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Distal radial fracture- Dorsal plating with Depuy-Synthes 2.4mm VA locking radial column plate assisted by wrist arthroscopy using Acumed ARC tower

    Overview

    Professional Guidelines Included
    Learn the Distal radial fracture: Dorsal plating with Depuy/Synthes 24mm VA locking radial column plate assisted by wrist arthroscopy using Acumed ARC tower surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Distal radial fracture: Dorsal plating with Depuy/Synthes 24mm VA locking radial column plate assisted by wrist arthroscopy using Acumed ARC tower surgical procedure.
    This is a detailed step by step instruction through a arthroscopic assisted dorsal plating of a distal radius.
    The operation is performed to restore the bone anatomy of the distal radius following a wrist fracture. Specific attention is paid to the congruency of the distal radius articular surface viewed by the arthroscopy.
    Adding an arthroscopy to a plating of a distal radius is only necessary for intra-articular fractures. It could be argued that all intra-articular fractures would benefit from an addition of arthroscopy to check joint congruence, however most intra-articular wrist fixation takes place without arthroscopy. For those surgeons who routinely perform arthroscopy of the wrist, its addition to a plating of a distal radius can be valuable, particularly in the presence of die punch or stepped fractures not easily seen or reduced by other means.
    The joint fragments can be reduced using probes or wires through the fracture site once the wrist is opened and the reduction checked by the arthroscopy or the fragments may be reduced using the probe through the arthroscopy portals and position checked once the plate(s) is applied.
    It is sometimes unnerving how the radiographic images taken intra-operatively can appear well reduced and only when the joint is directly viewed through an arthroscope is it noted how much of an articular step remains.
    As far back as 1999 Doi et al (1) showed of the 82 patients treated there was a decreased incidence of mid term arthritis in the arthroscopic assisted fixation group rather than those with no arthroscopy, 47% versus 58%. Abe et al (2) revealed why this may be the case as they showed that in 35% of patients who appeared to have an anatomical reduction on fluoroscopy had a step-off or gap in the articular surface >2mm found at arthroscopy.
    Other advantages of arthroscopic assisted distal radius fixation are to discover any concomitant ligament or cartilage injuries and any screw penetration.
    Addition of an arthroscopy does prolong the procedure aiming to improve joint congruence and reduce later arthritic changes. The procedure take from 90-150 mins depending on the complexity of the fracture and the delay between injury and operation.
    The operation is performed as a daycase procedure and the patient is placed in cast for 4-6 weeks following the procedure to start focussed rehabilitation once casting is complete.
    Patients often return to light work at 8 weeks, heavy work at 3 months and continue to strength and improve up to a year post-operation.
    The plating system used in this particular case was the 2.4mm Variable angle LCP Dorsal Distal radius plates from DePuy Synthes. The features of the plates are an array of short and long anatomically contoured options including a radial column plate to place on the Radial styloid. Variable angle holes allowing a 15 degree arc in each direction (which is easily drilled with a specially designed variable angle drill guide) for more accurate screw placement in relation to the fracture fragments. They are low profile and have undercut notches to allow bending. They have k-wire holes to allow temporary plate placement and an oval non-locking hole for the first shaft screw to allow minor adjustments.
    This operation should be read after first studying and understanding the wrist arthroscopy technique on OrthOracle https://www.orthoracle.com/library/diagnostic-wrist-arthroscopy-acumed-arc-tower/

    Doi K, Hatturi T, Otusaka K, et al. Intraarticular fractures of the distal aspect of the radius arthroscopically assisted reduction comparedwith open reduction and internal fixation. J Bone Joint Surg1999;81A:1093–1110.
    Abe Y, Yoshida K, Tominaga Y. Less invasive surgery with wrist arthroscopy for distal radius fracture. J Orthop Sci 2013;18:398–404.


    Author: Mr Mark Brewster FRCS (Tr & Orth).
    Institution: The Royal Orthopaedic Hospital, Birmingham, UK.


