An Essay Submitted For Partial Fulfillment Of The

Requirement For M.Sc. Of Orthopedic Surgery

Supervisors
Prof. Dr. Mohamed Morsy Ibrahim Wahba
Professor of Orthopedic Surgery
Faculty of Medicine, Mansoura University

Dr. Mohamed Fathy Mohamed Mostafa
Assistant Professor of Orthopedic Surgery
Faculty of Medicine, Mansoura University

Dr. Ahmed El-Sayed Magdy El-Hawary
Lecturer of Orthopedic Surgery
Faculty of Medicine, Mansoura University

2014
Mansoura University
Faculty of Medicine
Orthopedic Surgery Department
THE USE OF LOCKED PLATES IN
DISTAL RADIUS FRACTURES
f
I






BY
Mohamed El-Sayed El-Mekawy
M. B. B. Ch (Mansoura)
Resident of Orthopedic Surgery


















-

4102



Anatomy

5

fragment. The surgical reconstruction of the distal radius should be
based on the knowledge of these columns. Almost 80% of the
transmitted forces go over the distal radius by longitudinal loading of
the wrist, if radius and ulna are equally long (ulna neutral).
Lengthening of the ulna shifts force transmission in the direction of
the ulna, whereas ulnar shortening shifts forces towards the radius.
[15]

Trabecular pattern of the distal radius
analysing the radiographic trabecular pattern of an area of the
distal radius revealed that the pattern runs along the direction of the
bone, as shown in figure 1 but is not nearly as organised as that
observed in the femoral head since the loading of the radius is not as
consistent.
[16]



(Fig. 1) Trabecular pattern of distal radius.
[16]
Anatomy

6

Radiological anatomy of the distal radius
The normal distal radius articular surface inclines radially
between 22 and 23 degrees in the frontal plane.
[17]
(Fig 2)

Radial length refers to the distance between the tip of the
radial styloid process and the distal articular surface of the ulnar
head.
[18]
The average radial length is 11 to 12 mm. Ulnar variance is
the relative length between the head of the ulna and the articular
surface of the distal radius. This measurement must be taken from a
neutral rotation posteroanterior (PA) radiograph because forearm
rotation affects the relative length from the distal radius to the
ulna.
[19]
The average ulna and radius end within 1 mm of one
another.
[20]
These anatomic parameters have become well accepted in
the radiographic evaluation of distal radius fractures (Fig. 3).
[21]

(Fig. 2) Normal x-ray anatomy. PA view. Measurement of radial height and inclination
and ulnar variance.
[13]
Anatomy

7

The joint surface slopes palmward between 4 and 22 degrees, with an
average palmar inclination of 10 to 12 degrees. This is best appreciated on a
true lateral radiograph.
[17]

(Fig. 3) Normal x-ray anatomy, lateral view. Measurement of palmar inclination.
[13]


Blood Supply of the Distal Radius
Blood supply to the distal radius includes the radial, ulnar, anterior
interosseous, and posterior interosseous arteries. Anastomoses between the
anterior branch of the anterior interosseous artery and the palmar carpal arch
and also between the anterior and posterior interosseous arteries and the
dorsal carpal arch are always present. Small vessels coming from the
anterior interosseous artery and the insertion of pronator quadratus over the
sigmoid notch of the radius were also present. The intraosseous areas of
vascularization came from these adjacent small branches.
[22]
The distal radius is supplied by three main vascular systems:
epiphyseal, metaphyseal, and diaphyseal. The palmar epiphyseal vessels
Anatomy

9

and descending branches of the medullary artery. These branches subdivide
into arterioles, which enter the endosteal surface of all portions of the
diaphysis.
[22]



(Fig. 4) A. Dorsal and B. palmar views of blood supply of distal radius.
[23]












Biomechanics

11


(Fig. 5) A, In radial deviation, the proximal carpal row deviates toward the radius, translates toward the
ulna, and flexes as seen by visualizing the lunate on the lateral radiograph. B, With the wrist in neutral, the
capitate, lunate, and radius are nearly colinear. C, In ulnar deviation, the proximal row deviates toward the
ulna, translates toward the radius, and extends as visualized by the lunate on the lateral radiograph.
[28]
Biomechanics

14

most pegs are directed into the dorsal ulnar edge of the radius to incorporate
styloid and dorsal die-punch fragments. Failure to incorporate the dorsal
die-punch fragment may lead to loss of reduction and arthrosis. The distal
palmar edge of the plate supports palmar die-punch fractures, which also
may be incorporated with pegs.
[34]





