required as by the required patient, by the the injury, patient, and the the injury, personality and the personality of the fracture. of the fracture. Early, Early, active active mobilization mobilization Early Early and and safe safe mobilization mobilization and and rehabilitation rehabilitation of of the the injured injured part part and and the the patient patient as as a whole. a whole. 4 3 Preservation Preservation of of blood blood supply supply Preservation Preservation of of the the blood blood supply supply to to soft soft tissues tissues and and bone bone by by gentle reduction gentle reduction techniques techniques and and careful careful handling. handling. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer Rüedi 1. Müller TP, RE ME, Buckley, Allgöwer CG M, Moran. Schneider AO Principles R, Willenegger of Fracture H. Manual Management. of Internal Fixation. 2nd ed. 3rd Stuttgart, ed. Berlin, New Heidelberg, York: Thieme. New York: Springer-Verlag; Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart New York: Thieme; DePuy Synthes Sterile Distal Radius Kit Surgical Technique

11 Clinical Cases Case 1 24-year-old male with AO 23C2.1 fracture, fall from scaffold Preoperative, AP view Preoperative, lateral view Postoperative, AP view Postoperative, lateral view Case 2 77-year-old female with AO 23C1 fracture, fall Preoperative, AP view Preoperative, lateral view Postoperative, AP view Postoperative, lateral view Sterile Distal Radius Kit Surgical Technique DePuy Synthes 9

12 Approach Make a longitudinal incision slightly radial to the flexor carpi radialis tendon (FCR). Dissect between the FCR and the radial artery, exposing the pronator quadratus. Detach the pronator quadratus from the lateral border of the radius and elevate it toward the ulna. Note: Leave the volar wrist capsule intact to avoid devascularization of the fracture fragments and destabilization of the volar wrist ligaments. 10 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

13 Implantation Steps 1. Select implant Instrument S Trial Implants for VA-LCP Two-Column Distal Radius Plate 2.4, sterile Trial implants Double-sided sterile trial implants may be used to identify the desired plate size prior to opening a distal radius sterile kit. Trial implants with 3 shaft holes are available for VA-LCP Two-Column Volar Distal Radius Plates 2.4. Trial implant choices, for VA-LCP Two-Column Volar Distal Radius Plates 2.4 (narrow, standard, wide head sizes). Trial implants are marked with Left (L) and Right (R) as well as the corresponding plate type (narrow, standard, wide). Select the correct distal radius sterile kit according to the trial implant matching the bone and fracture pattern with respect to side (left and right, facing up) and size (narrow, standard, wide). Precaution: Ensure proper plate selection by verifying the L (left) and R (right) etching on the trial implant. The trial implant s distal lip is slightly lower on the radial side. Note: Excessive and repetitive bending of the trial implants should be avoided. Trial implants are double-sided (L and R version). Sterile Distal Radius Kit Surgical Technique DePuy Synthes 11

14 Implantation Steps 2. Reduce fracture and position plate Instrument Kirschner Wires Ø 1.25 mm, with trocar tip Reduce the fracture The reduction method will be fracture-specific. Position plate Apply the plate to fit the volar surface. The order of screw insertion and the use of K-wires may vary depending on the fracture pattern and reduction technique. If necessary, use 1.25 mm K-wires inserted through the desired Kirschner-wire hole to temporarily fix the plate distally. The distal K-wire holes of the plate are designed to indicate the nominal screw trajectory angle of the screw hole medial to the respective K-wire hole. Perform several radiographic views of the distal radius to ensure alignment, plate placement, and fracture reduction. Additional options for preliminary Kirschner wire fixation 12 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