    Indications

    Indications.
    This procedure is indicated for a intra-articular distal radius fracture which has been chosen to undergo operative fixation.
    It is used in intra-articular fractures which, based on a CT scan, are anticipated to pose a challenge when trying to reduce the distal radial articular surface due to a stepped or die punch pattern of fracture.
    Arthroscopy is used as an adjunct to plating of the distal radius.
    The decision of whether to plate a distal intra-articular fracture will depend on patient factors and fracture pattern factors.
    Patient factors
    Elderly patient – may have poor bone stock and if they have a very comminuted fracture or low function may benefit from a bridging plate or external fixator to achieve an indirect reduction instead.
    Poly-trauma patient – a short duration operation may often be required primarily in these patients. Bridging plate or external fiaxtor
    Large soft tissue defect – this patient will benefit from an external fixator to reduce the risk of infection of exposed plates if primary skin closure is not achievable.
    Fracture factors
    Comminution – if very severally comminuted a bridging plate or external fixator may be employed to achieve an indirect reduction.
    Open fracture – as above with tissue defect.
    Simple and reducible – if it is a simple intra-articular fracture reducible closed then k-wires rather than plate fixation may be used as per the DRAFFT trial.
    Symptoms.
    The operation is for acute distal radius fracture which have not started to heal and therefore allow easy mobilisation of the fragments. The can be anytime up to 2 weeks but is simpler the sooner the operation is undertaken.
    Pain and swelling will be present and possibly tingling if the swelling or fracture displacement is causing nerve compression.
    Examination.
    In young patients particularly, these injuries are high energy and therefore an ATLS approach needs to be take to the examination in particular assessing the elbow and hand for concomitant injuries.
    Specific to the wrist fracture the skin needs to be examined for any breech which would make this an open fracture. The hands neuro-vascular status needs to be examined and recorded.
    Capillary refill should be < 2 seconds, any tingling or numbest should be assessed in the median, ulnar and radial nerves with the median being most likely to be affected.
    Movement of the fingers and thumb can be assessed however this is often difficult due pain related to the fracture.
    If a high energy injury then an awarenesses of the signs of compartment syndrome of the forearm needs to be present.
    These would be as severe pain beyond that expected for the injury, increased pain on finger extension and a tight forearm. Neuro-vascular symptoms are a very late sign in compartment syndrome and should not be relied on to make the diagnosis.
    Investigations.
    Plain X-rays
    As part of the diagnosis the patient will have undergone a PA and lateral radiograph. If they have had a wrist manipulation in the emergency department and a plaster cast replied then a repeat radiograph in the cast is essential.
    CT scan
    For intra-articular fractures a CT scan is strongly advised to appreciate the anatomy of the fracture in particular the displacement of the dorsal ulnar corner of the distal radius. This fragment is difficult to see on plain radiographs and affects both the radoiocarpal and distal radio-ulnar joints.
    Non operative treatments.
    The fractures which are appropriate for arthroscopic assisted fixation are not appropriate for non-operative treatment unless the patient is so unwell that an operation would be life threatening.
    Alternative operative treatments.
    As discussed there are alternative treatments such as external fixator or bridging plate in certain circumstances related to patient and fracture factors which may be more appropriate than plate fixation.
    The true alternative with the same fracture in the same patient is to perform the plating without arthroscopic assistance which is the most frequent way these fractures are performed. This is likely to be a combination of a resource and skill issues with not everyone performing wrist fracture surgery also able to perform wrist arthroscopy.
    Contra-indications.
    Absolute
    -A patient who cannot undergo a 2 hour operation due to their current health status.
    – A surgeon who does not have the arthroscopic skills to perform the procedure.

    Setup

    The operative is performed under regional or general anaesthetic.
    In addition to standard surgical instruments, equipment required will be an Esmarch bandage, arthroscopy tower, and set (camera, trocar, obturator, probe), 50ml syringe and tube to deliver saline to trocar, fine suction tube, Depuy Synthes 2.4mm VA dorsal plating system, an image intensifier and a plaster cast.

