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Palmar Plating System for Colles’ Fractures—A Preliminary Report
Palmar Plating System for Colles’ Fractures—A Preliminary Report Masayuki Kamano, MD, PhD, Masaru Koshimune, MD, PhD, Masahiko Toyama, MD, Kenichi Kazuki, MD, PhD, Osaka, Japan
Purpose: To present our results of the palmar plating system that we developed for the treatment of Colles’ fractures. Methods: By using the palmar plating system that we developed a consecutive series of 40 acute Colles’ fractures were treated surgically. There were 12 men and 28 women with a mean age of 57 years at the time of the injury (range, 25–90 y). All patients had internal fixation using the trans–flexor carpi radialis tendon approach. The system has 3 main features. First, the plate is small in size, being 1.1 mm in thickness and 47 mm in length. Only a 3- to 4-cm skin incision is required for application of the plate. Second, the screw is cannulated and cancellous in type, with a low-profile head. Subchondral screw fixation is achieved both easily and safely by using a guidewire. Third, the plate has a window through which injectable bone cement can be placed. Results: Union was achieved in all patients. The palmar tilt, radial inclination, radial length, and ulnar variance were maintained after surgery. According to the Gartland and Werley rating scale that was modified by Sarmiento there were 12 excellent and 28 good results. There were no extensor tendon injuries that could occur when the dorsal approach was used. Conclusions: This palmar plating system can make fixation of the distal radius easy, safe, and effective in the treatment of unstable Colles’ fractures. (J Hand Surg 2005;30A:750 –755. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Colles’ fracture, palmar plating, subchondral screw fixation.
Palmar plating has been accepted as one alternative for the treatment of an unstable Colles’ fracture.1–7 The first advantage of palmar plating is the avoidance of opening the extensor retinaculum with its potential for damage to the extensor tendons. The second
From the Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital, Osaka, Japan; the Department of Orthopaedic Surgery, Baba Memorial Hospital, Osaka, Japan; and the Department of Orthopaedic Surgery, Osaka City University Medical School, Osaka, Japan. Received for publication September 13, 2004; accepted in revised form February 8, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Masayuki Kamano, MD, PhD, Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital, Shibata 2-10-39, Kitaku, Osaka City 530-0012, Japan; e-mail: [email protected] Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A04-0016$30.00/0 doi:10.1016/j.jhsa.2005.02.009
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The Journal of Hand Surgery
advantage is that it is easy to reduce the palmar cortex anatomically under direct vision. We show that anatomic reduction of the palmar cortex prevents shortening of the distal radius using plates that are different from the plate reported here.3,4 In addition subchondral screw fixation of the distal fragment is necessary for maintaining anatomic reduction. To make subchondral screw fixation of the distal fragment secure, 3 or 4 cancellous screws should be inserted into the subchondral bone of the distal radius and the radial styloid process correctly. It is, however, technically demanding.3,4 In 2002 a fixed-angle internal device was provided to fix the distal fragment automatically.5 The basic concept of the fixation was subchondral support. Distal pegs introduced under the subchondral plate of the distal fragment support the distal fragment. To prevent loss of reduction pegs should be introduced as closely as possible
Kamano et al / Palmar Plating System for Colles’ Fractures
to the subchondral plate. Although each peg is fixed at different angles according to the shape of the distal radius, it is not easy for all pegs to be introduced close to the subchondral plate. In addition there is a possibility that some pegs may be introduced into the radiocarpal joint if the plate is situated distally near the wrist joint. In the other locking plate system1 all the distal screws are fixed at the same angle. This system also has the same technical difficulties as that previously mentioned. In addition a case in which all the distal screws cut through the subchondral bone and penetrated into the joint has been reported.8 In the current palmar plating system all screws are both cannulated and cancellous. Thus all the screws can be inserted easily into the subchondral bone using a guidewire at a maximum of 10° from the vertical of each screw hole in any direction. One can introduce 3 or 4 screws into the subchondral bone for fixing the distal fragment firmly. Our concept of fixation is subchondral fixation; this is the major difference from the 2 earlier-mentioned systems. In this article we describe a palmar plating system for Colles’ fractures and its clinical results.