15 Implantation Steps 3. Insertion of proximal screws Instruments mm Drill Bit, quick coupling mm VA/Cortex Drill Guide mm Coaxial Drill Guide /2.7 mm Depth Gauge Nm Torque-limiting Screwdriver, T8 Determine where 2.4 mm locking screws and 2.4 mm cortex screws will be used in the plate. The order of screw insertion in the shaft and metaphysis may vary depending on the fracture pattern and reduction technique. Verify plate and distal screw location with a drill bit or K-wires before inserting multiple screws Cortex Screws Drill using VA/Cortex Drill Guide Beginning with the center of the elongated hole in the shaft of the plate, drill with the 1.8 mm drill bit using the 1.8 mm VA/Cortex drill guide. Note: The 1.8 mm VA/Cortex drill guide should be fully inserted in cortex or VA plate holes. Moderate pressure should be applied to keep guide inserted in plate hole when drilling. Precaution: Excessive force should be avoided while drilling to avoid bending or damaging the drill. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 12

16 Implantation Steps Insertion of proximal screws (continued) Determine screw length of cortex screws Engage the hook of the 2.4/2.7 mm depth gauge at the opposite cortex and shift the sleeve down into the hole (1). Take the reading from the edge of the sleeve (2) and select a screw length corresponding to the reading Insert cortex (non-locking) screw Insert an appropriate length 2.4 mm cortex screw in the elongated hole in the plate shaft. Adjust the plate position if necessary and tighten the screw with the screwdriver. Depending on fixation requirements, additional cortex screws may be inserted into remaining unthreaded shaft holes following the steps above. Note: If dense bone is preventing screw insertion by engaging the torque-limiting function of the screwdriver before the screw head is seated, the torque-limiting stop should be attached to the torque-limiting screwdriver. Then carefully tighten the screw paying attention not to overtighten it. For assembly of the torque-limiting stop refer to chapter Torque-limiting Stop for Dense Bone. 14 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

17 Implantation Steps Insertion of proximal screws (continued) Locking Shaft Screws Drill using the Coaxial Drill Guide For locking screws, carefully insert the 1.8 mm coaxial drill guide into the threaded portion of the shaft hole until it is seated in the desired locking hole. Drill with the 1.8 mm drill bit. Note: The 1.8 mm coaxial drill guide should be inserted in-axis to the plate hole and tightened until held in plate. Excessive torque should be avoided. Precaution: Excessive force should be avoided while drilling to avoid bending or damaging the drill. Determine screw length Use the 2.4/2.7 mm depth gauge to determine the screw length.take the reading from the edge of the sleeve (see arrow). Insert a locking screw Using the T8 torque-limiting screwdriver, insert the screw perpendicular to the plate surface until the screw head is seated. Note: If dense bone is preventing screw insertion by engaging the torque-limiting function of the screwdriver before the screw head is seated, the torque-limiting stop should be attached to the torque-limiting screwdriver. Then carefully tighten the screw paying attention not to overtighten it. For assembly of the torque-limiting stop refer to chapter Torque-limiting Stop for Dense Bone. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 12

18 Implantation Steps 4. Insertion of distal screws For used instruments, please refer to page 13. 4a. Determine whether screws will be inserted at the pre-defined nominal angle (option 1) or at a variable angle (option 2). Option 1: Pre-defined angle drilling To follow the nominal trajectory of a locking hole, insert the 1.8 mm coaxial drill guide in-axis to the nominal angle of the plate hole. Drill with the 1.8 mm drill bit. Precaution: Excessive force should be avoided while drilling to avoid bending or damaging the drill. Option 2: Variable angle drilling Use the 1.8 mm VA/cortex drill guide. Fully seat it into the VA locking hole. Drill holes at the desired angle with the 1.8 mm drill bit. Moderate pressure should be applied to keep the guide inserted in the plate hole when drilling. Precaution: To ensure that the screw is locked correctly, do not angle it in excess of +/ 15 from the nominal trajectory of the hole. Excessive force should be avoided while drilling to avoid bending or damaging the drill. To achieve the desired angle, verify the drill bit angle under image intensifier control. If necessary, drill at a different angle and verify again under image intensifier control. 11 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