(Fig. 6) A, Threaded standard screw. B, Partially threaded standard screw. C, Threaded locking screw. D,
Locking peg. Arrows pointing to C and D indicate a space between the locking plate and the bone.
Standard holes and flexible bushings in locking holes allow 15 degrees of screw angulation from the
perpendicular position. (Universal Distal Radius System; courtesy of Striker Leibinger Micro Implants,
Portage, MI.)
[4]






Biomechanics

15











(Fig. 7) A, First-generation DVP plate. B, Undersurface first generation DVP plate with a row of locking
pegs (arrow in B) designed to parallel and support the subchondral portion of the articular surface of the
distal radius. C, Second-generation DVP plate. D, A proximal row of screws (arrow 1) or pegs (arrow 2)
may be inserted to incorporate or support the dorsal lip or fragments of the distal radius. (Courtesy of Hand
Innovations, Miami, FL.)
[4]

Biomechanics

17




(Fig. 8) A to C, Combihole (A) allows engagement of a conventional screw (B) or a locking screw (C).
Arrow 1, The smooth portion of the combihole accommodates a standard screw head. Arrow 2, The
threaded portion of the combiholeaccommodates a locking screw head. Arrow 3, Space between the
fixed-angle locking plate and the bone surface. Standard screw holes or bushings incorporated in locking
plate holes may allow a few degrees of angulation from the vertical position. (Courtesy of Synthes, Paoli,
PA.)
[4]




(Fig. 9) Small fragment locking T-plate used as an internal fixator with a small space between parts of
the plate and the bone (arrows). (Courtesy of Synthes, Paoli, PA.)
[4]
Biomechanics

19





(Fig. 10) Schematic diagram showing volar fixation maintaining the anatomy of the radius but screw toggle
leads to plate motion relative to the shaft, which can lead to late failure.
[40]






(Fig. 11) Schematic diagram showing fixed-angle implant transferring load stress from the fixed distal
fragment to the proximal radial shaft.
[40]


Mechanism of injury & Classification

25



(Fig. 12)The three column concept of Rickli & Regazzoni.
[15]


Classification
Various classification systems have been proposed to describe the
injury and help formulate a treatment plan. Broadly they tend to be
anatomical classifications that group fracture patterns, biomechanical that
describe the mechanism of injury and fracture stability or a combination of
both.
[46]
The eponymous descriptions associated with distal radius fractures
have traditionally been good indicators of the type of injury and treatment.
Colles fracture: It is an extra-articular distal radius fracture with dorsal
comminution, dorsal angulation, dorsal displacement, and radial
shortening.
[49]

Mechanism of injury & Classification

26



(Fig. 13): Colles' fracture, Diagrammatic representation of displacement, Top, Characteristic dorsal
angulation and impaction with shortening (lateral view). Below, loss of radial angulation, Radial shortening
with impaction and radial displacement (postero-anterior view)
[50]

Smiths fracture: It is a fracture of the distal radius with volar
displacement.
[51]



(Fig. 14): Smith's fracture. Modified Thomas classification. Palmar angulated fracture. Type 1, extra-
articular transverse, Type 2,extra-articular oblique with palmar carpal displacement and Type 3,intra-
articular palmar displacement of the carpus entering the radiocarpal joint. Type 3, is equivalent to a palmar
Barton fracture-dislocation
[50]

Mechanism of injury & Classification

27

Bartons fracture: It is is a displaced, unstablearticular fracture-subluxation
of the distal radius with displacementof the carpus along with the articular
fracture fragment.These may be either dorsal or volar.
[52]

(Fig. 15): Palmar Barton's fracture, palmar displacement of the carpus with intra-articular component
(identical to Smith type 3). Dorsal Barton's fracture, dorsal displacement of the carpus, presenting as
complex fracture of the distal radius or as fracture-disloaction of the wrist.
[50]


Chauffeurs fracture: It is a fracture of the radial styloid. It may be
associated with displacement of the carpus and may be the only bony
component of perilunate injury.
[53]

Die-punch fracture: It is an intra-articular fracture with depression of the
dorsal aspect of the lunate fossa.
[54]

FRYKMAN'S CLASSIFICATION:

In 1967, Frykman published a classification system that was important
in being the first to recognize the involvement (and relevance) of injuries to
the distal ulna.
[55]
Mechanism of injury & Classification

28


Type I: Is an extra-articular radial fracture.
Type II: Is an extra-articular radial fracture with an ulnar styloid
fracture.
Type III: Is an intra-arlicular fracture of the radiocarpal joint.
Type IV: Is an intra-articular fracture of the radiocarpal joint with an
ulnar styloid fracture.
Type V: Is an intra-articular fracture of the radioulnar joint.
Type VI: Is an intra-articular fracture of the radioulnar joint with
fracture of the ulnar styloid.
Type VII: Is an intra-articular fracture involving both radio-carpal and
radioulnar joints.
Type VIII: Is an intra-articular fracture involving both radiocarpal and
radioulnar joints with an ulnar styloid fracture.




