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DOI: 10.1055/s-0043-1760736
A Stepwise Intraoperative Protocol to Minimize Complications after Volar Plating
Abstract
Background Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described.
Purpose We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making.
Conclusion Large prospective studies of the “WRIST” protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.
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Open reduction and anatomical fixation with an anatomical volar locking plate has become the golden standard to treat distal radius fractures.[1] [2] [3] Although results are generally good, care should be taken to avoid specific iatrogenic and preventable complications. Incidence of these complications ranges from 14 to 18%.[4] [5] Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint (DRUJ) instability due to unstable triangular fibrocartilaginous complex (TFCC) lesions or unstable ulnar styloid base fractures all have been described.[5] [6] [7]
We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we propose to introduce the WRIST protocol that combines multiple fluoroscopic measurements to guide intraoperative decision making.
The WRIST Protocol
The protocol is also summarized in [Table 1].
Abbreviations: DRUJ, distal radioulnar joint; TFCC, triangular fibrocartilaginous complex.
W = Wrist Anatomy
Treatment of distal radial fractures aims to restore normal anatomy to optimize clinical and functional outcomes. Insufficient fracture reduction may result in short-term secondary displacement or long-term malunion, leading to secondary complications like adaptive carpal instability or ulnocarpal abutment syndrome.[8] [9] To optimize radial anatomy, the following parameters should be assessed and properly restored: radial inclination, volar tilt, ulnar variance, and articular congruency ([Fig. 1]). Dorsal tilt > –10 degrees, ulnar positive variance > 2 mm, and articular step-off of > 2 mm must be considered as insufficient and should be corrected.[10] [11] [12] These parameters can be assessed intraoperatively on an anteroposterior (AP) and lateral wrist view using fluoroscopy.
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R = Range of Motion
Smooth and complete passive range of motion (flexion/extension, radial/ulnar deviation, and pronation/supination) should be obtained after fixation and tested under dynamic fluoroscopy if needed. If passive mobility is limited, active mobility will also be impaired. When crepitation or clicking is encountered, intra-articular screw position should be excluded.[13]
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I = Instability
Static fluoroscopic assessment might fail to unveil residual instability. Fracture fixation stability can be tested using provocative mobilization maneuvers under dynamic fluoroscopy.[14] [15] If a fracture fragment displaces under passive loading, there is insufficient plate or screw fixation stability. Volar rim instability can be tested by flexion in a lateral view, volar-ulnar corner instability by flexion in a volar oblique 45-degree view ([Fig. 2]). Dorsal rim instability is tested by extension in a lateral view, dorso-ulnar corner instability by extension in a dorsal oblique 45-degree view, and the stability of the radial styloid by radial deviation in an AP view ([Fig. 3]). Persistent fracture instability after plate fixation may result in loss of reduction during the healing process. Fragment-specific osteosynthesis using specially designed plate or screws can enhance fixation stability. For example, instability of the volar rim suggests that the plate must be placed more distally or fragment-specific rim plates must be used.[16] [17] Insufficient dorsal rim stability can be managed by intraoperative conversion to longer screws, changing the direction toward the dorsal fragment, or adding dorsal implants like screws, pins, or plates.[18] [19] Consequentially, if sufficient dorsal fracture stability is found after volar plating, this obliterates the need for extra dorsal fragment fixation (such as the “sandwich” technique).[20] Of course, preoperative computed tomography scan is often mandatory to provide indicative information to plan the surgery and which plate to use.