19 Implantation Steps 4b. Determine screw length Use the 2.4/2.7 mm depth gauge to determine the screw length. If the fracture type allows, choose a screw length shorter than measured to ensure the screw does not protrude from the dorsal cortex. 3,10 4c. Insert VA locking screws Using the T8 torque-limiting screwdriver, insert the screw in the direction of the previously drilled hole until the screw head is seated. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 11

20 Implantation Steps 5. Ensure proper joint reconstruction Ensure proper joint reconstruction, screw placement and screw length using multiple radiographic views. Verify that the distal screws are not in the joint by using additional views such as a 10 dorsally tilted, 20 inclined lateral, 45 pronated oblique, and the dorsal tangential view. 5,6 11 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

21 Implantation Steps 6. Final fixation of VA locking screws Instruments Torque-limiting Screwdriver, T Torque-limiting Stop Optional: intended to be used only in case of dense bone (optional) Use the T8 torque-limiting screwdriver to perform the final locking step for VA locking screws. Insert the screw until you hear a click. The torque-limiting screwdriver prevents over-tightening and ensures that the VA locking screws are securely locked into the plate. Note: For dense bone, visually inspect if the screw is appropriately threaded and seated after tightening with the torque-limiting screwdriver. If dense bone is preventing screw insertion, the torque-limiting stop should be attached to the torque-limiting screwdriver. Then carefully tighten the screw until the head is flush with the plate surface. For a detailed description of screw insertion and assembly of the torque-limiting stop refer to chapter Torque-limiting Stop for Dense Bone. Precaution: Remove the torque-limiting stop from the screwdriver when not necessary to overcome dense bone. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 19

22 Implantation Steps Torque-limiting Stop for Dense Bone (optional) Instruments Torque-limiting Screwdriver, T Torque-limiting Stop Optional: intended to be used only in case of dense bone (optional) Visually inspect if the screw is appropriately threaded and seated after tightening with the torque-limiting handle. If dense bone is preventing screw insertion, the torque-limiting stop should be attached to the torque-limiting handle. To attach the torque-limiting stop ensure that the triangles on both the torque-limiting stop and the handle are aligned. Rotation may be required for alignment. Then carefully tighten so that the screw head is flush with the plate surface. Confirm final locking with the torque-limiting stop removed. Precaution: Remove the torque-limiting stop from the screwdriver when not necessary to overcome dense bone. 20 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

23 Postoperative Treatment and Implant Removal Postoperative treatment Postoperative treatment with VA locking compression plates does not differ from conventional internal fixation procedures and is at the discretion of the clinician. Implant removal Instrument S Screwdriver, T8, non-retaining, sterile For implant removal The screwdriver for implant removal is not designed for screw retention. Before attempting screw removal clean all screw head recesses of tissue or ingrown/overgrown bone using a dental pick or other appropriate instrument. To remove locking screws, first unlock all screws from the plate; then remove the screws completely from the bone. The last screw removed should be a non-locking screw on the shaft. This prevents the plate from spinning when locking screws are removed. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 22

24 Product Information Sterile Implant and Instrument Kits with VA-LCP Two-Column Volar Distal Radius Plates Stainless Steel* Head size Head Shaft Length Left/ Part number (mm) holes holes (mm) Right KS narrow R KS narrow L KS standard R KS standard L KS wide R KS wide L Titanium** Head size Head Shaft Length Left/ Part number (mm) holes holes (mm) Right KS narrow R KS narrow L KS standard R KS standard L KS wide R KS wide L Trial Implants for Two-Column Distal Radius Plates S Trial Implants for VA-LCP Two-Column Distal Radius Plates 2.4, sterile S Trial Implants for VA-LCP Two-Column Distal Radius Plates 2.4/2.7, Extra-Long, sterile Implant Removal Screwdriver S Screwdriver, T8, non-retaining, sterile For implant removal S S * Plates and screws are made from stainless steel (316L). ** Plates are made from commercially pure titanium (TiCP), and screws are made from titanium alloy (Ti-6Al-7Nb). 22 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