(Fig. 16): Frykman classification. Six types of intra-articular fractures: 3/4, radiocarpal joint alone+/- ulnar
styloid; 5/6, radioulnar joint alone +/- ulnar styloid; and 7/8, both radiocarpal and radioulnar joints.
[50]
Mechanism of injury & Classification

30

(Fig. 17): Melon classification. A, classification of articular fractures on the basis of consistent patterns
results from the characteristic die punch mechanism of injury. Four articular fractures: 1, Radial shaft; 2,
Radial styloid; 3, Lunate fossa, dorsal medial ; and 4, Lunate fossa , palmar medial.
[50]

UNIVERSAL CLASSIFICATION:


A fracture may be defined as either extra-articular or intra-articular.
[57]
Type I: Extra-articular non displaced
Type II: Extra-articular displaced
Type III: Intra-articular non-displaced
Type IV: Intra-articular displaced
Further, displaced articular or nonarticular fractures may be:
a) Reducible, Stable.
b) Reducible, Unstable.
c) Complex, Irreducible.
Indicators of instability are:
i. Shortening of greater than 5 mm.
ii. Dorsal angulation greater than 20.
iii. Marked dorsal comminution.
iv. Displacement in a plaster of Paris cast.
Mechanism of injury & Classification

31



(Fig. 18): Universal classification. Type I, Nonarticular (extra-articular), undisplaced, and stable. Type II,
Nonarticular (extra-articular), displaced, and unstable. Type III, Intra-articular, undisplaced, and
stable.Type IV, Intra-articular and displaced.A, Reducible and stable after the reduction.B, Reducible but
unstable.C, Irreducible and unstable. D, Complex (comminuted, unstable, and irreducible) (not shown)
[50]

MODIFIED "MAYO CLINIC" CLASSIFICATION:

For more clear distinguishing of different articular fractures that
individually can be involved with DRFs, this classification has been
proposed as a second sub-classification in which the scaphoid, lunate, and
sigmoid notch of the distal radius are considered as separate articulations.
[58]

This classification has four types:-
Type I: Fractures are intra-articular but un-displaced.
Type II: Fractures are displaced and involve the radio-scaphoid joint.
Type III: Fractures are displaced and involve the radio-lunate joint.
Type IV: Fractures are displaced and involve both the radio-scapho-lunate
joints and the sigmoid fossa of the distal radius.


Mechanism of injury & Classification

32




(Fig. 19): Modified Mayos classification of DRFs. Intra-articular fractures involve one or more
articular fossae of the distal radius. Type I, Intra-articular but undisplaced involving the radio-lunate
joint. Type II, Radioscaphoid (RS) fossa fracture, displaced. Type III, Radiolunate fossa fracture with
die punch fracture (thin arrows) components. Direction of fracture displacement (thick arrows). Type
IV, Radio-scapho-lunate fossa involvement with extension into the distal radioulnar joint. The fracture
surface involvement extends into all three joints with articular step-off and displacement. D, dorsal; L,
lunate; S, scaphoid; V, volar.
[50]




Mechanism of injury & Classification

35

C2: Complete articular fracture, of radius, articular simple, metaphyseal
multi-fragmentary
1. Sagittal articular fracture line
2. Frontal articular fracture line
3. Extending into diaphysis
C3: Complete articular fracture, of radius, multi-fragmentary
1. Metaphyseal simple
2. Metaphyseal multi-fragmentary
3. Extending into diaphysis


(Fig. 20) AO Classification of DRFs.
[60]
Treatment

38

Cast treatment typically consists of immobilization in a sugar-tong
splint for three weeks immediately following closed reduction, which is then
converted to a short arm cast for an additional three weeks. Patients are
usually given a removable splint for a final three weeks and instructed to
perform active range of motion exercises to regain flexibility. Early in the
treatment course, radiographs should be obtained weekly to ensure fracture
stability. The palmar crease should be free to allow full motion about the
metacarpophalangeal joints (Fig. 21).
[42]


(Fig. 21) A well molded short arm cast applied for a stable distal radius fracture.
[42]


Treatment

40


(a) (b)

(c) (d)

(Fig. 22) Percutaneous pin fixation of an unstable distal radius fracture: a. The xrays of the initial fracture.
b. Two percutaneous pins through the radial styloid. c. Fracture healing in an anatomic position.
d. Functional result.
[42]


