Instrument and Implant for wrist fracture Jansri Janpanya Product specialist The Bangkok Unitrade Co,.ltd.
Objectives Type of LCP for distal radius Fx. The new LCP design for distal radius Fx. Have knowledge to use Instruments for LCP distal radius system
WRIST FRACTURE AND FIXATION
External Fixator ORIF - Palmar plating - Radial column plating - Dorsoradial double plating
ORIF - TYPE OF IMPLANTS
LCP Distal Radius System 2.4 - Low profile plate - Locking screw Ø 2.4 mm - Cortex screw Ø 2.4 mm - Cortex screw Ø 2.7 mm - Stardrive recess T8 - Self tapping screw
LCP 2.4 Distal Radius System Volar plate 11
Indications Displaced extraarticular distal radius fractures (A2-A3) Partial articular distal radius fractures (B1-B3) Intraarticular distal radius fractures (C1-C3) Corrective osteotomies of the distal radius
Approach technique - Dorsal approach - Volar(Palmar) approach
Dorsal Approach 2-plate technique increases stability with smaller plates placed at 70-90 angle Strong construct Avoids removal of Lister s tubercle 70-90
LCP 2.4: Dorsal Plate Radial column 2 straight plates Pre-bent Provisional K-wire fixation to stabilize styloid Fixed Angle Plate Intermediate column 8 right-angle plates 4 oblique plates 2 T-plates
LCP2.4 for dorsal approach - Locked fixed-angle screws are useful - Low profile to avoid tendon ruptures - Useful for osteotomies Radial column plate Intermediate column plate 18
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Volar approach Decreases tendon & soft tissue irritation 20
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LCP 2.4- Volar plate Juxta-articular plates Extra-articular plates
LCP Juxta-Articular Distal Radius Plates More complex fractures 5 proximal angulation for more distal plate placement Fractures involving RCJ and/or DRUJ, requiring very distal support of the articular surface Loss of palmar buttress Colles-type fx Smith and rev. Barton fx Comminuted fx Corrective osteotomies A2&3, B1-B3, C1-C3
-Juxta articular standard and Buttress Plates 4 volar standard plates 3 holes 5 holes 2 volar buttress plates 3 holes
Juxta articular plate Standard Buttress Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 25
Juxta-Articular Plates - Function Distal part function like a rake through angular stability Buttress articular surface
Palmar Approach - Extra-Articular Plates Placement of this plate is farther away from the articular surface than the juxta-articular plates Screws diverge to secure styloid and dorsally displaced fragments Screws are angled towards articular surface in an array Profile height 2 mm, SSt/Ti Screws: like standard volar plates
Extra Long Volar Plates Distal radius fx which extend into the shaft 8, 10 and 12 holes SSt available from April 2006 100 mm 120 mm 140 mm
Juxta vs. Extra Volar standard and Buttress Extra-articular 32
Instruments for LCP 2.4-323.029 Threaded Drill Sleeve 2.4, with scale for Drill Bit 1.8 mm - Drill Bit B 1.8 mm with marking - 03.111.005 Depth Gauge for S. Ø 2.0-2.7mm - 319.006 Depth Gauge for S. Ø 2.0-2.4 mm. - 319.01 Depth Gauge for S Ø 2.7-3.5 mm. 34
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Universal Drill Guide 1.8 /2.4 Screwdriver shaft stardrive T8,self holding Holding Sleeve for Screws Stardrive 2.4 Torque limiter 0.8 Nm Handle with quick coupling 36
Optional instruments Universal Drill Guide 2.0/ 2.7 Drill bit 2.0 mm Drill bit 2.4 mm Drill bit 2.7 mm - Handle for Torque Limiters 0.4/0.8/1.2 Nm - 311.023.97 Ratcheting Screwdriver Handle Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 37
- 329.12 Bending Pliers,140 mm, for 1.5 mm and 2.0 mm plates - 329.922 Bending Pin, for 2.4 mm locking plates - 398.41 Reduction Forceps with Points, broad, ratchet, 132 mm length - Hohmann Retractor, 8 mm width, small, short narrow tip, 160 mm length - Periosteal Elevator, 3 mm width, curved blade, round edge 38
Set Configuration: Graphic Case Set include screw rack and module 303.100