    Operation – 1

    The arm is prepped and draped and in arthroscopy traction tower with surface anatomy and portals marked.
    Once prepped and draped the finger traps are applied to the index and middle and the hand is held in the Acumed ARC Traction Tower.
    Details of this set up and portal placements should be read in the ‘Diagnostic wrist arthroscopy operative technique’ https://www.orthoracle.com/library/diagnostic-wrist-arthroscopy-acumed-arc-tower/
    Once in traction, the outline of the ulna head and styloid, Lister’s tubercle (LT) and the distal radius are marked.
    The 3-4 and 6R radiocarpal portals are marked.
    Once marked, an Esmarch bandage is used to exsanguinate the arm and the tourniquet is inflated to 250mmHg. This is left until just before the first incision to limit the tourniquet time which may be up to 2.5 hours in difficult fractures.

    Wrist is washed out through radiocarpal portalsTo identify 3-4 RC portal the surgeon places their thumb on Lister’s tubercle and slides it distally around 1-1.5cm. Here can be felt a soft area. This area is quite large and overlies the dorsal lunate and dorsal capitate. If the surgeons thumb inter-phalangeal joint (IPJ) is flexed fully and the thumb nail used feel the most proximal extent of the soft area just distal to the dorsal lip of the radius this is the site for the 3-4 RC portal.
    To identify 6R portal the surgeons thumb is place over the ulna head and slid distally until it drops into a soft area with the ECU tendon on the ulna aspect. This will be at the level of the TFCC therefore the portal needs to be marked about 5mm distal (just proximal to where the dorsal triquetral can be palpated).
    As this is a distal radius fracture, the joint surface will not be smooth and there will be a haemarthrosis which needs to be cleared before assessment can be carried out.
    Once the portals are made the obturator of the arthroscopy trochar can be gently swiped around inside the joint to loosen the haematoma and feel for any steps with its blunt tip.
    The trochar is then inserted into the 3-4 portal with saline attached via a 50ml syringe and tube and the suction is inserted into the 6R portal.
    The insertion needs to be carried out very carefully to avoid iatrogenic damage to the cartilage which may be stepped inside the joint.

    Trochar and suction are swapped over in portals to complete washout from both sides of the radiocarpal joint.It is important to limit the pressure and volume of fluid pushed through the wrist and maintain a constant flow checking that the suction does not become blocked. Unlike a standard arthroscopy the fluid can escape into the fracture and into the forearm with a theoretical possibility of causing compartment syndrome.

    Arthroscopic anatomy of the bones and portals
    Blue – Radial Midcarpal
    Red – Ulnar Midcarpal
    Orange – 3-4 Radiocarpal
    Green – 6 Ulnar

    Arthroscopic ligament anatomy.

    The radio-carpal joint is viewed initially from the 3-4 portal looking towards the radial styloid.On the image the scaphoid (Sc) is above, the scaphoid fosse of the radius below with intra-articular fracture and granulation tissue overlying the fracture.
    Left is volar (V) and right is dorsal (D) in the wrist joint.
    A – The central area of granulation is covering the intra-articular fracture of the distal radius.

    Probe inserted to mobilise granulation tissue.Mobilising the granulation tissue will reveal the presence of a gap or step in the radius articular surface.

    The step (A) and gap (B) in the articular surface is revealed by the probe.

    Ulnar and Radial mid-carpal portals are created.The Radial midcarpal (RMC) portal is roughly 1cm distal and just to the radial aspect of the 3-4RC portal. A joint line can usually be felt at this point if the tip of the thumb nail is used as before and the site can also be confirmed by palpating the tendons of the 4th extensor compartment and dropping of their radial aspect into the soft area in line with the 2nd web space.
    The Ulnar midcarpal (UMC) portal is roughly 1cm distal and just to the ulnar aspect of the 6R portal. A joint line can usually be felt at this point if the tip of the thumb nail is used as before and the site can also be confirmed by palpating the tendons of the 4th extensor compartment and dropping of their ulnar aspect into the soft area in line with the 4th web space.

    The Scapho-trapezio-trapezoidal (STT) joint is visualised through the Radial Mid-carpal portalSc – Scaphoid
    Td – Trapezoid
    Tm – Trapezium

    With the scope in the Radial midcarpal portal a needle is used to identify the ulnar mid carpal portal.

    The needle is seen from within the joint affirming the portal site before the skin is incised.

