The Modified Orbay Approach: A New Perspective to Obtain Better Exposure of the Radial Styloid

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Anatomical Description and Quantification of Articular Surface Area Visualized in a Cadaveric Model

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Volar Surgical Correction of Madelung's Deformity

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

Volar fixation of dorsally unstable distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without the complications of the dorsal approach. A new, fixed-angle fixation device, the distal volar radius (DVR) plate, (Fig. 1) has been introduced for this purpose. Experience gained by applying this technique to clinically complex cases led us to the realization that more exposure, especially in a dorsal direction, was necessary than that provided by the traditional volar approaches. The need to reduce fractures with significant articular displacement (Fig. 2) and the need to release dorsal callus in inveterate fractures or nascent malunions led us to use an extended form of the flexor carpi radialis (FCR) approach. Volar displaced distal radius fractures are commonly managed with volar buttress plates through the FCR approach. This approach goes deep to the forearm fascia through the FCR tendon sheath and is continuous with the distal part of the Henry approach. The traditional FCR approach provides access to the volar aspect of the distal radius, the volar wrist capsule, and the scaphoid. In comparison with dorsal approaches, which present a high incidence of extensor tendon problems, the FCR approach is relatively free of complications. We extend the FCR approach by releasing the radial septum, by mobilizing the proximal radial fragment, and by using the fracture plane for exposure or what is known as intrafocal technique. Therefore, understanding the anatomy of the radial septum is important. On its proximal aspect, it is a simple fascial wall separating the flexor and extensor compartments of the forearm. At the level of the radial metaphysis, the radial septum is a complex fascial structure that includes the first extensor compartment and the insertion of the brachioradialis. More distally, the radial septum forms the radial insertion of the carpal ligament and ends as the FCR tendon sheath approaches the tuberosity of the scaphoid. The proximal radial fragment has a dependable endosteal blood supply that permits its subperiosteal release and subsequent mobilization. Pronating this fragment out of the way provides wide exposure of the fracture surfaces. This allows the volar reduction and fixation of even the most complex dorsally displaced distal radius fractures. Address correspondence and reprint requests to Dr. Jorge L. Orbay, Miami Hand Center, 8905 SW 87 Ave., Suite 100, Miami, Florida 33176; e-mail: MIAHANDS@ix.netcom.com Techniques in Hand and Upper Extremity Surgery 5(4):204–211, 2001 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

The management of highly comminuted distal radius fractures still remains a major treatment challenge. Articular comminution and compromised bone quality are the culprits. One novel approach is the technique of Internal Distraction Plating which involves "bridging" the fracture with the use of a standard 3.5mm plate applied dorsally in distraction from the radius, proximal to the fracture, to the long finger metacarpal distally, bypassing the comminuted segment. The plate is removed once fracture union has been achieved. The present study was conducted with the aim to evaluate the role of internal dorsal distraction plating as an alternative method in the treatment of fracture distal radius in terms of special indications, technique and outcome. This study was a prospective longitudinal study on 20 patients (mean age 62 years) treated with internal distraction plating for comminuted distal radius fractures with specific indications. Regular follow-ups with standard radiographs and analysis were done upto 24 months. Functional outcome were assessed by DASH Score and the Gartland and Werley demerit score. At final follow-up, all fractures had united and X-rays showed mean palmar tilt of 7°, positive ulnar variance of 0.5mm, radial inclination of 18° and average loss of 2mm of radial height. Mean range of motion values for wrist flexion 46°, extension 50°, pronation 79° and supination 77° At final follow-up, the mean DASH score was 32. 85% patient had excellent to good result as per Gartland and Werley demerit score. This construct has yield satisfactory clinical and radiographic results with these very challenging injuries. The purpose of this study was to report the radiographic and the functional outcomes of treatment with this technique. External fixator and volar plating in communited distal end radius fractures are not always satisfactory in old age with osteoporotic bone because of complications associated with them. The current technique represents an alternative that provides union of the comminuted distal radius fracture with anatomical alignment, optimal range of motion and with minimal clinical disability.