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After fracture stability is attained, a displacement of the carpus relative to the radius must raise suspicion for radiocarpal capsuloligamentous lesions. If the carpus shifts ulnarly during a provocative ulnar shift maneuver, lesions to the radioscaphocapitate, short radiolunate, and/or long radiolunate ligament are present ([Fig. 4]). If the carpus shifts volarly during a provocative volar shift maneuver, the capsular attachments (short and long radiolunate ligament) of the lunate are most likely still detached. Capsuloligamentous lesions can be addressed by capsuloligamentous sutures or rigid immobilization enhanced by radiocarpal pinning, radiocarpal plating, or bridging external fixator.[21] [22]
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S = Soong Classification
Soong et al published a classification that describes the relation of the most prominent part of the plate in relation to the watershed line, grading from less prominent to more prominent 0 to 2.[23] Later, they described how plate design, implant prominence, and inappropriate plate positioning might result in delayed flexor tendon rupture.[24] We advocate not only to assess the volar prominent plate edge projection, but also dorsal screw tip extrusion, with possible extensor tendon conflict, on the lateral view and the skyline view ([Fig. 5]).[25] If necessary, the volar plate should be reapplied with firm contact to the volar cortex of the distal radius.[26] A bicortical screw positioned in a distal row screw hole of the plate might aid in achieving optimal plate position and optimal plate-bone contact. The bicortical screw can be changed to an angle-stable screw at the end of the procedure. Fragment-specific plates may also reduce plate-tendon conflict.[27]
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T = TFCC
As a final assessment, we propose inspection of the distal ulna and the stability of the DRUJ. The ballottement test of the DRUJ (AP translation) does not require fluoroscopy. A highly unstable ballottement test suggests instability of the DRUJ. This may be provoked by several reasons: articular incongruency of the DRUJ, radioulnar ligament injury, peripheral TFCC injury with inclusion of the foveal insertion, or an unstable ulnar styloid base fracture. The instability of the DRUJ should be compared with the instability on the contralateral nonaffected wrist.[28] It is still under discussion whether TFCC injuries should be addressed immediately or during a secondary intervention if necessary.[29] [30] However, in our experience, with sufficient wrist arthroscopy experience radioulnar ligament and TFCC injuries may be treated in the same time after addressing the distal radial fracture. Ulnar styloid base fractures are considered unstable if the displacement is > 2 mm ([Fig. 6]). Especially, in combination with a positive ballottement test, ulnar styloid base fractures should be fixed to prevent persistent DRUJ instability and/or nonunion of the ulnar styloid base which may become symptomatic. Several treatment options exist to fix the styloid base: tension band wiring, hook plate, pins, or headless compression screws.[31] [32]
![](https://www.thieme-connect.de/media/jws/202305/thumbnails/10-1055-s-0043-1760736-i2200109-6.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
During wrist arthroscopy, other associated lesions like scapholunate lesions can also be assessed. The differentiation between acute and chronic scapholunate lesions, especially in the elderly, is sometimes challenging. Wrist arthroscopy enhances diagnostic accuracy. Treatment can be performed immediately with scapholunate pinning and/or capsuloligamentous suture.[33] [34]
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Discussion
We firmly believe that our stepwise WRIST protocol could drastically improve the quality of volar distal radius plating and reduce known complications. The protocol serves to primarily influence the intraoperative radiological outcome, which is known to not always correlate with the clinical and functional outcome. Large prospective studies of the WRIST protocol are needed for validation, to evaluate its user friendliness, and its effectiveness to reduce complications after volar distal radius plating. To our knowledge, currently no other authors have published an intraoperative guide to assess the necessity for additional dorsal plating during surgery.
In conclusion we believe that using our WRIST protocol may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.
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Conflict of Interest
None declared.
Authors' Contributions
- Conception of the protocol: C.K.G.
- Testing and reviewing of the protocol during surgery: C.K.G., G.V.E., N.D., K.V.R.
- Main writer of manuscript: C.K.G.
- Assisting writers of manuscript: G.V.E., N.D., K.V.R.
- Review of the submission: C.K.G., G.V.E., N.D.
All authors have met the ICMJE criteria for authorship.