LDRP 2.4: Key Features and Benefits Feature Angular stability Low plate/screw profile Highly polished surface Benefit purchase in bone of bad quality support of reconstructed articular surface no primary or secondary loss of reduction No screw back-out Prevents tendon irritation and tendon adhesion SS and Titanium Dorsal or Volar Plates Extra- or Juxta-Articular Plates Surgeons choice (Juxta: very distal pos. treatm. C3 fx!) Precontoured and variety of lengths Compatible with LCP Compact Hand 2.4 Less OR time Less inventory
Compact Hand Modular System
New Design Variable Angle Locking Plate VA-LCP
VA-LCP Two-Column Volar Distal Radius Plate 2.4 mm
VA-LCP Drill Guide 2.4 Cloverleaf design VA-hole Fixed Angle
VA-Locking holes 15 Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 48
Implants & Instrumentation
System Description: Implants 6-hole head, narrow Width 19.5 mm 6-hole head standard 22.0 mm 7-hole head 25.5 mm 50
Optional Standard System Description: Screws VA-Locking Screw 2.4mm, self-tapping Applicable in VA locking holes 2.4 0X.210.108-0X.210.130, 8-30mm Cortex Screw 2.4mm, self-tapping Applicable in VA locking holes 2.4 and combi holes 2.4 X01.756 X01.780, 6-30mm VA-Buttress Pin 1.8mm Applicable in VA locking holes 2.4 0X.210.078 0x.210.100, 8-30mm Locking Screw 2.4mm, self-tapping Applicable in VA locking holes 2.4, but only in nominal angle X12.806 X12.830, 6-30mm Cortex Screw 2.7mm, self-tapping Applicable in combi holes 2.4 X02.866 X02.890, 6-30mm 51
Key Features & Benefits Features Variable Angle Kirschner Wire holes Benefits Up to 15 off-axis screw angulation in order to address the individual fracture patterns Better support of lunate facet and DRUJ Proper fixation of radial styloid Possibility of new-positioning of screw Rotation stable fixation of fragments (with 2 screws) Preliminary plate fixation with Kirschner Wires or Plate Reduction Wires Oblong LCP combihole Allows accurate plate positioning on the bone Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 53
Key Features & Benefits Features Rounded edges, polished surface and countersunk screws Benefits Reduced risk of soft tissue irritations Anatomically precontoured Plate sits very close to volar ridge on the ulnar side to achieve optimal support of the lunate facet Two-Column design 1 Window helps to see fracture lines Window allows bone graft insertion 1 Picture by Prof. Ladislav Nagy, Balgrist Clinic Zurich 54
Key Features & Benefits Features Trial Implants Benefits Plate dimension determination for sterile users Guiding Block / Quick drill sleeve Allows guided drilling and screw insertion in the pre-defined nominal angle Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 55
Key Features & Benefits Features Rounded corners on radial and ulnar edges to fit into smaller area Benefits For treatment of small-statured patients Allows a more minimally invasive approach of patients with simple fractures Adapted anatomical shape Especially designed for smaller radii Distal angulation lowered from 25 20 for fit on small radii Plate sits very close to volar ridge on the ulnar side to achieve optimal support of the lunate facet Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 56
Indications Variable Angle LCP Two-Column Volar Distal Radius Plates 2.4 mm are indicated for the fixation of intra- and extra-articular fractures and osteotomies of the distal radius. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 57
X-Ray Examples 53 year old small statued female with AO 23 A3 fracture Pre-op Post-op Note: use of K wires for preliminary fixation Note: screws have intentionally been chosen to be far below opposite cortex Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 60
Holes & Screws 2.4mm Variable Angle Locking Holes - 2.4mm VA locking screws - 2.4mm locking screws (only nominal angle) - 1.8mm buttress pins - 2.4mm cortex screws* Kirschner Wire Holes - 1.25mm K-Wires - 1.25mm Plate Reduction Wire with small stop - 1.25mm Plate Reduction Wire with large stop Hole for Guiding Block fixation Holes for attaching the guiding blocks Plate Reduction Wire (all holes) - 1.25mm Plate Reduction Wire with large stop 2.4mm LCP Combi Hole (locking portion) - 2.4mm VA locking screws (only nominal angle - 2.4mm locking screws 2.4mm VA Combi Hole (compression portion) - 2.4mm cortex screws - 2.7mm cortex screws 61