Background: The distal radius metaphysis is composed mainly of cancellous bone. On articular surface there is a biconcave articulating surface with the proximally placed carpal row (scaphoid and lunate fossae) and also a notch for articulation with the ulna. Objective of the research was to study the functional outcome in distal end radius fracture with volar displacement treated by locking compression plate. Methods: A hospital based descriptive, longitudinal study was conducted with 114 patients aged between 20-60 years to assess functional outcome in patients of distal end radius fracture with volar displacement treated by locking compression plate. Results: According to demerit point score system of Gartland and Werley, 75 (69.4%) patients had excellent score while 24 (17.5%) and 15 (13.1%) patients had good and fair score respectively. No patient had poor score. 6 (5.3%) and 2 (1.8%) patients had superficial infection and hypertrophic scar respectively while 1 (0.9%) patient had developed malunion. Conclusions: Volar plating has excellent functional outcome with minimal complications thus proving that it is the prime modality of treatment for distal radius fractures.

Objective To investigate the curative effect of structural bone graft in treatment of high energy injury-induced complicated distal radius fractures combined with articular surface collapse and comminuted epiphyseal bone defect. Methods The study involved 38 patients with distal radius fractures (AO classification, type C3) treated from January 2007 to October 2010.The patients were treated with temporary Kirschner wire fixation to recover the wrist articular surface, distal radius length and palmar tilt angle at the greatest possibility.According to the form of the bone defects, the iliac bone taken from three layers of the cortical bone was embedded in the subchondral bone to support the bone graft, and a small amount of cancellous bone graft was collected to fill the articular surface collapse as much as possible for anatomical reduction of the articular surface, and anatomical form of the distal radius was reconstructed.Modified Sarmiento Gartland and Werley evaluation systems were used to evaluate the articular function recovery. Results The follow-up lasted for 1-3.2 years, which showed no complications such as plate rupture or iatrogenic nerve blood vessels injuries.The fracture healing time was 15-22 weeks (mean 18.3 weeks).The wrist articular function in some patients obtained obvious improvement through functional rehabilitation training.According to the modified Gartland and Werley function evaluation systems, the curative effects reached excellence rate of 87％.During follow-up, there were two patients with high progressive loss in the height of the distal radius and two with articular surface collapse and severe carpal joint flexion and extension dysfunction. Conclusions The high energy injury-induced distal radius fractures with articular surface collapse and epiphyseal bone defect need recovery of the wrist articular surface, distal radius length and palmar tilt angle.Structural bone graft can effectively support the grafted bone and maintain the flatness of the radiocarpal articular surface, restore the anatomy of the distal radius and facilitate the functional recovery of the wrist. Key words: Radius fractures; Bone transplantation; Joints; Fracture healing

Adjunctive dorsal spanning plate fixation for challenging distal radius injuries

Objective To report the clinical efficacy of internal fixation of locking compression plate with partially reserving pronator quadratus through volar approach in the treatment of unstable fractures of the distal radius. Methods From January 2014 to December 2016, 109 cases of unstable fractures of the distal radius were treated with locking compression plate. Part of pronator quadratus was reserved during the operation. The operation time and intraoperative blood loss were recorded. The fracture healing was evaluated by imaging observation. The wrist function was evaluated by Gartland-Werley Scoring Scale. Results The operation time ranged from 50 to 70 minutes with the average being (60±10) minutes. The intraoperative blood loss ranged from 10 to 20 ml with an average of (15±5) ml. All the patients were follow-up for 12 to 36 months with an average of 20 months. All the fractures achieved healing. The healing time ranged from 4 to 8 weeks with the average being 6 weeks. No fracture block displacement, internal fixation failure, locking plate and screw loosening or break, wound infection occurred. The wrist function recovered well. According to Gartland-Werley Scoring Scale, the wrist function was rated excellent in 89 cases, good in 18 cases and fair in 2 cases, with an excellent and good rate of 98.2%. The rupture of extensor hallucis longus tendon 4 months after the operation occurred in 1 case. Thumb extension of extensor pollicis longus muscle tendon was reconstructed by transplantation of palmaris longus tendon 12 months after the operation when removing the internal fixator. Conclusion The unstable fractures of the distal radius can be effectively treated by locking compression plate with partially reserving pronator quadratus through volar approach. It reduces the excessive dissection of the soft tissue, retains the pronator quadratus and has fewer complications, faster fracture healing, better wrist function recovery and definite curative effect. Key words: Radius fractures; Fracture fixation,internal; Locking compression plate; Volar approach

