Pronator Quadratus Repair Research Articles

Ultrasound Evaluation of the Protector Role of the Pronator Quadratus Suture in Volar Plating.

The main complication of volar locking plates for distal radius fractures is flexor tendon rupture. The flexor pollicis longus (FPL) is the most commonly ruptured. Repair of the pronator quadratus (PQ) is one of the ways to prevent tendon rupture. The main purpose of this series was to evaluate the role of PQ repair after volar plating to prevent flexor tendon rupture using ultrasound (US). This work was a mono-operator prospective series of 20 consecutive patients with volar locking plates for distal radius fracture between September 2014 and May 2015. The PQ was repaired in all patients. A clinical, ultrasound, and perioperative evaluation of the flexor tendon was performed by this same surgeon. There was no flexor tendon rupture or tenosynovitis. There were no type A cases, which are characterized by contact between the plate and the FPL, and mostly type C cases, which are characterized by no contact between the plate and the FPL on US imaging. The suture of the PQ was sustainable over time when we removed the plate. Pronator quadratus repair is one of the ways to prevent flexor tendon rupture after volar plating. The outward-running suture is an effective technique for repairing the PQ. Ultrasound may be helpful during follow-up to detect asymptomatic flexor tendon irritation.

A randomized controlled trial on management of distal radius fractures with plating followed by pronator quadratus repair versus no repair in a tertiary care hospital in Andhra Pradesh, India

A randomized controlled trial on management of distal radius fractures with plating followed by pronator quadratus repair versus no repair in a tertiary care hospital in Andhra Pradesh, India

A randomized controlled trial on management of distal radius fractures with plating followed by pronator quadratus repair versus no repair in a tertiary care hospital in Andhra Pradesh, India

A randomized controlled trial on management of distal radius fractures with plating followed by pronator quadratus repair versus no repair in a tertiary care hospital in Andhra Pradesh, India

Assessment of Pronator Quadratus Repair Integrity Using Dynamic Ultrasonography Following Volar Plate Fixation for Distal Radius Fractures.

Background: Previous work evaluating the pronator quadratus (PQ) muscle following volar plate fixation (VPF) of distal radius fractures (DRF) suggests that PQ repair often fails in the postoperative period. The purpose of this investigation was to assess PQ repair integrity following VPF of DRF using dynamic musculoskeletal ultrasonography. Methods: Twenty adult patients who underwent VPF of DRF with repair of the PQ with a minimum follow-up of 3 months underwent bilateral dynamic wrist ultrasonography. The integrity of the PQ repair, wrist range of motion (ROM) and strength, and functional outcome scores were assessed. Results: Mean patient age at the time of surgery was 59 ± 14 years, and 50% underwent VPF of their dominant wrist. Patients were evaluated at a mean 9 ± 4 months after VPF. All patients had an intact PQ repair. The volar plate was completely covered by the PQ in 55% of patients and was associated with a larger PQ when compared to patients with an incompletely covered volar plate (P = .026). The flexor pollicis longus tendon was in contact with the volar plate in 20% of patients, with those patients demonstrating a trend toward significantly increased wrist flexion (P = .053). No difference in ROM, strength, or outcome scores was noted among wrists with completely or incompletely covered volar plates. Conclusions: The PQ demonstrates substantial durability after repair following VPF. Wrist ROM, strength, and functional outcomes are similar in wrists in which the volar plate is completely or incompletely covered by the repaired PQ.

Ultrasonographic evaluation of the distance between the flexor pollicis longus tendon and volar prominence of the plate as a function of volar plate positioning and pronator quadratus repair — A cadaver study

Flexor tendon injury after volar plating of distal radius fractures is due to friction against the plate. To assess this risk, the distance between the flexor pollicis longus (FPL) and the volar prominence of the plate was measured with ultrasonography under various conditions: a standard plate fixed proximal or distal to the watershed line and a low-profile volar rim plate, with and without transection of the pronator quadratus (PQ). Distance from the FPL to the volar prominence of the plate decreased significantly when the PQ was cut and when a standard plate was placed distal to the watershed line, with the tendon often bulging over the plate. No statistical difference was measured between a volar rim plate and a standard plate distal to the watershed line. Our results confirm the importance of positioning the volar plate proximal to the watershed line and of repairing the PQ.