    The Scapho-lunate joint is assessed arthroscopically.The Scapholunate ligament is assessed both from the radoiocarpal and mid carpal joint as per the Geissler classification below.
    The probe can pass into the joint making this case a Geissler grade 3 injury to the Scapho-lunate ligament
    A normal joint would not allow passage of the probe.
    The Geissler Classification
    A Grade 1 injury to the Scapho-lunate ligament would show bruising of the ligament from the radoiocarpal joint
    A Grade 2 injury an abnormal step in the joint from the mid carpal joint
    A Grade 3 (as in this case) the probe can pass into the joint
    A Grade 4 injury the camera (2.4mm) can be passed into the joint know as the ‘drive through sign’.

    The luno-triquetral joint is assessed arthroscopicallyThe probe can pass into the joint making this a Geissler grade 3 injury to the Luno-triquetral ligament

    The dorsal approach for the radial plating is marked in the midline and incised.With the hand off traction the dorsal wrist approach can proceed.
    This incision is sited just ulnar to Lister’s tubercle and extends from the level of the radoiocarpal joint (or the portals in this case) distally then extending around 7cm proximally depending on the level and comminution of the fracture within the metaphysis.

    Fat in line with the incision and vein branches are diathermised to allow access to the deep fascia.

    The fat is cleared from the dorsum to reveal the extensor retinaculum.The tendons of the 4th compartment are being identified with the scissors and the purple muscle bellies of the 1st extensor compartment can also be seen.

    The self retainer is placed carefully in the skin to avoid damage to the superficial radial nerveSRN – Superficial radial nerve
    The SRN is a terminal branch of the radial nerve and is very sensitive to injury. It is a pure sensory nerve which runs beneath the Brachioradialis and exits this plane at Wartenberg’s point to sit superficial to the forearm fascia.
    This point is where the nerve passes between the tendons of Brachioradialis and Extensor carpi radialis longus around 5-8cm proximal to the radial styloid.
    The SRN supplies the wrist joint and the skin over the 1st dorsal web space and the dorsum of the thumb, index, middle and half the ring finger up to PIPJ level.

    The 3rd extensor compartment is opened to reveal the Extensor pollicis longus (EPL)The 3rd compartment is opened first to allow access to the 4th compartment whilst creating a large flap of the extensor retinaculum to repair at the end of the procedure. Mobilising the EPL also provided greater access and is safe to reduce the risk of tendon injury intra-operatively and post-operatively by the plates.
    The 4th extensor compartment is then opened through its side wall to maintain the extensor reticular flap and the EPL is retracted radially and the contents of the 4th compartment (Extensor indices and Extensor digitorum communis tendons) are retracted ulnarward.

    The EPL is placed beneath the self retainer and the posterior interosseous nerve and artery (PIN+A) are exposed.Scissors pointing at the PIN and PIA
    The PIN is the other terminal branch of the radial nerve which after it branches of the from the SRN it passes through the Supinator muscle which it supplies and after supplying the extensors to the fingers and thumb then terminates as a sensory branch to the wrist capsule.
    The PIA is a terminal branch from the ulna artery, then the common interosseous artery (also providing the anterior interosseous artery) which lies on the interosseous membrane and joins the PIN in the mid forearm.
    At the level of the extensor retinaculum they lie together on the most radial aspect of the 4th extensor compartment.

    Watson-Cheyne elevator is placed into the fracture and used to elevate the depressed articular fragmentAs the majority of the joint is in a good position the main aim at this point is to elevated the die-punch fragment to make the joint congruent and allow it to be held with the fixation.
    The joint level can be estimated by the position of the previously placed radoiocarpal arthroscopic portals or a needle can be used to locate it once the tendons are retracted. This can sometimes be difficult with a comminuted fracture with many sites a needle can be inserted and if in doubt a fluoroscopy can be used.
    On this image the joint line is just proximal to the Ragnell retractor on the left. (RCJ)
    Remember there is an 11 degree volar tilt of the radius when localising the joint on fluoroscopy if the fracture is reduced.

    The radiograph shows the elevator beneath the bony fragment aligning the joint surface.

