Distal radius fracture: minimally invasive approach with pronator quadrates preservation
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Published:
May 11, 2015
Keywords:
Volar locking plate, Minimally invasive technique, Pronator quadratus preservation, Distal radius fracture
Main Article Content
Abstract
ObjectiveThe purpose of this study is to describe and analyze a technique of volar locking plate for distal radius fractures with Pronator Quadratus (PQ) preservation.MethodsWe retrospectively reviewed 24 patients who underwent minimally invasive approach (16 women, 8 men), with a mean age of 65 years, finding seven fractures type A, five type B and the five remaining type C. The surgical technique involves making an incision of 25mm and deepened to expose the PQ. Afterwards, we continued with a distal edge dissection of the PQ in order 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, functional and radiological assessment.ResultsAt the time of the last control, all patients had clinical and radiographic signs of bone healing. The average score on the DASH scale during the last control was 4.8 points. There was a postoperative 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 postoperative controls.ConclusionAlthough we did not obtain better results with this technique than 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 carrying out this technique with PQ preservation, especially in patients concerned about the cosmetic appearance of the scar.
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Clembosky, G., Gómez Rodríguez, G. L., Perrone, J. M., & Gómez, D. J. (2015). Distal radius fracture: minimally invasive approach with pronator quadrates preservation. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 80(3), 150-157. https://doi.org/10.15417/355
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Clinical Research
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References
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2. Jupiter JP, Marent-Huber M. Operative management of distal radial fractures with 2.4-millimeter locking plates. A multicenter
prospective case series. J Bone Joint Surg Am 2009;91:55-65.
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J Bone Joint Surg Am 2007;89:256-66.
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J Bone Joint Surg Am 2009;91:1868-73.
5. Lozano-Calderon SA, Doornberg JN, Ring D. Retrospective comparison of percutaneous fixation and volar internal fixation of
distal radius fractures. Hand (NY) 2008;3:102-10.
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plate versus external fixation. J Hand Surg Am 2005;30:289-99.
7. Henry AK. Extensile exposures. Edinburgh: Churchill Livingston; 1973:19.
8. Dos Remedios C, Nebout J, Benlarbi H, Caremier E, Sam-Wing JF, Beya R. Pronator quadratus preservation for distal radius
fractures with locking palmar plate osteosynthesis. Surgical technique. Chir Main 2009;28:224-9.
9. Figl M, Weninger P, Liska M, Hofbauer M, Leixnering M. Volar fixed-angle plate osteosynthesis of unstable distal radius
fractures: 12 months results. Arch Orthop Trauma Surg 2009;129:661-9.
10. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci
2007;12:134-40.
11. Gordon KD, Pardo RD, Johnson JA, King GJ, Miller TA. Electromyographic activity and strength during maximum isometric
pronation and supination efforts in healthy adults. J Orthop Res 2004;22:208-13.
12. Stuart PR. Pronator quadratus revisited. J Hand Surg Br 1996;21:714-22.
13. Graff S, Jupiter J. Fracture of the distal radius: classification of treatment and indications for external fixation. Injury
1994;25(Suppl. 4):S-D14-25.
14. Kapandji A. L’embrochage intra-focal des fractures de l’extrémité inférieure du radius dix ans après. Ann Chir Main 1987;6:
57-63.
15. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (Disabilities of the
Arm, Shoulder and Hand). Am J Ind Med 1996;29:602-8.
16. Cooney WP, Bussey R, Dobyns J, Linscheid R. Difficult wrist fractures. Perilunate fracture–dislocations of the wrist. Clin
Orthop Relat Res 1987;214:136-47.
17. Goldfarb CA, Yin Y, Gilula LA, Fisher A, Boyer M. Wrist fractures: what the clinician wants to know. Radiology 2001;219:
11-28.
18. Metz VM, Gilula LA. Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am 1993;24:217-28.
19. Heidari N, Clement H, Kosuge D, Grechenig W,Tesch N, Weinberg A. Is sparing the pronator quadrates muscle possible in volar
plating of the distal radius? J Hand Surg Eur Vol. 2012;37:402.