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References
- 1 Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005; 21 (03) 347-354
- 2 Salibian AA, Bruckman KC, Bekisz JM, Mirrer J, Thanik VD, Hacquebord JH. Management of unstable distal radius fractures: a survey of hand surgeons. J Wrist Surg 2019; 8 (04) 335-343
- 3 van Schaik DE, Goorens CK, Wernaers P, Hendrickx B, Scheerlinck T, Goubau JF. Evaluation of current treatment techniques for distal radius fractures amongst Belgian orthopaedic surgeons. Acta Orthop Belg 2015; 81 (02) 321-326
- 4 DeGeorge Jr BR, Brogan DM, Becker HA, Shin AY. Incidence of complications following volar locking plate fixation of distal radius fractures: an analysis of 647 cases. Plast Reconstr Surg 2020; 145 (04) 969-976
- 5 Thorninger R, Madsen ML, Wæver D, Borris LC, Rölfing JHD. Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up. Injury 2017; 48 (06) 1104-1109
- 6 Bentohami A, de Burlet K, de Korte N, van den Bekerom MP, Goslings JC, Schep NW. Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol 2014; 39 (07) 745-754
- 7 Holbrook HS, Doering TA, Mauck BM. Common complications of distal radial fractures. Orthop Clin North Am 2021; 52 (03) 241-250
- 8 Aibinder WR, Izadpanah A, Elhassan BT. Ulnar shortening versus distal radius corrective osteotomy in the management of ulnar impaction after distal radius malunion. Hand (N Y) 2018; 13 (02) 194-201
- 9 Cognet JM, Mares O. Distal radius malunion in adults. Orthop Traumatol Surg Res 2021; 107 (1S): 102755
- 10 Lalone EA, Grewal R, King GJ, MacDermid JC. A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures. Hand (N Y) 2015; 10 (04) 621-638
- 11 Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006; 88 (09) 1944-1951
- 12 Walenkamp MM, Aydin S, Mulders MA, Goslings JC, Schep NW. Predictors of unstable distal radius fractures: a systematic review and meta-analysis. J Hand Surg Eur Vol 2016; 41 (05) 501-515
- 13 Rhee PC, Dennison DG, Kakar S. Avoiding and treating perioperative complications of distal radius fractures. Hand Clin 2012; 28 (02) 185-198
- 14 Kamei S, Osada D, Tamai K. et al. Stability of volar locking plate systems for AO type C3 fractures of the distal radius: biomechanical study in a cadaveric model. J Orthop Sci 2010; 15 (03) 357-364
- 15 Patrick NC, Lewis GS, Roush EP, Black SS, Henderson SR, Taylor KF. Biomechanical stability of volar plate only versus addition of dorsal ulnar pin plate: a dorsal ulnar fragment, c-3-type, distal radius, cadaver fracture model. J Orthop Trauma 2020; 34 (09) e298-e303
- 16 Gavaskar AS, Parthasarathy S, Balamurugan J, Raj RV, Anurag R, Gopinath D. Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures. Injury 2021; 52 (01) 85-89
- 17 Goorens CK, Geeurickx S, Wernaers P, Staelens B, Scheerlinck T, Goubau J. Midterm follow-up of treating volar marginal rim fractures with variable angle lcp volar rim distal radius plates. J Hand Surg Asian Pac Vol 2017; 22 (02) 184-187
- 18 Ruch DS, Tocci FL, Grier AJ. et al. Integrated compression screw stabilization of the dorsal lunate facet in intra-articular distal radius fractures. J Hand Surg Am 2020; 45 (04) 361.e1-361.e7
- 19 Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am 2012; 37 (03) 446-453
- 20 Day CS, Kamath AF, Makhni E, Jean-Gilles J, Zurakowski D. “Sandwich” plating for intra-articular distal radius fractures with volar and dorsal metaphyseal comminution. Hand (N Y) 2008; 3 (01) 47-54
- 21 Bohm KC, Geissler J, Ward CM. Volar radiocarpal ligament repair with suture anchors for radiocarpal fracture dislocations: case series. J Wrist Surg 2021; 10 (02) 169-175
- 22 Potter MQ, Haller JM, Tyser AR. Ligamentous radiocarpal fracture-dislocation treated with wrist-spanning plate and volar ligament repair. J Wrist Surg 2014; 3 (04) 265-268
- 23 Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am 2011; 93 (04) 328-335
- 24 Gören Y, Sauerbier M, Arsalan-Werner A. Impact of Soong grading on flexor tendon ruptures following palmar plating for distal radial fractures. J Hand Surg Eur Vol 2020; 45 (04) 348-353