    The interval between extensor compartment 1 and 2 is exposed.The dissection must see the fracture line at the base of the styloid and allow enough room for a radial column plate to be applied. Usually the fascia over the tendons and muscle of the 1st extensor compartment is split to mobilise the tendons and allow access

    The scissors are used to identify the tip of the radial styloid to guide plate placement

    The Depuy Synthes 2.4mm VA locking radial column plate contoured for the radial styloid.
    They come pin a 5 and 6 hole depending on how proximally the styloid fracture extends.
    The plate is usually used as a buttress plate on the styloid.
    This and the T plate used can have standard or variable angle locking plates which can locking with a freedom of 15 degrees in any direction and thus a 30 degree total arc. The plates also have an oval non-locking hole to allow adjustment of the plates position at initial fixation.

    Operation – 2

    The radial columnn plate is inserted on the styloid.See how the proximal end of the plate sits beneath the tendon of the 1st and 2nd compartments and care is taken to avoid the plate sitting too distal on the styloid to avoid impingement.
    A gliding hole in the plate can aid positioning if used as the primary hole.

    A T plate is next used the buttress the dorsal radius and provide fixture sites for screws to support the articular surface.Primarily the sliding hole is used and X-Ray used to guide the exact position of the plate. Once happy a locking screw is inserted to fix rotation and proximal to distal location.

    A step is still seen in the articular surface with the arthroscope back in the wrist which is again on traction A – Step in joint surface
    The plates are now fixed to the radial and dross of the wrist acting as buttresses however no distal screws supporting the fragment have been inserted.
    The previous reduction manoeuvre was to show the reduction was possible but it was not stabilised.

    With the plate fixed proximally the first distal screw is placed into the dorsal T plate to support the articular fragment.With the arthroscope in the 3-4 portal monitoring the position of the articular fragment, this is now being held up by a k-wire or probe from the dorsum.
    A screw can then be placed proximal to the fragment and locked in to the plate to support the joint surface.
    Ensuring that the joint is now congruent.
    A variable angle guide with 15 degrees of freedom in each direction is used to allow the screw to be sited as close to the subchondral bone as possible. With the variable angle screw the angler of the screw in the plate and therefore the position of the fragment can be adjusted slightly when locking the screw into the plate to allow for the best reduction of the fracture.

    The view from the arthroscopy shows the fracture reduced. In addition there is a small amount of granulation in the fracture which will eventually disappear.

    The rest of the screws required are inserted whilst the arthroscopy continues to monitor the articular congruence.The central distal screw in the T plate was left out as its insertion was pushing on the articular fragment displacing it.

    The 1st extensor compartment is retracted to access the most proximal screw hole. If this is still difficult the tendons can be retracted distally to expose the final screw hole.
    Often all screw holes will be filled but on occasion the most distal hole would breech the joint if a screw was inserted and therefore this may be left empty.

    The tendons are relocated and the extensor retinaculum repaired if possible.If the retinaculum is short then it is closed to recreate the 4th extensor compartment and the EPL is exteriorised.
    Care must be taken not to injury the SRN during closure.

    Skin is closed with 4/0 vicryl rapide

    An occlusive dressing is applied
    The tourniquet is then deflated for 5 mins to allow swelling before further dressing are applied.

    The back slab cast is applied.The wool beneath the crepe is split around the wrist to allow swelling with less discomfort from the tight dressings.

    The PA radiograph reveals the long metaphysical split and die punch fragment in line with the scapho-lunate joint.

    The lateral image reveals the dorsal lip involvement within the fracture pattern

    Coronal CT slice reveals the die punch fragment and articular incongruity

    Sagittal CT slice reveals the die punch fragment and articular incongruity

    Transverse CT slice reveals the die punch fragment and articular incongruity

    Intra-operative PA images of the plates in situ and fragment elevated into position.

    Intra-operative Lateral images of the plates in situ and fragment elevated into position.