Materials and Methods A consecutive series of 40 patients with acute Colles’ fractures were treated surgically by using our palmar plating system. There were 12 men and 28 women with a mean age of 57 years at the time of the injury (range, 25–90 y). The type of fracture was classified according to the AO/ASIF classification.9 There were 18 cases of A2.2, 16 of A3.2, 2 of C1.2, 3 of C2.1, and 1 of C3.1. Indications for surgery were failure of initial closed reduction in a cast. In all patients with type A fractures, more than 10° of the dorsal tilt remained because of comminution of the dorsal cortex after closed reduction. An intra-articular step-off of greater than 1 mm was also an indication for surgery. The follow-up period ranged from 12 to 14 months (mean, 12 mo) after surgery. Seventeen patients were more than 60 years of age. The cause of the fractures in the 17 elderly patients was a simple fall while walking. The causes of all fractures in the male patients were work- or sportsrelated accidents. In 20 patients the fracture affected their dominant hand. All fractures were closed. There were no patients presenting with median nerve symptoms before surgery.
Surgical Technique Under a brachial nerve block the palmar plating was performed through a trans–flexor carpi radialis (FCR) tendon approach. Only a 3- to 4-cm skin incision was
751
Figure 1. The palmar plate we developed. The maximum length is 47 mm, the width is 9 mm, and the thickness is 1.1 mm. All screw holes are shaped conically.
necessary along the tendon. After detachment of the pronator quadratus muscle from its radius insertion, with a 4- to 5-mm margin retained for later closure, good exposure for an anatomic reduction of the palmar cortex of the distal radius and for application of the plate was provided. In extra-articular fractures the anatomic reduction of the palmar cortex was obtained after the distal fragment was flexed. Temporary percutaneous fixation with K-wires was performed to maintain the reduction before plating. In intra-articular fractures manipulation under fluoroscopy was performed first. If anatomic reduction was obtained then temporary percutaneous fixation with K-wires was performed. There were no cases in which an additional dorsal skin incision was required to fix the die-punch fragment or other intra-articular fragments in the current study. The recently designed plate (Biotechni Co., Ltd., Ciotat, France) for the distal radius is made from titanium-6 aluminum-4 vanadium (Ti-6Al-4V) (Fig. 1). There is only 1 size with 2 types: one for the left and one for the right hand. The maximal length of the plate is 47 mm and the thickness is only 1.1 mm. The plate has 20° of palmar angulation and has 4 holes distally and 2 holes proximally. One of the proximal holes is oval in shape. Thus one can insert 1 or 2 screws through the hole. The plate has a triangular window between the proximal and distal holes. In 4 patients with severe osteoporosis a metaphyseal bone defect was found when performing reduction. Injectable calcium bone cement was used for bone grafting in the current study. A drill hole was made with a drill 2.5 mm in diameter within the window and injectable bone cement was instilled under fluoro-
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The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Figure 2. The cannulated cancellous screw we used. The head has 3 slots and has a low profile with a conically shaped design. The tip is round and self-tapping.
has been possible to design the head with a low profile. In addition the screw cannot be tightened if each nail of the driver is not placed in each slot. With the standard hexagonal socket head the socket may be destroyed when the screw is tightened if the screwdriver is not inserted into the hole correctly. The other feature of the screw is that it is cannulated so that the screws can be inserted correctly and safely by using a guidewire into the subchondral bone of the distal fragment. A 1.1-mm diameter guidewire can be introduced into the subchondral bone and the radial styloid process under fluoroscopy. Subchondral screw fixation is performed easily and accurately with safety (Fig. 3). Mechanical properties of the plate were tested using a tension-testing machine (SHIMADZ Co., Ltd., Kyoto, Japan). The mechanical properties of the Ti-6AL-4V plate are in accordance with the world mechanical standard ASTM F136-98.
Postoperative Management scopic control through the hole after the plating was completed. Both the screw hole and head are shaped conically and this allows for the screw to be inserted at a maximum of 10° from the vertical in any direction. The screws are self-tapped cancellous in type, with a low-profile head and a round tip for avoiding damage to soft tissues. The screw has a conically shaped head and 3 slots and a hole for a guidewire (Fig. 2). Because the socket head is not hexagonal, it
A bandage was required for postoperative immobilization for 7 to 10 days after surgery. Active exercises of the finger and the wrist were commenced on the day after surgery.