Treatment of Distal Radius Metaphyseal Comminution Fracture by Volar Locking Plate Fixation

Objective: The pronator quadratus (PQ) has important functions such as pronation and robust blood supply of metaphysis. However, PQ repair is difficult when using conventional approach, which is necessary to release PQ for volar plate fixation of distal radius fracture. In addition, anatomical reduction is difficult in patients with distal radius metaphyseal comminution fracture. Therefore, the purpose of this study is to compare the results of volar locking plate fixation using PQ sparing technique and conventional volar approach technique for patients with distal radius metaphyseal comminution fracture. Materials and Methods: In total, 30 patients treated with volar locking plate using PQ sparing approach were compared with 29 patients using conventional approach in distal radius metaphyseal comminution fracture. Mean follow-up periods were 19 and 26 months each. Postoperative clinical evaluation was performed with wrist range of motions, pronation power, and modified Mayo wrist score measured at last follow-up. Radiologic evaluation was performed with mean bone union period and measurement of radial length, radial inclination, and volar tilt at last follow-up. Results: Mean range of motion, pronation power, and modified Mayo wrist score were significantly superior in PQ sparing approach group. Bony union was achieved in all two groups. However, mean bone union period was superior in PQ sparing approach group (8.7 weeks in PQ sparing group vs 12.5 weeks in conventional group). Radial length, radial inclination, and volar tilt did not show significant differences. Conclusion: We propose that a volar locking plate fixation using PQ sparing technique is a more effective treatment method than conventional approach for patients with distal radius metaphyseal comminution fracture.

Significance of a Pronator Quadratus-Sparing Approach for Volar Locking Plate Fixation of Comminuted Intra-articular Fractures of the Distal Radius.

The preservation of the integrity of the pronator quadratus (PQ) muscle is expected to have many benefits, particularly in cases of highly comminuted intra-articular fractures of the distal radius. Therefore, we examined the significance of a PQ muscle-sparing approach for volar locking plate (VLP) fixation of these types of fractures. Sixty-five patients who sustained AO Foundation and Orthopaedic Trauma Association (AO/OTA) type C2 and C3 distal radius fractures were treated with VLP fixation using either a PQ muscle release and repair (PQ-releasing group, n = 30) or a PQ muscle-sparing approach (PQ-sparing group, n = 35). Radiographic parameters, active range of motion (ROM), percentage of the grip power of the injured hand compared with that of the opposite hand, wrist pain visual analog scale (VAS) score, and Quick Disability of the Arm, Shoulder, and Hand (DASH) score (disability/symptom) were evaluated monthly up to 12 months after surgery. The mean VAS score was significantly lower in the PQ-sparing group at 2, 3, and 4 months postoperatively than in the PQ-releasing group. Furthermore, the mean Quick DASH score in the PQ-sparing group was significantly lower than that in the PQ-releasing group at 1 and 2 months postoperatively. There were no significant differences, however, in the other functional parameters in the groups through the observation period. The PQ muscle-sparing approach appears to achieve satisfactory results in patients undergoing VLP fixation of comminuted intra-articular fractures of the distal radius.

A Brachioradialis Splitting Approach Sparing the Pronator Quadratus for Volar Plating of the Distal Radius.

Fractures of the distal radius account for up to 15% of all extremity fractures. Volar plating has become more popular, as it allows locking plate technology to be applied. Traditionally, access to the volar radius has been achieved through the approach of Henry using the interval between flexor carpi radialis and the radial artery, involving incising the radial border of the pronator quadratus (PQ). With this approach, PQ repair is difficult, and when attempted is often incomplete or tenuous, as it is a direct muscle-to-muscle repair. Theoretical advantages of repairing the PQ include the provision of plate coverage, a protective gliding layer, a well-vascularized coverage of the fracture fragments, and a protective barrier against deep infection in the case of superficial infection. Techniques have been developed to try and improve on the Henry approach. We have developed a surgical approach to volar plating that utilizes the anatomic relationship between brachioradialis and PQ in a way that allows simple and stable reattachment of the PQ muscle. We have termed the technique the "Brachioradialis splitting" approach. We present it here.