20. Imatani J, Noda T, Morito Y, Sato T, Hashizume H. Minimally invasive plate osteosynthesis for comminuted fractures of the
metaphysis of the radius. J Hand Surg Br 2005;30:220-5.
21. Johnson RK, Shrewsbury MM. The pronator quadratus in motions and in stabilization of the radius and ulna at the distal
radioulnar joint. J Hand Surg 1976;1:205-9.
22. Klug RA, Press CM, Gonzalez MH. Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius
fracture: a case report. J Hand Surg Am 2007;32:984-8.
23. McConkey MO, Schwab TD, Travlos A, Oxland T, Goetz T. Quantification of pronator quadratus contribution to isometric
pronation torque of the forearm. J Hand Surg Am 2009;34:1612-7.
24. Mikic Z. The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk. Clin Orthop Relat
Res 1992;275:19-28.
25. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5:103-12.
26. Rath S, Hung LK, Leung PC. Vascular anatomy of the pronator quadratus muscle-bone flap: a justification for its use with a
distally based blood supply. J Hand Surg Am 1990;15:630-6.
27. Sen MK, Strauss N, Harvey EJ. Minimally invasive plate osteosynthesis of distal radius fractures using a pronator sparing
approach. Tech Hand Up Extrem Surg 2008;12:2-6.
28. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized
pedicled bone grafts. J Hand Surg Am 1995;20:902-14.
29. Swigart CR, Badon MA, Bruegel VL, Dodds S. Assessment of pronator quadratus repair integrity following volar plate fixation
for distal radius fractures: a prospective clinical cohort study. J Hand Surg Am 2012;37:1868-73.
30. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol K. The effects of pronator quadratus repair on outcomes after
volar plating of distal radius fractures. J Orthop Trauma 2013;27(3):130-3.
31. Zenke Y, Sakai A, Oshige T, Moritani S, Fuse Y, Maehara T, Nakamura T. Clinical results of volar locking plate for distal radius
fractures: conventional versus minimally invasive plate osteosynthesis. J Orthop Trauma 2011;25(7):425-31.
32. Yoshikawa Y, Saito T, Matsui H. A new cosmetic approach for volar fixed-angle plate fixation to treat distal radius fractures.
J Jpn Soc Surg Hand 2008;24:889-93.
33. Zemirline A, Naito K, Lebailly F, Facca S, Liverneaux P. Distal radius fixation through a mini-invasive approach of 15 mm –
feasibility study. J Hand Surg Eur 2014;24(6):1031-5.
Int 1998;8:341-8.
2. Jupiter JP, Marent-Huber M. Operative management of distal radial fractures with 2.4-millimeter locking plates. A multicenter
prospective case series. J Bone Joint Surg Am 2009;91:55-65.
3. Chung KC, Petruska EA. Treatment of unstable distal radial fractures with the volar locking plating system. Surgical technique.
J Bone Joint Surg Am 2007;89:256-66.
4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly.
J Bone Joint Surg Am 2009;91:1868-73.
5. Lozano-Calderon SA, Doornberg JN, Ring D. Retrospective comparison of percutaneous fixation and volar internal fixation of
distal radius fractures. Hand (NY) 2008;3:102-10.
6. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine
plate versus external fixation. J Hand Surg Am 2005;30:289-99.
7. Henry AK. Extensile exposures. Edinburgh: Churchill Livingston; 1973:19.
8. Dos Remedios C, Nebout J, Benlarbi H, Caremier E, Sam-Wing JF, Beya R. Pronator quadratus preservation for distal radius
fractures with locking palmar plate osteosynthesis. Surgical technique. Chir Main 2009;28:224-9.
9. Figl M, Weninger P, Liska M, Hofbauer M, Leixnering M. Volar fixed-angle plate osteosynthesis of unstable distal radius
fractures: 12 months results. Arch Orthop Trauma Surg 2009;129:661-9.
10. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci
2007;12:134-40.
11. Gordon KD, Pardo RD, Johnson JA, King GJ, Miller TA. Electromyographic activity and strength during maximum isometric
pronation and supination efforts in healthy adults. J Orthop Res 2004;22:208-13.
12. Stuart PR. Pronator quadratus revisited. J Hand Surg Br 1996;21:714-22.
13. Graff S, Jupiter J. Fracture of the distal radius: classification of treatment and indications for external fixation. Injury
1994;25(Suppl. 4):S-D14-25.
14. Kapandji A. L’embrochage intra-focal des fractures de l’extrémité inférieure du radius dix ans après. Ann Chir Main 1987;6:
57-63.
15. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (Disabilities of the
Arm, Shoulder and Hand). Am J Ind Med 1996;29:602-8.
16. Cooney WP, Bussey R, Dobyns J, Linscheid R. Difficult wrist fractures. Perilunate fracture–dislocations of the wrist. Clin
Orthop Relat Res 1987;214:136-47.
17. Goldfarb CA, Yin Y, Gilula LA, Fisher A, Boyer M. Wrist fractures: what the clinician wants to know. Radiology 2001;219:
11-28.
18. Metz VM, Gilula LA. Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am 1993;24:217-28.
19. Heidari N, Clement H, Kosuge D, Grechenig W,Tesch N, Weinberg A. Is sparing the pronator quadrates muscle possible in volar
plating of the distal radius? J Hand Surg Eur Vol. 2012;37:402.
20. Imatani J, Noda T, Morito Y, Sato T, Hashizume H. Minimally invasive plate osteosynthesis for comminuted fractures of the
metaphysis of the radius. J Hand Surg Br 2005;30:220-5.
21. Johnson RK, Shrewsbury MM. The pronator quadratus in motions and in stabilization of the radius and ulna at the distal
radioulnar joint. J Hand Surg 1976;1:205-9.
22. Klug RA, Press CM, Gonzalez MH. Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius
fracture: a case report. J Hand Surg Am 2007;32:984-8.
23. McConkey MO, Schwab TD, Travlos A, Oxland T, Goetz T. Quantification of pronator quadratus contribution to isometric
pronation torque of the forearm. J Hand Surg Am 2009;34:1612-7.
24. Mikic Z. The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk. Clin Orthop Relat
Res 1992;275:19-28.
25. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5:103-12.
26. Rath S, Hung LK, Leung PC. Vascular anatomy of the pronator quadratus muscle-bone flap: a justification for its use with a
distally based blood supply. J Hand Surg Am 1990;15:630-6.
27. Sen MK, Strauss N, Harvey EJ. Minimally invasive plate osteosynthesis of distal radius fractures using a pronator sparing
approach. Tech Hand Up Extrem Surg 2008;12:2-6.
28. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized
pedicled bone grafts. J Hand Surg Am 1995;20:902-14.
29. Swigart CR, Badon MA, Bruegel VL, Dodds S. Assessment of pronator quadratus repair integrity following volar plate fixation
for distal radius fractures: a prospective clinical cohort study. J Hand Surg Am 2012;37:1868-73.
30. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol K. The effects of pronator quadratus repair on outcomes after
volar plating of distal radius fractures. J Orthop Trauma 2013;27(3):130-3.
31. Zenke Y, Sakai A, Oshige T, Moritani S, Fuse Y, Maehara T, Nakamura T. Clinical results of volar locking plate for distal radius
fractures: conventional versus minimally invasive plate osteosynthesis. J Orthop Trauma 2011;25(7):425-31.
32. Yoshikawa Y, Saito T, Matsui H. A new cosmetic approach for volar fixed-angle plate fixation to treat distal radius fractures.
J Jpn Soc Surg Hand 2008;24:889-93.
33. Zemirline A, Naito K, Lebailly F, Facca S, Liverneaux P. Distal radius fixation through a mini-invasive approach of 15 mm –
feasibility study. J Hand Surg Eur 2014;24(6):1031-5.