Radiographic Examination and Clinical Evaluation The palmar tilt, radial inclination, and radial length were measured radiographically 3 times: before sur-
Figure 3. A C1.2 fracture in a 28-year-old woman. (A) Posteroanterior and (B) lateral radiographs after plating. Four screws were inserted into the radial styloid and the subchondral bone of the distal fragment. Subchondral fixation was obtained.
Kamano et al / Palmar Plating System for Colles’ Fractures
753
Table 1. Radiographic Parameter Palmar tilting angle (°)
Before Surgery
After Surgery
⫺21.4 ⫾ 11.1
8.4 ⫾ 4.2
p value Radial inclination (°)
p ⬍ .001
15 ⫾ 4.8
p value Radial length (mm) p value
Final Follow-Up Evaluation 7.4 ⫾ 4 ND
22 ⫾ 3.3 p ⬍ .001
4.9 ⫾ 2
21 ⫾ 2.8 ND
9.9 ⫾ 2.9 p ⬍ .001
Ulnar variance (mm)
9.5 ⫾ 3.0 ND
0.6 ⫾ 1.5
p value
1.1 ⫾ 1.5 ND
Mean ⫾ SD. ND, no difference.
gery, immediately after surgery, and at the final follow-up evaluation. The ulnar variance was measured 2 times: immediately after surgery and at the final follow-up evaluation. The paired Student t test was used to compare each radiographic parameter. Subjective and objective data were graded by using the demerit point system of Gartland and Werley,10 which has been modified by Sarmiento et al.11 At the final follow-up evaluation each extensor tendon was checked clinically. Any other clinical signs of problems relating to our surgical approach were also reviewed at the final examination. All surgeries were performed by 2 of the authors (M.T., M.K.). Each radiographic parameter was measured by a physician who also performed the clinical evaluation (M.K.).
of 35° to 57°, 16° radial deviation (86% of the opposite side) with a range of 12° to 20°, 29° ulnar deviation (88% of opposite side) with a range of 15° to 35°, 80° pronation (90% of the opposite side) with a range of 70° to 90°, and 80° supination (90% of opposite side) with a range of 70° to 97°. At the final follow-up evaluation none of the patients had clinical evidence of damage to the extensor tendons. There were no injuries to the radial artery or to the median nerve. There were no symptoms caused by to the trans-FCR approach. One patient developed a chronic regional pain syndrome. Early recognition of the syndrome and oral medication resulted in resolution. One patient with diabetes had a mild skin infection that resolved with antibiotics.
Results
Discussion
Bony union was achieved in all patients. There was no statistical significance between each parameter immediately after surgery and at the final follow-up evaluation. All radiographic parameters are shown in Table 1 According to the modified Gartland and Werley10 rating scale there were 12 excellent and 28 good results. The mean grip strength recovered 78% (range, 60%–100%) as compared with the opposite side. The wrist range of motion was assessed with a goniometer at the final follow-up evaluation and averaged 57° extension (88% as compared with the opposite side) with a range of 45° to 65°, 48° flexion (79% compared with the opposite side) with a range
The first report concerning palmar plating for Colles’ fractures was by Georgoulis et al2 in German in 1992. In the English literature Orbay6 first mentioned the safety and the effectiveness of volar plating for unstable Colles’ fractures in 2000. Subsequently several investigators have reported palmar plating for dorsally displaced fractures of the distal radius.1–7 The great advantage of palmar plating is its simplicity and safety in approaching the distal radius. Difficulties with the dorsal approach and dorsal plating have discouraged surgeons from internal fixation. The most serious complication of dorsal plating is extensor tendon rupture. Several investigators have
8–10 3–4 0 0 12 28 19 12 79 78 27 29 17 16 57 48 59 57 21 22 5 8
— 9.9
8–10 4 8 8 78 — — 62
Flexion Extension
61 12 23 0
Ulnar Deviation Radial Deviation Radial Length (mm) Radial Inclination (°) Palmar Tilt (°) Reporter
Constantine et al (20 patients) Orbay and 5 Fernandez (31 patients) Kamano (40 patients)
Fair Good Excellent
Modified Gartland and 10 Werley (No. of Cases)
Grip Strength Compared With Opposite Side (%) Final Wrist Motion (° Average) Radiographic Parameter (Average)