25 Product Information Instrument-only Kit S VA-LCP Instrument Kit 2.4, sterile Individually Packed Sterile Plates Available for use with Instrument-only Kit VA-LCP Two-Column Volar Distal Radius Plates 2.4, sterile Narrow, width 19.5 mm Head Shaft Length Left/ Stainless Steel Titanium holes holes (mm) Right S S R S S L S S R S S L S S R S S L S S R S S L Standard, width 22 mm Head Shaft Length Left/ Stainless Steel Titanium holes holes (mm) Right S S R S S L S S R S S L S S R S S L S S R S S L Wide, width 25.5 mm Head Shaft Length Left/ Stainless Steel Titanium holes Holes (mm) Right S S R S S L S S R S S L S S R S S L S S R S S L All plates are sterile packed. Images show selected right plates in both stainless steel (316L) and commercially pure titanium (TiCP) materials. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 22

26 Product Information VA-LCP Two-Column Volar Distal Radius Plates 2.4/2.7, Extra-Long, sterile Head size Head Shaft Length Left/ Stainless Steel Titanium (mm) holes holes (mm) Right S S narrow R S S narrow L S S standard R S S standard L S S wide R S S wide L S S standard R S S standard L S S standard R S S standard L VA-LCP Extra-Articular Volar Distal Radius Plates 2.4, sterile Head Shaft Length Left/ Stainless Steel Titanium holes holes (mm) Right S S R S S L S S R S S L S S R S S L S S R S S L All plates are sterile packed. Images show selected right plates in both stainless steel (316L) and commercially pure titanium (TiCP) materials. 24 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

27 Product Information VA-LCP Dorsal Distal Radius Plates 2.4, sterile Radial Column Shaft Length Stainless Steel Titanium holes (mm) S S S S 6 57 Intermediate Column, 2 head holes Note: The plates for the right radius (0x and 0x ) are angled left and the plates for the left radius (0x and 0x ) are angled right. Shaft Length Stainless Steel Titanium holes (mm) Angle S S S S S S S S L-Plates, 2 head holes Shaft Length Stainless Steel Titanium holes (mm) Angle S S S S S S S S L-Plates, 3 head holes Shaft Length Stainless Steel Titanium holes (mm) Angle S S S S S S S S All plates are sterile packed. Images show selected right plates in both stainless steel (316L) and commercially pure titanium (TiCP) materials. Sterile Distal Radius Kit Surgical Technique DePuy Synthes 22

28 Product Information L-Plates, oblique, 3 head holes Shaft Length Stainless Steel Titanium holes (mm) Angle S S S S S S S S T-Plates, 3 head holes Shaft Length Stainless Steel Titanium holes (mm) S S Note: This Surgical Technique does not include information necessary for selection and use of Variable Angle LCP Extra-Articular Volar Distal Radius Plates 2.4 and Variable Angle LCP Dorsal Distal Radius Plates 2.4. Please refer to the corresponding Surgical Technique for all necessary implant-specific information. All plates are sterile packed. Images show selected right plates in both stainless steel (316L) and commercially pure titanium (TiCP) materials. 21 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

29 Product Information Individually Packed Sterile Screws Ordering Information Variable Angle Locking Screws Ø 2.4 mm, with T8 StarDrive recess, tube sterile Stainless Steel* Titanium* Length (mm) TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS 30 Cortex Screws Ø 2.4 mm, with T8 StarDrive recess, tube sterile Stainless Steel* Titanium* Length (mm) TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS TS 30 * Stainless Steel (316L) Titanium Alloy (Ti-6AI-7Nb) Sterile Distal Radius Kit Surgical Technique DePuy Synthes 22

