Bluntly dissect to avoid branches of the sural or superficial peroneal nerve and peroneal tendons, which usually lie inferior and posterior to dissection, but can be located directly in line with incision if dislocated. Excision of the calcaneofibular ligament and any capsular tissue is performed to help access the posterior facet. Remove any hematoma or irreparable fragments of free-floating articular cartilage from the joint.

Place one or two 3.2-4.0mm cortical screws across the posterior facet to the tip of the sustentaculum to stabilize the articular fragment. If fracture comminution is minimal, screws can be placed in lag fashion. Positional screws should be used in more comminuted fractures (i.e. Sanders III or IV). Care should be taken to not plunge when drilling and to properly measure screw length to avoid iatrogenic injury to the neurovascular bundle or flexor hallucis longus tendon medially.

Grasp plate and insert through the incision. Temporarily hold plate with K-wire and confirm extramedullary placement via Harris Heel view.

Using the variable angle bearing holes, aim guide to desired position between previously placed screws to support the posterior facet. Finger tighten guide to lock. Insert 1.1mm K-wire to confirm trajectory under fluoroscopy and to determine proper depth. Measure length using the wire gauge. Drill over K-wire with 2.1mm cannulated drill. Remove K-wire and insert 2.3mm peg. Repeat steps for additional pegs.

After plate fixation and final fluoroscopy images are obtained, one must assess peroneal tendon reduction. If the peroneal tendons are dislocated, the incision should be extended 2-3 cm along the posterior border of the fibula. Repair of the superior peroneal retinaculum can be performed by placing suture anchors into the posterolateral aspect of the fibula and repairing the retinaculum to the fibula with the tendons relocated into the fibular groove.

Perform standard wound closure.

Brachioradialis Release
Release or excision of the insertion of the Brachioradialis (BR) tendon is required to provide adequate exposure of the radius and to remove one of the deforming forces. This action also releases the Pronator Quadratus muscle from its radial attachment. Identify and avoid the radial artery that is traveling parallel and palmar to the BR tendon.

Distal Fixation
Once the correct distal position of the plate is determined, distal fixation of the plate is performed with 3 locking screws. Care is taken not to place any screws into the radial sigmoid notch. Note that the notch has a concave surface which may make this difficult to evaluate intra-operatively.

Supplemental Fixation and Bone Grafting
Supplemental fixation is obtained by placing a “wire-form” on the palmar side of the osteotomy, creating a “90-90” construct after a corticocancellous bone graft is inserted from the iliac crest (shape the graft to accommodate the defect). Reattachment of the PQ muscle can be performed by placing sutures through the empty holes on the radial plate.

Indications

1. OTA Type A. fractures
2. OTA Type B. fractures

The primary indication for using the Radial Locking Plate is an extra-articular or simple
intra-articular fracture of the distal radius. On some rare occasions, this plate may also be used for fractures with a large styloid fragment. The assessment should be made on post-reduction radiographs. If a fracture is too distal and enough screw purchase is not possible, then another type of fixation should be utilized.

Type I Pattern
Type I has a single distal branching pattern. The SBRN is mobilized using a gentle “lift technique”. The nerve can be moved palmarly or dorsally as necessary.

Tendon Release of First Dorsal Extensor Compartment
An extensive release of the APL & EPB tendons is required to allow for the plate to be placed in the appropriate position. The EPB tendon is often found in a separate compartment. This tendon must also be released. The septum (if present) between the compartment also needs to be excised. Open the 1st dorsal compartment and mobilize the APL and EPB tendons. A large penrose drain provides for protection of the tendons and allows for easy access to the distal radius.

Brachioradialis Release (BR)
Release or excise the terminal insertion of the BR. Release the pronator quadratus (PQ) muscle off its radial attachment to allow for visualization of the volar surface of the distal radius. Now continue the dissection dorsally. The dorsal, palmar and radial surfaces of the radius are now exposed, aiding the ORIF. The PQ protects the flexor tendons.