reported this complication when using dorsal plating.12–15 In the treatment of dorsally displaced fractures with palmar plating a buttress effect cannot be expected. To prevent loss of reduction or to minimize it, a fixed-angle screw-and-plate system was developed that involves an AO/ASIF titanium volar distal radius T plate (Synthes, Paoli, PA). All distal screws have a fixed angle for supporting the subchondral plate of the distal fragment. Constantine et al1 reported the clinical results of the plate in 2002. They treated 20 cases (AO type A, 4 cases; type C, 16 cases) of unstable dorsally displaced fractures of the distal radius by using a volar Henry approach. An 8to 10-cm skin incision was made in line with the radial border of the FCR tendon. There were 8 excellent, 8 good, and 4 fair results using the modified Gartland and Werley9 scale. Orbay and Fernandez5 also used a fixed-angle internal device (DVR Plate; Hand Innovation, Miami, FL) and reported their results in 2002. They treated 31 dorsally displaced unstable fractures of the distal radius using the extended FCR approach. An 8to 10-cm skin incision was made over the FCR tendon. Distal pegs, introduced in the immediate subchondral plate of the distal fragment, fixed the distal fragment. The overall outcomes according to Gartland and Werley10 scales showed 19 excellent and 12 good results. Comparison of the clinical results with these 2 studies is shown in Table 2. There were no differences in the average grip strength between our cases and the 2 other studies. The average extension-flexion arc of the wrist in our patients was the smallest of the 3 studies. In the final outcome there were no fair or poor results in our patients; however, there were 4 fair results in the study by Constantine et al.1 As compared with the results from the study by Orbay and Fernandez,5 the percentage of good results was higher in our patients. The basic concept of fixation in the 2 previous studies was subchondral support. Distal pegs or screws introduced under the subchondral plate of the distal fragment support the distal fragment. To prevent loss of reduction the pegs or screws should be introduced as closely as possible to the subchondral plate. Although each peg is fixed at a different suitable angle according to the shape of the distal radius, it is not easy for all pegs to be introduced close to the subchondral plate. Especially in the plate used by Constantine et al1 (AO/ASIF titanium volar distal radius T plate [Synthes]), all screws are fixed at the same angle. Thus all screws are inserted in fixed
Skin Incision (cm)
The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Table 2. Comparison of Clinical Results
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Kamano et al / Palmar Plating System for Colles’ Fractures
directions and there is a possibility that some screws may be introduced into the radiocarpal joint when it is necessary for the plate to be situated distally. Recently a case was reported in which all the distal locking screws did cut through the subchondral bone and penetrated into the joint.8 As compared with the concept of subchondral support, our concept of fixation is subchondral fixation. By using a guidewire one can insert a cannulated screw into the subchondral bone correctly and easily. There is an extremely small possibility that a screw will be inserted into the radiocarpal joint. The plate we used is thin and small with adequate mechanical properties. One can cover the plate with the pronator quadratus, totally avoiding mechanical damage to the median nerve and the flexor tendons if the muscle is not damaged at the time of fracture. In our patients the muscle was injured partially in 7 of 16 patients with A3.2 fractures. Total coverage was impossible in only 2 patients. Compared with the surgical approaches previously reported1,5 our plating system is less invasive. Our plate system, however, has only 1 size and 2 variations for the right and left hand. Our plate is not indicated when a fracture extends to the proximal radius. Although having such limitations, the palmar plating system we developed makes fixation of the distal radius easy, safe, and effective in the treatment of unstable Colles’ fractures. This is a preliminary report, however, further investigation is necessary.
References 1. Constantine KJ, Clawson MC, Stern PJ. Volar neutralization plate fixation of dorsally displaced distal radius fractures. Orthopedics 2002;25:125–128. 2. Georgoulis A, Lais E, Hertel BP. Die volare Plattenosteo-
3.
4.
5.
6. 7.
8.
9.
10. 11. 12.
13.
14.
15.