- 25 Vaiss L, Ichihara S, Hendriks S, Taleb C, Liverneaux P, Facca S. The utility of the fluoroscopic skyline view during volar locking plate fixation of distal radius fractures. J Wrist Surg 2014; 3 (04) 245-249
- 26 Goorens CK, Van Royen K, Grijseels S. et al. 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. Hand Surg Rehabil 2018; 37 (03) 171-174
- 27 Kaiser P, Gruber H, Loth F, Schmidle G, Arora R, Gabl M. Positioning of a volar locking plate with a central flexor pollicis longus tendon notch in distal radius fractures. J Wrist Surg 2019; 8 (06) 482-488
- 28 Onishi T, Omokawa S, Iida A. et al. Biomechanical study of distal radioulnar joint ballottement test. J Orthop Res 2017; 35 (05) 1123-1127
- 29 Xiao AX, Graf AR, Dawes A, Daley C, Wagner ER, Gottschalk MB. Management of acute distal radioulnar joint instability following a distal radius fracture: a systematic review and meta-analysis. J Hand Surg Glob Online 2021; 3 (03) 133-138
- 30 Im J, Kang SJ, Lee SJ. A comparative study between conservative and surgical treatments of triangular fibrocartilage complex injury of the wrist with distal radius fractures. Clin Orthop Surg 2021; 13 (01) 105-109
- 31 Kim KW, Lee CH, Choi JH, Ahn JM, Gong HS. Distal radius fracture with concomitant ulnar styloid fracture: does distal radioulnar joint stability depend on the location of the ulnar styloid fracture?. Arch Orthop Trauma Surg 2021
- 32 Chen AC, Chiu CH, Weng CJ, Chang SS, Cheng CY. Early and late fixation of ulnar styloid base fractures yields different outcomes. J Orthop Surg Res 2018; 13 (01) 193
- 33 Jones VM, Everding NG, Desmarais JM, Soong MC. Scapholunate instability after distal radius volar plating. Hand (N Y) 2015; 10 (04) 678-682
- 34 Kastenberger T, Kaiser P, Schmidle G, Schwendinger P, Gabl M, Arora R. Arthroscopic assisted treatment of distal radius fractures and concomitant injuries. Arch Orthop Trauma Surg 2020; 140 (05) 623-638
Address for correspondence
Publikationsverlauf
Eingereicht: 11. Oktober 2022
Angenommen: 28. November 2022
Artikel online veröffentlicht:
09. Februar 2023
© 2023. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
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References
- 1 Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005; 21 (03) 347-354
- 2 Salibian AA, Bruckman KC, Bekisz JM, Mirrer J, Thanik VD, Hacquebord JH. Management of unstable distal radius fractures: a survey of hand surgeons. J Wrist Surg 2019; 8 (04) 335-343
- 3 van Schaik DE, Goorens CK, Wernaers P, Hendrickx B, Scheerlinck T, Goubau JF. Evaluation of current treatment techniques for distal radius fractures amongst Belgian orthopaedic surgeons. Acta Orthop Belg 2015; 81 (02) 321-326
- 4 DeGeorge Jr BR, Brogan DM, Becker HA, Shin AY. Incidence of complications following volar locking plate fixation of distal radius fractures: an analysis of 647 cases. Plast Reconstr Surg 2020; 145 (04) 969-976
- 5 Thorninger R, Madsen ML, Wæver D, Borris LC, Rölfing JHD. Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up. Injury 2017; 48 (06) 1104-1109
- 6 Bentohami A, de Burlet K, de Korte N, van den Bekerom MP, Goslings JC, Schep NW. Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol 2014; 39 (07) 745-754
- 7 Holbrook HS, Doering TA, Mauck BM. Common complications of distal radial fractures. Orthop Clin North Am 2021; 52 (03) 241-250
- 8 Aibinder WR, Izadpanah A, Elhassan BT. Ulnar shortening versus distal radius corrective osteotomy in the management of ulnar impaction after distal radius malunion. Hand (N Y) 2018; 13 (02) 194-201
- 9 Cognet JM, Mares O. Distal radius malunion in adults. Orthop Traumatol Surg Res 2021; 107 (1S): 102755
- 10 Lalone EA, Grewal R, King GJ, MacDermid JC. A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures. Hand (N Y) 2015; 10 (04) 621-638
- 11 Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006; 88 (09) 1944-1951
- 12 Walenkamp MM, Aydin S, Mulders MA, Goslings JC, Schep NW. Predictors of unstable distal radius fractures: a systematic review and meta-analysis. J Hand Surg Eur Vol 2016; 41 (05) 501-515