Proximal Fixation
Lift the proximal end of the plate to the midline axis of the radial shaft to restore the normal palmar tilt of the articular surface. Use your thumb on the palmar side of the fracture, to maintain fracture reduction while the plate is being positioned. Attach a peg-guide and use a 1.75mm drill to drill bicortically or unicortically. Measure depth and insert proximal locking peg. Repeat procedure for the other two proximal holes.

Pronator Quadratus (PQ) Muscle Reattachment
The PQ muscle can be reattached to the volar side of the radius using one or two of the empty screw or K-wire holes on the plate. Bone graft can be added if there is a large dorsal gap.

Post-Op Protocol

• Patients are usually seen back in one week.
• A removable splint is given.
• The patient is referred to hand therapy and range of motion exercises are started for the shoulder, elbow, forearm, wrist and fingers.
• Scar management and desensitization is also initiated.
• The patient can remove the splint for light activity.
• Sutures are removed in two weeks.
• Full flexion and extension of the fingers should be obtained by  3 weeks if exercises are performed correctly.

The incision can vary depending on the number and location of bones being fused, as well as the intended placement of the implant.

All cartilage and fibrous tissue are resected and the fusion sites are prepared. Meticulous decortication of cartilage must be performed. Use of a scalpel, curette, rongeur, osteotome or high speed burr can facilitate this process.

The bones to be fused are aligned and temporarily fixed with a reduction clamp, K-wires or both. Ensure that the temporary fixation is situated beyond the circumference of the reamer and set deeper than the reamer will cut.

Press the desired diameter of implant onto the handle, and visually assess implant size and placement relative to the fusion site.

Ream in the orientation and to a depth where the cup will sit flush or just below the surface of the bone. Periodically remove contents from the reamer blades to improve cutting and set aside as additional graft material. At these intervals also check reaming depth and orientation until optimal.

It is possible to drill 10° off center of each hole. Under fluoroscopy the radiolucent implant affords complete visualization to assure ideal screw placement. Drill, measure and insert screws, but do not completely tighten screws until all have been inserted. Alternately tighten screws opposite each other until all screw heads are brought flush with, but not below, the surface of the implant.

Obtain final fluoroscopic images in multiple planes to confirm bone alignment and screw placement. The wound is closed in layers. Patients are placed in a cast for 6-8 weeks.

A dorsal longitudinal incision is made over the wrist in line with the scaphotrapeziotrapezoid (STT) joint, extending proximally in line with the extensor pollicis longus (EPL) to Lister’s tubercle. Skin flaps are elevated, and the dorsal sensory branch of the radial nerve (DRSN) is protected.

Once reduced to normal anatomical position, fusion sites are prepared. This is the most important part of the procedure. Meticulously decorticate cartilage of the scaphoid-trapezium-trapezoid joints.

A scalpel, curette, rongeur, osteotome or high speed burr can be used to denude the cartilage between the three bones, down through subchrondral bone to bleeding cancellous bone. To achieve optimal cancellous bone contact for fusion, denuding of the cartilage is carried down to the volar aspect of the STT joint.

Autologous cancellous bone graft is taken from either Lister’s tubercle or elsewhere. The graft is packed between each of the joint surfaces to be fused and at the junction of the STT fusion down through the volar aspect. It is noteworthy that no bone graft has extruded into the scaphocapitate joint surface.

With bone graft packed into all interstices, confirm STT alignment and stability before reaming.

Rotate Fusion Cup for optimal alignment, allowing for two screws into each of the STT bones. Drill, measure and insert screws, but do not completely tighten until all screws have been inserted. Alternately tighten screws that are opposite to each other.

The capsule and/or retinaculum flap is repaired with absorbable sutures after copious amounts of irrigation. Hemostasis is assured. The skin is repaired. A short arm thumb spica splint is placed.