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synthese bei der typischen und a typischen distalen Radiusfraktur. Akt Traumatol 1992;22:9 –14. Kamano M, Honda Y, Kazuki K, Yasuda M. Palmar plating for dorsally displaced fractures of the distal radius. Clin Orthop 2002;397:403– 408. Kamano M, Honda Y, Kazuki K, Yasudab M. Palmar plating with calcium phosphate bone cement for unstable Colles’ fractures. Clin Orthop 2003;416:285–290. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205–215. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5:103–112. Schutz M, Kolbeck S, Spranger A, Arndt-Kolbeck M, Haas NP. [Palmar plating with the locking compression plate for dorsally displaced fractures of the distal radius—first clinical experiences.] Zentralbl Chir 2003;128:997–1002. Sommer C, Babst R, Müller M, Hanson B. Locking compression plate loosening and plate breakage—a report of four cases. J Orthop Trauma 2004;18:571–577. Orthopaedic Trauma Association. Orthopaedic Trauma Association Fracture and Dislocation Compendium. J Orthop Trauma 1996;10(suppl 1):16 –30. Gartland JJ Jr, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg 1951;33A:805–907. Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures. J Bone Joint Surg 1975;57A:311–317. Carter PR, Frederick HA, Laseter GF. Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surg 1998;23A:300 –307. Kambouroglou GK, Axelrod TS. Complications of the AO/ ASIF titanium distal radius plate system ( plate) in internal fixation of the distal radius: a brief report. J Hand Surg 1998;23A:737–741. Lucas GL, Fejfar ST. Complications in internal fixation of the distal radius [letter to the editor]. J Hand Surg 1998;23A: 1117. Ring D, Jupiter JB, Brenwald J, Büchler U, Hastings H II. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 1997;22A:777–784.
Purpose: To present our results of the palmar plating system that we developed for the treatment of Colles’ fractures. Methods: By using the palmar plating system that we developed a consecutive series of 40 acute Colles’ fractures were treated surgically. There were 12 men and 28 women with a mean age of 57 years at the time of the injury (range, 25–90 y). All patients had internal fixation using the trans–flexor carpi radialis tendon approach. The system has 3 main features. First, the plate is small in size, being 1.1 mm in thickness and 47 mm in length. Only a 3- to 4-cm skin incision is required for application of the plate. Second, the screw is cannulated and cancellous in type, with a low-profile head. Subchondral screw fixation is achieved both easily and safely by using a guidewire. Third, the plate has a window through which injectable bone cement can be placed. Results: Union was achieved in all patients. The palmar tilt, radial inclination, radial length, and ulnar variance were maintained after surgery. According to the Gartland and Werley rating scale that was modified by Sarmiento there were 12 excellent and 28 good results. There were no extensor tendon injuries that could occur when the dorsal approach was used. Conclusions: This palmar plating system can make fixation of the distal radius easy, safe, and effective in the treatment of unstable Colles’ fractures. (J Hand Surg 2005;30A:750 –755. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Colles’ fracture, palmar plating, subchondral screw fixation.
Palmar plating has been accepted as one alternative for the treatment of an unstable Colles’ fracture.1–7 The first advantage of palmar plating is the avoidance of opening the extensor retinaculum with its potential for damage to the extensor tendons. The second
From the Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital, Osaka, Japan; the Department of Orthopaedic Surgery, Baba Memorial Hospital, Osaka, Japan; and the Department of Orthopaedic Surgery, Osaka City University Medical School, Osaka, Japan. Received for publication September 13, 2004; accepted in revised form February 8, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Masayuki Kamano, MD, PhD, Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital, Shibata 2-10-39, Kitaku, Osaka City 530-0012, Japan; e-mail: [email protected] Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A04-0016$30.00/0 doi:10.1016/j.jhsa.2005.02.009
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The Journal of Hand Surgery
advantage is that it is easy to reduce the palmar cortex anatomically under direct vision. We show that anatomic reduction of the palmar cortex prevents shortening of the distal radius using plates that are different from the plate reported here.3,4 In addition subchondral screw fixation of the distal fragment is necessary for maintaining anatomic reduction. To make subchondral screw fixation of the distal fragment secure, 3 or 4 cancellous screws should be inserted into the subchondral bone of the distal radius and the radial styloid process correctly. It is, however, technically demanding.3,4 In 2002 a fixed-angle internal device was provided to fix the distal fragment automatically.5 The basic concept of the fixation was subchondral support. Distal pegs introduced under the subchondral plate of the distal fragment support the distal fragment. To prevent loss of reduction pegs should be introduced as closely as possible
Kamano et al / Palmar Plating System for Colles’ Fractures
to the subchondral plate. Although each peg is fixed at different angles according to the shape of the distal radius, it is not easy for all pegs to be introduced close to the subchondral plate. In addition there is a possibility that some pegs may be introduced into the radiocarpal joint if the plate is situated distally near the wrist joint. In the other locking plate system1 all the distal screws are fixed at the same angle. This system also has the same technical difficulties as that previously mentioned. In addition a case in which all the distal screws cut through the subchondral bone and penetrated into the joint has been reported.8 In the current palmar plating system all screws are both cannulated and cancellous. Thus all the screws can be inserted easily into the subchondral bone using a guidewire at a maximum of 10° from the vertical of each screw hole in any direction. One can introduce 3 or 4 screws into the subchondral bone for fixing the distal fragment firmly. Our concept of fixation is subchondral fixation; this is the major difference from the 2 earlier-mentioned systems. In this article we describe a palmar plating system for Colles’ fractures and its clinical results.