<p>Background: Fractures of lower end radius are most common fractures of the upper extremity. Increased awareness of the complexity of the distal end radius fractures have stimulated a growing interest and promoted new ideas regarding their management. Close reduction and cast immobilization had been the mainstay of treatment of these fractures but poor functional and cosmetic results are not uncommon. The volar plate system has been shown to be reliable for the fixation of distal radius fractures. As open reduction and volar plating ensures more consistent correction of displacement and maintenance of reduction, this prospective study evaluates the anatomical and functional outcome of open reduction and plate fixation in the management of fracture distal end radius.</p> <p>Method: In this study 40 patients with distal end radius fractures were included, informed consent was and clearance from ethical committee of the institute was taken. The study was Prospective, interventional and observational for the methods used for management of the fracture. Patients were evaluated pre operatively and post operatively at the end of first, fourth, sixth week,3 months and then once in 3months up to 12 months.</p> <p>Results: In the prospective study conducted with forty patients,88% anatomical and 93% functional, excellent to good results suggests that stabilizing the fracture fragments with volar plate and screws in the management of the fractures of distal radius, is an effective method to maintain the reduction till union and prevent collapse of the fracture fragments, even when the fracture is grossly comminuted / intra-articular / unstable and / or the bone is osteoporotic.</p> <p>Conclusion: This study concludes that open reduction and internal fixation with volar plating has excellent functional outcome with minimal complications. The procedure is applicable for all types of Frykman fractures in young patients with a good bone stock as well as in elderly osteoporotic patients.</p>

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Background: One of the most common injuries encountered in orthopedic practice are Distal Radius fractures. This comprises of 8%−15% of all fractures in adults. The reason for comminuted DER fractures is high-energy trauma in young and low-energytrauma in elderly. They present as shear and impacted fractures involving the articular surface of the distal radius with displacement of the fragments. External fixation for distal radius fracture relies on the principle of Ligamentotaxisin which, a distraction force applied to the carpus aligns the fragments by means of intact ligaments. The length and alignment of fracture fragment is guided by pull and counter pull which are otherwise difficult to control. Objective: To study functional outcome of distal end radius fracture treated by ligamentotaxis with evaluation of functional results according to Disabilities of the Arm, Shoulder and Hand (DASH) score system. Material and Methods: We included 30 patients (Male 24 and Female 6) treated for distal end radius fracture during a period from 2015 to 2017. Patients were evaluated clinically by subjective assessment using DASH Scoring system. Result: After functional evaluation of patients according to the scheduled follow up with mean DASH Score of 76.08 at 1st month, 62.92 at 3rd month and 42.60 at 6th month, and was found to be Highly Significant (p<0.001) among all the compared groups. Conclusion: We concluded that external fixation and ligamentotaxis applied to complex distal radius fractures, when added with augmented K-wire fixation can provide direct augmentation of fracture stability and a good wrist function.

Objective To explore the clinical efficacy of internal fixation with wrist arthroscope assistance in type C fractures of distal radius.Methods Thirty-nine patients with distal radius type C fractures were involved.Under the wrist arthroccope monitoring,the fracture fragments of the distal radius were manually reduced so the articular surface was smooth and the displacement was less than 2 mm.Then the volar locking compression plate or K-wire external fixator was applied to fix the radius.The wrist joint ligaments were further examined under the arthroscope especially paying attention to the scapholunate ligament,lunotriquetral ligament and triangular fibrocartilage complex (TFCC).The corresponding cartilage and ligament damage was debrided under the wrist arthroscopy.Results Among the 39 cases of distal radius type C fracture,there were 4 cases of scapholunate ligament tear,3 cases of lunotriquetral ligament tear and 6 cases of TFCC tear.Postoperative follow-up ranged from 6 to 24 months with an average time of 11.3 months.Complete union of the fracture was achieved in all the patients about 8 to 16 weeks postoperatively,with a mean healing time of 11.4 weeks.The volar tilt and ulnar inclination angles were 8° to 17° and 16° to 26° respectively.Wrist functions were evaluated according to the Gartland-Werley system and rated as excellent in 23 cases,good in 11 cases and fair in 5 cases,with a good and excellent rate of 87.2％.Conclusion Wrist arthroscope-assisted treatment of type C fractures of the distal radius can not only restore the articular surface and reduce the occurrence of traumatic osteoarthritis,but also allows visualization of damages of TFCC and intra-articular ligaments.This enables early treatment so chronic wrist pain or wrist joint instability can be avoided. Key words: Radius fractures; Arthroscopy; Intra-articular