Under brachial tourniquet control, a longitudinal incision is made along the line of the 3rd metacarpal over the radiocarpal and midcarpal joints. Skin flaps are elevated, sensory nerves protected. The third extensor compartment is opened and the extensor policis longus is retracted radialward. An ulnarly based flap of retinaculum is created by dividing the septum between the 3rd and 4th, and 4th and 5th extensor compartments. The extensor tendons are retracted and a posterior interosseous neurectomy is performed.

The articular surfaces of the radiocarpal joint are carefully examined. If the radiolunate articulation is without degenerative changes, one can proceed with scaphoid excision. The dorsal scapholunate ligament, membranous portion and volar ligament are sharply divided. Care is taken not to damage the radioscaphocapitate or long radiolunate volar ligaments. The scaphoid can be removed piecemeal or whole. Using sharp elevators, soft tissue attachments can be systematically elevated from the scaphoid until it is removed. The RSC and LRL must
be preserved!

Correction of the DISI deformity (dorsal tilting of the lunate) is imperative to prevent dorsal radiocarpal impingement. Using a fluoroscope, a lateral image is obtained. The wrist is flexed until the radiolunate angle is neutral (0 degrees). A 0.0625” K wire is used to transfix the radius to lunate to maintain this relationship. The K wire should be place at an angle such that it is not in the way when the burr is used to prepare the bones for the Fusion Cup.

Once bone graft is packed into all areas, the alignment confirmed and the carpal bones have been transfixed with  K wires, the bones are reamed. The reamer central position is chosen such that all four bones will be reamed as equally as possible. The depth of the reaming should be such that the Fusion Cup is sunk just below the edge of the dorsal cortex.  If it is not, there will be plate impingement on the radius.  Once reaming is complete apply bone graft with the cancellous autograft as needed.

Drill, measure and insert screws but do not completely tighten screws until all screws have been inserted. Alternately tighten screws that are opposite to each other (illustrated) and bring screw head just flush with the Fusion Cup. Pay particular attention when placing screws into the triquetrum, since a long screw may result in pisotriquetral joint irritation.

A volar approach to the distal radius is made with an incision that follows the flexor carpi radialis tendon. Rarely is the incision made distal to the wrist crease, however, surgeon preference will dictate length of the incision. If a multi incision approach is made to the wrist, the incision can be shifted ulnarly by 0.5cm to allow enough of a soft tissue bridge between the radial incision (for the radial styloid fixation). Alternatively, the radial styloid can be fixed with an extended FCR incision by angling the distal portion of the incision radialward

The pronator quadratus muscle is identified and the radial and distal margins are visualized. The pronator quadratus is sharply elevated from the radial side of the radius and bluntly elevated from the distal margin, taking care not to divide the radiocarpal ligaments. It is important to elevate the pronator quadratus to the most ulnar aspect of the radius.

Holding the proximal aspect of the plate to the radius, the 1.8 mm drill is used to secure the plate to the radius shaft with a 2.3mm screw. A locking peg (either threaded or smooth) can then be placed in the locking hole when the dorsal fragments have been reduced. Verification of placement on fluoroscopic image is necessary. An additional Hook Plate can be placed radially if needed.

Consider the direction of carpal displacement before inserting the plate. This avoids catching the plate on or under fracture fragments as it is advanced.

Typically, the plate is passed proximally through the 2nd compartment. Alternatively, the plate can be inserted proximally beneath the muscle bellies of the outcroppers extraperiosteally and advanced distally between the ECRL and ECRB tendons. Some resistance will be encountered, but this can be overcome with gentle manipulation of the handle.

With a wrist in neutral rotation, and the plate aligned on the metacarpal and radial shafts, a non-locking 3.2mm cortical screw is placed into the distal end of the slotted hole to allow for additional distraction with the expander tool. The remaining holes are secured with locking or non-locking screws inserted with bicortical purchase.