Important Do not use any threaded drill guide in the variable angle locking holes in the head of the plate, as it could damage the threads in the hole. ** Threaded damage!!! 62
Standard System Description: Instruments 03.110.000 VA-LCP Drill Guide 2.4** 323.202 Universal Drill Guide 1.8 /2.4 323.260 Universal Drill Guide 2.0/ 2.7 310.509 Drill Bit 1.8 mm with marking 314.467 Screwdriver Shaft Stardrive 2.4 314.453 Screwdriver Shaft Stardrive 2.4, short 314.468 Holding Sleeve for Screws SD Ø 2.4 63
Standard System Description: Instruments 03.111.005 Depth Gauge for Screws Ø 2.0-2.7mm 511.776 Torque Limiter 0.8 Nm 03.110.005 Handle for Torque Limiters 0.4/0.8/1.2 Nm 311.430 Handle with Quick Coupling 292.120 Kirschner Wire Ø 1.25 mm with trocar tip 323.029 LCP Drill Sleeve 2.4 with scale Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 64
System Description: Instruments Optional 03.111.500 Guiding Block for Two-Column Distal Radius Plate 2.4, 6 holes, narrow, right 03.111.501 Guiding Block for Two-Column Distal Radius Plate 2.4, 6 holes, narrow, left 03.111.600 Guiding Block for Two-Column Distal Radius Plate 2.4, 6 holes, right 03.111.601 Guiding Block for Two-Column Distal Radius Plate 2.4, 6 holes, left 03.111.700 Guiding Block for Two-Column Distal Radius Plate 2.4, 7 holes, right 03.111.701 Guiding Block for Two-Column Distal Radius Plate 2.4, 7 holes, left 03.111.007 Screw for Guiding Block for Two-Column Distal Radius Plate 2.4 Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 66
System Description: Instruments Optional 03.111.000 Quick Drill Sleeve 2.4 with Scale, for Drill Bits Ø 1.8 mm, for Guiding Block, for VA- LCP Radius Plates 310.534 Drill Bit 2.0 mm with marking, length 110/85 mm, 2-fluted, for Quick Coupling 323.260 Universal Drill Guide 2.0/2.7mm. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 67
Preparing for a Case
Preparing for a Case: Overview The following modules / trays are necessary: Module with Plates Instrument Tray with instruments Screw Rack with screws Module Instrument Set for LCP + and VA-LCP Plates 2.4 + Standard 2.4/2.7 Screw Rack or Modular Mini Frag Screw Rack 2.0-3.5 Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 70
Technique
1. Select implant Technique: Preparation Select the plates according to the fracture pattern and anatomy of the bone. Important: Ensure the proper plate selection by verifying the L (left) and R (right) etching on the plate shaft. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 74
Technique: Surgical steps 2. Reduce fracture and position plate Reduce the fracture. The reduction method will be fracture-specific. Apply the plate to fit the volar surface. If necessary, use 1.25 mm Kirschner wires inserted through the desired Kirschner wire hole to temporarily fix the plate. Alternatively, the 1.25mm plate reduction wires can be used for preliminary plate fixation. Note: The plate reduction wires are single use items, do not re-use. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 75
Technique: Surgical steps 3. Drill screw hole for cortex screw Beginning with the elongated hole in the shaft of the plate, drill with the 1.8 mm drill bit using the Universal Drill Guide 2.4 for a 2.4mm cortex screw. For inserting a 2.7mm cortex screw, drill with the 2.0 mm drill bit using the Universal Drill Guide 2.7. 4. Determine screw length Determine the screw length with the depth gauge. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 76
5. Insert cortex screw Technique: Surgical steps Insert the self-tapping cortex screw using the self-holding T8 Stardrive screwdriver shaft and the quick coupling handle. Adjust the plate position if necessary and tighten the screw. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 77