- 13 Rhee PC, Dennison DG, Kakar S. Avoiding and treating perioperative complications of distal radius fractures. Hand Clin 2012; 28 (02) 185-198
- 14 Kamei S, Osada D, Tamai K. et al. Stability of volar locking plate systems for AO type C3 fractures of the distal radius: biomechanical study in a cadaveric model. J Orthop Sci 2010; 15 (03) 357-364
- 15 Patrick NC, Lewis GS, Roush EP, Black SS, Henderson SR, Taylor KF. Biomechanical stability of volar plate only versus addition of dorsal ulnar pin plate: a dorsal ulnar fragment, c-3-type, distal radius, cadaver fracture model. J Orthop Trauma 2020; 34 (09) e298-e303
- 16 Gavaskar AS, Parthasarathy S, Balamurugan J, Raj RV, Anurag R, Gopinath D. Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures. Injury 2021; 52 (01) 85-89
- 17 Goorens CK, Geeurickx S, Wernaers P, Staelens B, Scheerlinck T, Goubau J. Midterm follow-up of treating volar marginal rim fractures with variable angle lcp volar rim distal radius plates. J Hand Surg Asian Pac Vol 2017; 22 (02) 184-187
- 18 Ruch DS, Tocci FL, Grier AJ. et al. Integrated compression screw stabilization of the dorsal lunate facet in intra-articular distal radius fractures. J Hand Surg Am 2020; 45 (04) 361.e1-361.e7
- 19 Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am 2012; 37 (03) 446-453
- 20 Day CS, Kamath AF, Makhni E, Jean-Gilles J, Zurakowski D. “Sandwich” plating for intra-articular distal radius fractures with volar and dorsal metaphyseal comminution. Hand (N Y) 2008; 3 (01) 47-54
- 21 Bohm KC, Geissler J, Ward CM. Volar radiocarpal ligament repair with suture anchors for radiocarpal fracture dislocations: case series. J Wrist Surg 2021; 10 (02) 169-175
- 22 Potter MQ, Haller JM, Tyser AR. Ligamentous radiocarpal fracture-dislocation treated with wrist-spanning plate and volar ligament repair. J Wrist Surg 2014; 3 (04) 265-268
- 23 Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am 2011; 93 (04) 328-335
- 24 Gören Y, Sauerbier M, Arsalan-Werner A. Impact of Soong grading on flexor tendon ruptures following palmar plating for distal radial fractures. J Hand Surg Eur Vol 2020; 45 (04) 348-353
- 25 Vaiss L, Ichihara S, Hendriks S, Taleb C, Liverneaux P, Facca S. The utility of the fluoroscopic skyline view during volar locking plate fixation of distal radius fractures. J Wrist Surg 2014; 3 (04) 245-249
- 26 Goorens CK, Van Royen K, Grijseels S. et al. 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. Hand Surg Rehabil 2018; 37 (03) 171-174
- 27 Kaiser P, Gruber H, Loth F, Schmidle G, Arora R, Gabl M. Positioning of a volar locking plate with a central flexor pollicis longus tendon notch in distal radius fractures. J Wrist Surg 2019; 8 (06) 482-488
- 28 Onishi T, Omokawa S, Iida A. et al. Biomechanical study of distal radioulnar joint ballottement test. J Orthop Res 2017; 35 (05) 1123-1127
- 29 Xiao AX, Graf AR, Dawes A, Daley C, Wagner ER, Gottschalk MB. Management of acute distal radioulnar joint instability following a distal radius fracture: a systematic review and meta-analysis. J Hand Surg Glob Online 2021; 3 (03) 133-138
- 30 Im J, Kang SJ, Lee SJ. A comparative study between conservative and surgical treatments of triangular fibrocartilage complex injury of the wrist with distal radius fractures. Clin Orthop Surg 2021; 13 (01) 105-109
- 31 Kim KW, Lee CH, Choi JH, Ahn JM, Gong HS. Distal radius fracture with concomitant ulnar styloid fracture: does distal radioulnar joint stability depend on the location of the ulnar styloid fracture?. Arch Orthop Trauma Surg 2021
- 32 Chen AC, Chiu CH, Weng CJ, Chang SS, Cheng CY. Early and late fixation of ulnar styloid base fractures yields different outcomes. J Orthop Surg Res 2018; 13 (01) 193
- 33 Jones VM, Everding NG, Desmarais JM, Soong MC. Scapholunate instability after distal radius volar plating. Hand (N Y) 2015; 10 (04) 678-682
- 34 Kastenberger T, Kaiser P, Schmidle G, Schwendinger P, Gabl M, Arora R. Arthroscopic assisted treatment of distal radius fractures and concomitant injuries. Arch Orthop Trauma Surg 2020; 140 (05) 623-638
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