Hippocrate
Claude
Pouteau
Abraham
Colles
Guillaume
Dupuytren
Joseph
Franois
Malgaigne
Nho JH et al. Examination of the pronator quadratus muscle during hardware removal procedures after volar plating for distal radius fractures. Clin
Orthop Surg. 2014 Sep;6(3):267-72.
Tosti R, Ilyas AM. Prospective evaluation of pronator quadratus repair following volar plate fixation of distal radius fractures. J Hand Surg Am. 2013
Sep;38(9):1678-84.
Swigart CR et al. Assessment of pronator quadratus repair integrity following volar plate fixation for distal radius fractures: a prospective clinical cohort
study. J Hand Surg Am. 2012 Sep;37(9):1868-73.
Conventional
2. Drobetz H et al. Volar fixed-angle plating of distal radius extension fractures : influence of plate position on secondary loss
of reduction : a biomechanic study in a cadaveric model. J Hand Surg Am 2006; 31 : 615-22.
3. Wall LB et al. The eects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar
locking plates. J Hand Surg Am. 2012;37(3):446e453.
1. Sgn TS et al. Screw prominences related to palmar locking plating of distal radius. J Hand Surg Eur Vol 2011 36:
320-324.
2. Varitimidis SE et al. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?
J Bone Joint Surg 2008;90B:778 785.
Fig. 1. Radius distal sec de face en lgre supination, de face en lgre pronation et de profil. La stylode nest pas dans le plan de lpiphyse. La prem
(double trait) du carr pronateur, termine la face plane du radius. La seconde ligne (en pointill) du partage des eaux ou watershed line , est le point le plus
du radius distal. Les implants ne doivent pas dpasser cette limite antrieure, au risque dentraner un conflit avec les tendons flchisseurs des doigts.
[(Fig._ 2)TD$FIG]
Between individuals
Between the radial and
ulnar side of the epiphysis
Imatani et al. An anatomical study of the watershed line on the volar distal aspect of the radius. J Hand Surg 2012; 37(8):1550-4
[(Fig._ 2)TD$FIG]
Inclination is 145 at
the lunate fossa, vs
155 over the scaphoid
fossa (average 150)
[(Fig._ 3)TD$FIG]
290
As a consequence
Buzzell JE, Weikert DR, Watson JT, Lee DH. Precontoured fixed-angle volar distal radius plates: a
comparison of anatomic fit. J Hand Surg Am 2008;33:114452.
Vascular anatomy
Vascularization of the distal epiphysis is
made by branches of the anterior and
posterior interosseous arteries
Avoid injuries to the medial part of the
radius
Dorsal side
Highly contoured shape of the
dorsal side
Extensor tendons are located
into gutters
The height of Listers tubercle
varies from 3,3 to 6,6 mm,
and the depth of the gutter of
the EPL may be as deep as
3,2 mm !
Ljungquist KL et al.Predicting a Safe Screw Length for Volar Plate Fixation of Distal Radius Fractures:
Lunate Depth as a Marker for Distal Radius Depth. J Hand Surg Am. 2015;40(5):940e944.
Surgical consequences
A screw must be 6,5 mm
longer than the cortical bone
in the radial side, and 3 mm
in the ulnar side to be seen
on the lateral view !
If you do lateral view with
pronation and supination, a
screw should be at least 2-3
mm longer than the cortical
bone to be seen
1. Maschke SD et al. Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius:
a cadaveric study. Hand 2007;2:144 150.
Surgical consequences
Use special fluoroscopic incidences
Skyline view (2010).
Sensibility, specificity and diagnostic
precision was 83% for screw longer
than 1 mm (compared to 77% for
pronation views and 51% for the
lateral view)
1. Riddick AP et al. Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius
fixation. J. Hand Surg. (Eur. Vol.) 2012; 37E(5) 407411.
1. Joseph SJ, Harvey JN. The Dorsal Horizon View: Detecting Screw Protrusion at the Distal Radius. J Hand Surg
2011;36A:16911693
?
Anatomy explains why 12-30% of distal screws
are intra-articular !
To avoid mis-placement of distal screws:
Start with the most medial screws
Fluoroscopic control with variation on the
angulation: AP with 10 of beam inclination;
lateral with 10 (medial side) and 20 of
inclination (lateral side)
10 angulation
helps to study
the articular
surface in the
frontal plane
20 angulation
helps to study
the articular
surface in the
sagittal plane
Conclusions
Anatomy has not changed
But it is our search for improving functional outcomes that
prompt us to design new implants
The use of these new implants has changed our knowledge
of the anatomy which is obviously more complex than
previously thought