Treatment

42



(Fig. 23) External fixator with K-wires in management of DRF
[42]
Treatment

44

disruption; and (5) the fracture should be stable to allow early range of
motion. The type of implant used should match the specific fracture
fragment being reduced via the use of limited volar and dorsal incisions.
[42]
Rikli and Regazzoni
[15]
reviewed a series of 20 patients with distal
radius fractures fixed with two 2.0 mm titanium plates placed at 50 - 70
degrees to one another. No cases of extensor tendon problems were noted,
most likely because they were able to place a flap of retinaculum over the
small dorsal plates. Clearly, fragment specific fixation may provide some
advantages over the traditional methods of dorsal or volar plating for
fractures at the distal end of the radius.
[15]
( Fig. 24)




(a)
Treatment

45


(b)
(Fig. 24) A complex articular fracture treated with fragment specific fixation with small Synthes
plates: a. The preoperative CT scan; b. Two plate dorsal fixation.
[42]

OPEN REDUCTION AND INTERNAL FIXATION
Open reduction internal fixation has obvious advantages over the
other methods discussed so far. It allows direct restoration of anatomy,
stable internal fixation, a decreased period of immobilization, and an earlier
return of wrist function. There are a number of different indications for open
reduction internal fixation, and these include: unstable articular fractures
(such as a volar Bartons injury), impacted articular fractures, radiocarpal
fracturedislocations, complex fractures requiring direct visualization of the
fracture fragments, and failed closed reductions.
[42]
Historically, distal radius fractures were treated nonoperatively until
1929, when techniques utilizing pins and plaster were introduced. External
skeletal fixation evolved in 1944 and remained popular even after the AO
group designed plates specifically for the treatment of distal radius fractures
in the 1970s. In 1994, Agee introduced the Wrist Jack (Hand Biomechanics
Treatment

47

theoretically permit early range of motion postoperatively, as the construct
can withstand physiologic loading.
[67]
Since its introduction in 2000, volar fixed-angle fixation technique has
provided an effective alternative for the management of dorsal and volar
fractures. This approach is used because fixed-angle plates eliminate the
need to place the implant on the unstable side of the fracture; therefore, the
more physiologic volar approach can be used to treat the majority of
fractures.
[68]
This approach is less disruptive to the tendons because there is
more space available on the volar aspect of the radius. Flexor tendons are
located away from the volar surface of the radius, while extensor tendons
run directly on the dorsal surface. The volar approach allows the use of a
thicker, stronger implant to better resist the loads applied during functional
rehabilitation. Refinements of volar fixed-angle fixation were based on
insights into the anatomy of the radius, biomechanics, and blood supply.
[69]

(Fig. 25) Bridging produces a load-free area to give added stability to the fracture zone.
[70]
Representative Cases

46

Case 1:
62 years old male, judge, presented to Mansoura Emergency hospital with
distal radius fracture due to falling from standing height on outstretched
hand, x-rays were done and he was prepared for surgery.




(Fig. 26) Case 1 preoperative PA and lateral x-rays.


Representative Cases

46

Immediate post-operative x-rays:




(Fig. 27) case 1 Immediate post-operative PA and lateral x-rays showing fixation by
volar locked plate and k-wires.


Representative Cases

44

2 months follow up:





(Fig. 28) Case 1 follow up after 2 months showing union.

Representative Cases

46









(Fig. 29) Case 1 functional outcome.



Representative Cases

46

Case 2:
20 years old male, manual worker, presented to Mansoura
Emergency hospital with distal radius fracture due to falling from 2
meters height on outstretched hand, x-rays were done and he was
prepared for surgery.


(Fig. 30) Case 2 preoperative PA and lateral x-rays.
Representative Cases

46




(Fig. 31) Case 2 preoperative CT scan showing articular depression.
Representative Cases

67

Immediate post-operative x-rays:




(Fig. 32) case 2 immediate post-operative PA and lateral x-rays showing fixation by
volar locked plate.


Representative Cases

67

3 months follow up:




(Fig. 33) Case 2 follow up after 3 months showing union.

Representative Cases

67




(Fig. 34) Case 2 functional outcome.

Representative Cases

67

Case 3:
32 years old male, Accountant, presented to Mansoura Emergency
hospital with distal radius fracture due struggle, x-rays were done and he
was prepared for surgery.




(Fig. 35) Case 3 preoperative PA and lateral x-rays.

Representative Cases

66

Immediate post-operative x-rays:





(Fig. 36) case 3 immediate post-operative PA and lateral x-rays showing fixation by
volar locked plate.

Representative Cases

66

3 months follow up:



(Fig. 37) Case 3 follow up after 3 months showing union.
Representative Cases

64







(Fig. 38) Case 3 functional outcome.