30 MRI Information Torque, Displacement and Image Artifacts according to ASTM F , ASTM F e1 and ASTM F Non-clinical testing of worst case scenario in a 3 T MRI system did not reveal any relevant torque or displacement of the construct for an experimentally measured local spatial gradient of the magnetic field of 3.69 T/m. The largest image artifact extended approximately 169 mm from the construct when scanned using the Gradient Echo (GE). Testing was conducted on a 3 T MRI system. Radio-Frequency-(RF-)induced heating according to ASTM F a Non-clinical electromagnetic and thermal testing of worst case scenario lead to peak temperature rise of 9.5 C with an average temperature rise of 6.6 C (1.5 T) and a peak temperature rise of 5.9 C (3 T) under MRI Conditions using RF Coils [whole body averaged specific absorption rate (SAR) of 2 W/kg for 6 minutes (1.5 T) and for 15 minutes (3 T)]. Precautions: The above mentioned test relies on non-clinical testing. The actual temperature rise in the patient will depend on a variety of factors beyond the specific absorption rate (SAR) and time of RF application. Thus, it is recommended to pay particular attention to the following points: It is recommended to thoroughly monitor patients undergoing MR scanning for perceived temperature and/or pain sensations. Patients with impaired thermo regulation or temperature sensation should be excluded from MR scanning procedures. Generally it is recommended to use a MR system with low field strength in the presence of conductive implants. The employed SAR should be reduced as far as possible. Using the ventilation system may further contribute to reduce temperature increase in the body. 22 DePuy Synthes Sterile Distal Radius Kit Surgical Technique

31 Bibliography 1. Brink PR, Rikli DA. Four-Corner Concept: CT-Based Assessment of Fracture Patterns in Distal Radius. J Wrist Surg. 2016;5: Hart A, Collins M, Chhatwal D, Steffen T, Harvey EJ, Martineau PA. Can the use of variable-angle volar locking plates compensate for suboptimal plate positioning in unstable distal radius fractures? A biomechanical study. J Orthop Trauma. 2015;29: Löw S, Herold D, Eingartner C. Standardized Palmar Plating of Dorsally Displaced Distal Radius Fractures. Tech Hand Up Extrem Surg. 2013;17: Oppermann J, Wacker M, Stein G, Springorum HP, Neiss WF, Burkhart KJ, Eysel P, Dargel J. Anatomical fit of seven different palmar distal radius plates. Arch Orthop Trauma Surg. 2014;134: Ozer K, Wolf JM, Watkins B, Hak DJ. Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius. J Hand Surg Am. 2012;37: Pace A, Cresswell T. Use of articular wrist views to assess intra-articular screw penetration in surgical fixation of distal radius fractures. J Hand Surg Am. 2010;35: Rausch S, Klos K, Stephan H, Hoffmeier K, Gras F, Windolf M, Gueorguiev B, Hofmann GO, Mückley T. Evaluation of a polyaxial angle-stable volar plate in a distal radius C-fracture model--a biomechanical study. Injury. 2011;42: Rausch S, Schlonski O, Klos K, Gras F, Gueorguiev B, Hofmann GO, Mückley T. Volar versus dorsal latest-generation variable-angle locking plates for the fixation of AO type 23C 2.1 distal radius fractures: a biomechanical study in cadavers. Injury. 2013;44: Stanbury SJ, Salo A, Elfar JC. Biomechanical analysis of a volar variable-angle locking plate: the effect of capturing a distal radial styloid fragment. J Hand Surg Am. 2012;37: Tarallo L, Mugnai R, Zambianchi F, Adani R, Catani F. Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events. J Orthop Trauma. 2013;27: Sterile Distal Radius Kit Surgical Technique DePuy Synthes 22

32 Synthes GmbH Eimattstrasse 3 Not all products are currently available in all markets Oberdorf Switzerland This publication is not intended for distribution in the USA. Tel: Fax: All surgical techniques are available as PDF files at DePuy Synthes Trauma, a division of Synthes GmbH All rights reserved. DSEM/TRM/1216/0773 1/17