    Post Operative

    The procedures are usually performed as a day case under axillary block or general anaesthetic.
    It is essential to provide adequate analgesia – paracetamol, codeine and oral morphine, and advise patients to start taking this pain relief sooner rather than later to avoid the axillary block wearing off completely before the analgesia has had time to work. We advise patients to take the paracetamol and codeine before bedtime that night, even if their arm is still numb, and have their morphine by their bed for use during the night or first thing in the morning. In addition we provide anti-emetics and laxatives to counteract the side effects of the opiates.
    In addition to analgesia the patient receives a Bradford sling to elevate their hand and advice to keep their hand elevated, start moving their fingers as soon as possible and to expect this to be a painful operation despite the analgesia. Often patients will sleep the first night or two in a chair which makes arm elevation easier and limits are movement more.
    Following discharge the patient attends a clinic within a week to change the plaster cast, which often has become tight and then loose again following the initial post-operative swelling.
    If still very swollen they are placed back into a half cast and seen the following week for a full cast. If the swelling is minimal the may receive a full cast at this point. The are also seen by the hand therapists at this point to encourage finger movements.
    At 6 weeks the cast is removed and wrist x-rayed.
    If all is well, a removable splint is provided for comfort and certain lifting tasks and the hand therapist will start wrist mobilisation encouraging the removal of the splint the majority of the time.
    Patients often return to light work at 8 weeks, heavy work at 3 months and continue to strengthen and improve their range of movement up to a year post-operation.

    Recommended Reading

    The results following distal radial fractures is dependant on many factors – associated injuries (particularly to the ulnar side of the wrist), pre-morbid state, adequacy of reduction of distal radial alignment and the articular surface, surrounding soft tissue injury and patient rehabilitation.
    Complications are related to the operative technique and the severity of the injury.
    Complications include infection, stiffness, persisting pain, chronic regional pain syndrome, neuro-vascular injury, scar tenderness, tendon injury, malunion, post-traumatic arthritis, secondary operation for plate removal and decreased grip strength.
    The frequency of complications related to the arthroscopic part of the procedure are greater the less experienced the surgeon. The complications are noted in the results section of the diagnostic wrist arthroscopy.
    Complications of general or regional anaesthetic also should be discussed with the patient.
    Below are some papers which will enhance your knowledge on the topic and may aid your future decision making for such patients.
    Treatment of intra-articular fracture of distal radius fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensitometric comparative study of 40 patients.
    Burnier M1, Le Chatelier Riquier M1, Herzberg G2. Orthop Traumatol Surg Res. 2018 Feb;104(1):89-93.
    In this paper 40 patients of similar fracture and patient characteristics were assessed prospectively with CT scan. They were assigned to either fluoroscopic or arthroscopic assisted reduction of their distal radius fracture and then reviewed with a CT again post-operatively to assess joint congruency.
    The steps and gaps were not significantly different preoperatively in the 2 groups however there was a statistically significant improvement in both the radoiocarpal and DRUJ articular surface in the arthroscopic compared with the fluoroscopic reduced patients. This included a significantly greater % of patients with a <1mm gap or step in the arthroscopic group which was noted as being the cut off associated with future joint arthritis.

    Arthroscopic-Assisted Reduction of Intra-articular Distal Radius Fracture.
    Abe Y, Fujii K. Hand Clin. 2017 Nov;33(4):659-668.
    The authors treated 248 consecutive distal radius fractures (the vast majority C1 & C3 types) with plating and arthroscopic assistance. In their study they noted advantages of arthroscopy which included – an acceptable reduction on fluoroscopy did then not correlate well with an acceptable joint reduction when viewed with arthroscopy (21% patients still had >2mm steps in articular surface despite looking acceptable on fluoroscopy), loose bodies not seen on fluoroscopy or CT scan were seen and dealt with arthroscopically, intra-articular screw protrusions were seen and could be resited, associated ligament injuries could be diagnoses and treated.
    199 of these patients were followed up >1 year and 76% were graded as excellent and 22% good on the Mayo Modified Wrist Score. Complications were 5 (2.5%) gross displacements of the distal fragment, 2 (1%) extensor pollicis longus tendon ruptures, and 1 (0.5%) complex regional pain syndrome.

    For more of an overview on wrist arthroscopy in conduction with distal radius fracture fixation a systematic review by can be read.
    F. Smeraglia, A. Del Buono & N. Maffulli. Wrist arthroscopy in the management of articular distal radius fractures. British Medical Bulletin, Volume 119, Issue 1, September 2016, Pages 157–165.

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