Minimally Invasive Approach With Pronator Quadratus Preservation for Distal Radius Fracture

Abstract

Objectives: The purpose of this study is to describe a technique of volar locking plate for distal radius fractures with pronator quadratus (PQ) preservation, determining whether, with a less invasive approach, we can achieve good clinical, radiographic, and functional outcomes. Methods: The study period extended from July 2012 to January 2015. This study comprised 72 patients with distal radius fracture who were followed up for a minimum period of 12 months. All of them underwent a minimally invasive approach (54 women, 18 men), with a mean age of 65 years. All fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, finding 35 fractures type A (13 A2 and 22 A3), 14 type B (9 B1, 2 B2, and 3 B3), and the remaining 23 fractures type C (12 C1, 8 C2, and 3 C3). In all cases, surgery was indicated based on (1) dorsal deviation greater than 10°, (2) radial inclination less than 15°, (3) ulnar variance greater than 3 mm, and (4) articular step greater than 2 mm. The surgical technique begins with a closed reduction and fixation with temporary K-wires under an image intensifier. A 25-mm transverse skin incision is then performed and deepened between the flexor carpi radialis tendon and radial artery to expose the PQ. Afterward, we continued with a distal edge dissection of the PQ to introduce the volar locking plate under the muscle. Distal screws are placed under direct vision and proximal screws percutaneously. Postoperative evaluation was determined by clinical and functional assessment by Visual Analog Scale, range of motion, grip strength, time to return to work activity, and Disability of the Arm, Shoulder and Hand (DASH) score. Radiographic evaluation was performed by measuring the volar tilt, radial inclination, ulnar variance, joint congruity of the distal radius, and plate alignment regarding the shaft of the radius. Results: At the time of the last control, all patients had clinical and radiographic signs of bone healing. Of the 72 patients, 47 were handworkers prior to suffering the fracture, and they were able to return to their jobs at an average of 8 weeks. The average score on the DASH scale during the last control was 4.2 points. Regarding postoperative radiographic evaluation, there was an average volar tilt of 14.3° and an average radial inclination of 26.3°. We observed no complications related to the fracture, implant, or surgical wound in none of the postoperative controls. Conclusion: Although we did not obtain better results with this technique than those published with the conventional one, and that there is no literature available which demonstrate that the minimally invasive technique is superior, we believe that the fact of getting similar results with both approaches justifies using this technique with PQ preservation, especially in patients concerned about the cosmetic appearance of the scar. However, we could see that the indication of this technique depends on certain limitations, such as the need to use a dorsal plate in certain fractures or the inability to reduce the fracture before skin incision.