Pronator quadratus repair after volar plating of distal radius fractures or not? Results of a prospective randomized trial.

BackgroundThe purpose of the present study was to investigate the influence of the pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures with special regards to the forearm pronation strength. During the early recovery period of 3 months, an improvement of pronation strength and functional scorings was hypothesized for the PQ repair when compared to no repair.MethodsThe inclusion criteria were (1) men or women between 18 and 80 years, (2) isolated, closed fractures of the distal radius, (3) A2 to B2 types of fracture according to the AO fracture classification system, (4) primary volar locking plate osteosynthesis. Patients were randomized to group A = PQ repair and group B = no repair. Follow-up examinations after 6 and 12 weeks included bilateral isometric pronation strength measurement, range of motion, the QuickDASH and the Mayo-Wrist-Score, and a visual analog scale (VAS).Results60 patients (n = 31 in group A and n = 29 in group B) with an average age of 54 years (range 22–77 years) returned for both follow-up visits. The pronation strength measurements showed no significant differences between groups (PQ repair vs. no repair) neither at 6 weeks nor at 12 weeks. Additionally, no statistical significant differences were noted for ROM, QuickDASH-Score or Mayo-Wrist-Score. The VAS scoring revealed a significant decreased pain level after PQ repair at 6 weeks postoperatively (p = 0.017).ConclusionAn improved pronation strength after PQ repair in the early rehabilitation period could not be confirmed. However, the PQ repair might reduce pain in the early postoperative period.Trial registration number: NCT02595229 (ClinicalTrials.gov, registered 02 November 2015)

Repair of the Pronator Quadratus Muscle with a Part of the Brachioradialis Muscle Insertion

Most surgeons don't repair the pronator quadratus (PQ) muscle in palmar plate fixation of a distal radius fracture because experience has shown that PQ repair yields no functional advantage. However, repair of the PQ may offer finger flexor tendon protection. In 9 human cadavers, the PQ was detached with a strong rim of connective tissue consisting of a fibrous portion of the roof of the first extensor compartment (RFEC) and the palmar limb of the brachioradialis muscle (BR) insertion. The gross anatomy and the dimensions of the dissected tissue were measured. After fixation of a palmar plate, the PQ was repaired. Stability was tested with 100 passive maximum pronation and supination repetitions. The average total width of the PQ with the strong rim of connective tissue consisting of the RFEC and the palmar limb of the BR insertion was 28 mm. Suture repair was possible in each specimen, and each palmar plate was completely covered distally. This dissection of the PQ with a strong rim of connective tissue consisting of the RFEC and the palmar limb of the BR insertion may offer a way to cover the distal edge of a palmar plate in open reduction and internal fixation of a distal radius fracture that affords finger flexor tendon protection.

Effect of fixing distal radius fracture with volar locking palmar plates while preserving pronator quadratus

Background L-shaped incision of pronator quadratus (PQ) muscle along its radial and distal borders was always taken for distal radius fractures reduction and internal fixation. Repair of the PQ muscle was always recommended at the end of operation for some instructive reasons. But repair of PQ is not satisfied because of poor quality of muscle and fascial tissues which may cause pain or impede forearm pronation and supination for post-operative scarring around PQ. Inserting the locking palmar plate to pass under the pronator quadratus muscle and the locking screws are inserted through miniincisions in pronator quadratus in some patients with distal radius fractures is a reasonable technique which can preserve the pronator quadratus. The purpose of this study was to evaluate and compare the clinical effects after volar plating of the distal radius fractures while preserving the pronator quadratus and pronator quadratus repair. Methods Between September 2010 and April 2012, 65 patients (42 males and 23 females; aged 20-68 years and a mean age of 42.5 years) with distal radius fracture underwent open reduction and internal fixation using the volar locking palmar plates (Depuy or Smith companies). The patients were classified as 23A-2 through 23C-3 according to the Orthopaedic Trauma Association (OTA) classifications. All surgeries were completed by the same trained team. The volar locking palmar plates of distal radius performed with preserving pronator quadratus group involved 30 patients including 19 males and 11 females and performed with pronator quadratus repair group involved 35 patients including 23 males and 12 females. We compared the two groups for wrist pain, forearm range of motion, grip strength, perioperative complications and wrist functional recovery score. Results The minimum follow-up for the whole cohort was one year. The differences between the two groups were significant with regard to wrist pain, forearm range of motion, grip strength and wrist function at 1, 2, and 6 weeks postoperatively, but insignificant at 6 and 12 months postoperatively. No significant differences were found in the perioperative complications and radiographs postoperatively. Conclusions Preservation of the pronator quadratus muscle is a satisfactory method for the treatment of majority of the fractures of the distal radius with volar locking palmar plates, as this technique can yield better early wrist function and shorten the rehabilitation.

Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures.

Background:Distal radius fractures are one of the the most common adult fractures encountered during the clinical practice of an orthopedic surgeon.12 Although several methods of treatment are suggested for these fractures, there are still controversies about the best treatment approach in the literature. Volar plating of distal radius fracture is a method of treatment which has become increasingly popular. One of the complications of this technique is flexor tendon rupture. The purpose of this study was to evaluate the protectiveness of complete repair of pronator quadratus muscle against flexor tendon rupture.Materials and Methods:From September 2010 to September 2012, a consecutive series of 157 patients who were younger than 60 years with unstable distal radius fractures were included in the study. A standard volar approach to the distal radius was carried out. The radial and distal ends of pronator quadratus muscle were meticulously elevated from the radius and after volar plate fixation of the fracture, pronator quadratus muscle was restored to its normal insertion. We achieved full coverage of the plate with this muscle and followed the patients postoperatively.Results:A total of 135 patients were studied. The mean age of patients was 34 ± 10 years (range 20-60 years). One 55-year-old diabetic female patient with flexor tendon rupture was identified. The flexor pollicis longus tendon had ruptured 16 months after surgery.Conclusions:Pronator quadratus repair should be done in distal radius fracture to protect flexor tendons.

Review of ‘The Importance of Pronator Quadratus Repair in the Treatment of Distal Radius Fractures with Volar Plating’

To the Editor: We read with interest the article by Ahsan and Yao [1], on the significance of pronator quadratus (PQ) repair during volar plating of distal radius fractures. The authors recommend doing a PQ repair, even though their study showed no significant difference in ROM, grip strength and complications between the complete and incomplete PQ repair groups. They conclude that the pronator is required to cover the distal part of the volar plate to protect the overlying flexor tendons from hardware irritation, but they did not have any incidences of tendon ruptures. This may be due to a small sample size. In a series of 353 patients, Casaletto et al. [2] noted a 1.9 % incidence of flexor pollicis longus (FPL) rupture, which was associated with the positioning of the plate, rather than the use of PQ.

Prospective Evaluation of Pronator Quadratus Repair Following Volar Plate Fixation of Distal Radius Fractures

To evaluate the efficacy of pronator quadratus (PQ) repair after volar plating of distal radius fractures. All consecutive distal radius fractures treated operatively with a volar plate during a 1-year period were assigned to receive a repair of the PQ versus no repair. Surgical exposure, reduction, and postoperative rehabilitation were equivalent in both groups. Clinical outcomes with a minimum follow-up of 12 months were assessed via range of motion; grip strength; Disabilities of the Arm, Shoulder, and Hand (DASH) scores; and visual analog scale (VAS) scores. A total of 60 consecutive distal radius fractures were treated operatively with a locking volar plate. Full follow-up data were available for 33 patients in the PQ repair group and 24 patients in the control group. At 12 months, the mean DASH score was 8 for the repair group and 5 for the control group. Range of motion at the wrist, grip strength, and VAS scores were also not significantly different between groups. In addition, we found no significant differences in any of the parameters at the 2-, 6-, or 12-week intervals, although we observed greater grip strength and wrist flexion in the repair group at 6 weeks. Reoperation was required for 4 patients in the repair group and 1 in the control group. Pronator quadratus repair after volar plating of a distal radius fractures did not significantly improve postoperative range of motion, grip strength, or DASH and VAS scores at 1 year. The rates of reoperation between groups were not significantly different.