Technique: Surgical steps 6. Drill screw hole for locking screw in plate shaft Carefully insert the LCP drill sleeve 2.4 with scale, perpendicular to the plate and in line with the hole s axis until it is seated in the desired locking hole. Drill with the drill bit 1.8 mm. Read the screw length directly from the laser mark on the drill bit. Alternatively, use the corresponding depth gauge to determine the screw length. 7. Insert locking screw in plate shaft Using the torque limiter, insert either a standard locking or variable angle locking screw. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 78
Technique: Surgical steps 8a) Drill screw hole for VA locking screw using variable angle technique Insert and lock the VA-LCP drill sleeve tip into the cloverleaf design of the VA locking hole. Use the 1.8 mm drill bit to drill to the desired depth at the desired angle. The funnel of the drill sleeve allows the drill bit to be angled up to 15 around the central axis of the locking hole. Important: To ensure that the screw is locked correctly, do not angle it in excess of +/ 15 from the nominal trajectory of the hole. 79
Technique: Surgical steps 8b) Drill screw hole for VA locking screw using nominal angle technique 8c) Drill screw hole using Guiding Blocks Alternatively, use the Two-Column Distal Radius Plate Guiding Block in combination with the Quick Drill Sleeve. Read the screw length directly from the scale on the instrument or use the depth gauge instead (see step 9). Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 80
Technique: Surgical steps 9. Determine screw length Determine the screw length with the depth gauge. If guiding block is applied, measure directly through the guiding block. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 81
Technique: Surgical steps 10. Insert VA locking screws Insert the VA locking screws manually with the self-holding T8 Stardrive screwdriver shaft Do not over-tighten the screw. This allows the screws to be easily removed should they not be in the desired position Technique Tip: When a guiding block is used, the locking screw (VA locking or standard LCP) may be inserted with a T8 screwdriver directly through the guiding block. 82
Technique: Surgical steps 11. Ensure proper joint reconstruction Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 83
Technique: Surgical steps 12. Final fixation of VA locking screws Use the 0.8 Nm torque limiter to perform the final locking step for the VA locking screws. (1) The torque limiter prevents over-tightening and ensures that the VA locking screws are securely locked into the plate. (2) Note: For dense bone, visually inspect if screw is countersunk after tightening with torque limiter. If required, carefully tighten without torque limiter until screw head is flush with plate surface. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 84
Technique: Tip Tip: Fine contouring the plate (optional) If necessary, bend the tabs of the plate to suit anatomical conditions as indicated. Avoid repetitive bending Recommendation: Use non-serrated bending pliers for preservation of the plate s smooth finish. Note: The design of the plate holes allows a certain degree of deformation. However, if threaded holes are significantly deformed, locking is not sufficiently efficient. Important: If using guiding blocks, avoid bending the head portion of the plate. Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 85
Implant removal 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. T8 Stardrive screwdriver shaft Handle with quick coupling 86
Take home messages LCP 2.4 mm forms and function Specific column designs Volar and Dorsal pate selection Films, CT, Fx.type, Surgeon dicision VA- LCP with special drill guide 100% stability Star-drive recess Instrument for removal Reduce OR time and risks 87
Thank you for your attention Version 2 / August 2011 / VA-LCP Two-Column Volar Distal Radius Plate 2.4 88