The Effects of Pronator Quadratus Repair on Outcomes After Volar Plating of Distal Radius Fractures

The purpose of this study was to evaluate forearm rotation after volar plating of the distal radius fractures with and without pronator quadratus repair. This was an institutional review board-approved retrospective review of prospectively collected data. The study was conducted at an Academic Medical Center. Over a 5-year period, 606 patients with distal radius fractures (OTA classifications 23-A through 23-C) were enrolled in an institutional review board-approved, prospectively collected, distal radius database. One hundred and seventy-five patients underwent open reduction and internal fixation with volar plating. Of these, 112 patients had complete 1-year follow-up (6 weeks, 3, 6, and 12 months) and were included in this study. Volar plating of the distal radius was performed with pronator quadratus repair (group A), versus volar plating without pronator quadratus repair (group B). Surgeries in group A were performed by a fellowship trained hand surgeon utilizing volar plates from Depuy Orthopedics (Warsaw, IN), whereas the surgeries in group B were performed by a fellowship trained orthopedic trauma surgeon utilizing volar plates from Stryker (Mahwah, NJ). Primary outcomes include forearm range of motion. Secondary outcomes include grip strength, pain levels, functional outcomes (DASH scores), radiographs, and complications. Baseline and demographic characteristics of the patients were similar between the 2 groups. There was no difference in mean pronation (P = 0.08) at 1 year. Among secondary analyses, radial deviation was significantly different (P = 0.03); however, pain (P = 0.13) and DASH scores (P = 0.14) were not. The only patient that requested plate removal had the pronator repaired (group A). We conclude that there is no advantage in repairing the pronator quadratus during volar plating of distal radius fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wrist & Hand

The December 2012 Wrist & Hand Roundup360 looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures.

Assessment of Pronator Quadratus Repair Integrity Following Volar Plate Fixation for Distal Radius Fractures: A Prospective Clinical Cohort Study

To assess prospectively the integrity of pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures and to compare the clinical and radiographic outcomes of durable versus failed repairs in 24 subjects. In addition, by grading the degree of PQ injury, an attempt was made to correlate failure of repair with the PQ injury severity. The extent of PQ injury was graded for each fracture. After fracture fixation, the PQ muscle was repaired along its radial and distal borders. Radiopaque hemoclips were attached to each side of the PQ repair, 2 radially and 2 distally. The distance between these markers at time 0 versus x-rays taken at approximately 2 weeks, 6 weeks, and 3 months was recorded. Clip displacement of 1 cm or more compared to time 0 indicated repair failure. One of 24 repairs (4%) failed at 3 months. No statistical difference was noted between the type of PQ injury and wrist flexion/extension, pronation/supination, and grip strength. Pronator quadratus repairs after volar plate fracture fixation are generally durable. They withstand forces that occur at the distal radius during the healing process with a 4% failure rate. No correlation was shown between type of PQ injury and radiographic failure of the repair.

The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating

Open reduction internal fixation (ORIF) of distal radius fractures via a volar approach involves surgical release of the overlying pronator quadratus (PQ) muscle. Complete repair of the PQ, defined as full and stable replacement of the periphery of the PQ back to its original anatomic location, is not always possible upon conclusion of the operation. Postoperative consequences of incomplete PQ repair with regards to range of motion (ROM), grip strength, and complications are not well documented. It was hypothesized that the completeness of PQ repair would yield no significant difference in the postoperative ROM, grip strength, and incidence of complications. A retrospective review was performed of 110 repairs of distal radius fractures with ORIF via placement of a volar locking plate. The following clinical data were extracted: complete or incomplete PQ repair, patient age, gender, follow-up ROM/grip strength, and incidence of postoperative complications. No significant difference in ROM, grip strength, and postoperative complications was detected between the complete and incomplete PQ repair groups. Complications consisted of two incidences of malunion requiring revision surgery and one occurrence of complex regional pain syndrome. There were no tendon ruptures. No statistical difference in ROM/grip strength or incidence of postoperative complications was detected between the complete and incomplete PQ repair groups. Regardless of the level of injury sustained by the PQ, surgeons should make an effort to cover the distal aspect of the volar plate during closure following distal radius fracture ORIF. Coverage of the distal aspect of the plate with the PQ (at a minimum) provides adequate results in ROM and grip strength, as well as protection against flexor tendon injury. Therapeutic Level III: Retrospective Comparative Study.