Materials and Methods A consecutive series of 40 patients with acute Colles’ fractures were treated surgically by using our palmar plating system. There were 12 men and 28 women with a mean age of 57 years at the time of the injury (range, 25–90 y). The type of fracture was classified according to the AO/ASIF classification.9 There were 18 cases of A2.2, 16 of A3.2, 2 of C1.2, 3 of C2.1, and 1 of C3.1. Indications for surgery were failure of initial closed reduction in a cast. In all patients with type A fractures, more than 10° of the dorsal tilt remained because of comminution of the dorsal cortex after closed reduction. An intra-articular step-off of greater than 1 mm was also an indication for surgery. The follow-up period ranged from 12 to 14 months (mean, 12 mo) after surgery. Seventeen patients were more than 60 years of age. The cause of the fractures in the 17 elderly patients was a simple fall while walking. The causes of all fractures in the male patients were work- or sportsrelated accidents. In 20 patients the fracture affected their dominant hand. All fractures were closed. There were no patients presenting with median nerve symptoms before surgery.
Surgical Technique Under a brachial nerve block the palmar plating was performed through a trans–flexor carpi radialis (FCR) tendon approach. Only a 3- to 4-cm skin incision was
751
Figure 1. The palmar plate we developed. The maximum length is 47 mm, the width is 9 mm, and the thickness is 1.1 mm. All screw holes are shaped conically.
necessary along the tendon. After detachment of the pronator quadratus muscle from its radius insertion, with a 4- to 5-mm margin retained for later closure, good exposure for an anatomic reduction of the palmar cortex of the distal radius and for application of the plate was provided. In extra-articular fractures the anatomic reduction of the palmar cortex was obtained after the distal fragment was flexed. Temporary percutaneous fixation with K-wires was performed to maintain the reduction before plating. In intra-articular fractures manipulation under fluoroscopy was performed first. If anatomic reduction was obtained then temporary percutaneous fixation with K-wires was performed. There were no cases in which an additional dorsal skin incision was required to fix the die-punch fragment or other intra-articular fragments in the current study. The recently designed plate (Biotechni Co., Ltd., Ciotat, France) for the distal radius is made from titanium-6 aluminum-4 vanadium (Ti-6Al-4V) (Fig. 1). There is only 1 size with 2 types: one for the left and one for the right hand. The maximal length of the plate is 47 mm and the thickness is only 1.1 mm. The plate has 20° of palmar angulation and has 4 holes distally and 2 holes proximally. One of the proximal holes is oval in shape. Thus one can insert 1 or 2 screws through the hole. The plate has a triangular window between the proximal and distal holes. In 4 patients with severe osteoporosis a metaphyseal bone defect was found when performing reduction. Injectable calcium bone cement was used for bone grafting in the current study. A drill hole was made with a drill 2.5 mm in diameter within the window and injectable bone cement was instilled under fluoro-
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The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Figure 2. The cannulated cancellous screw we used. The head has 3 slots and has a low profile with a conically shaped design. The tip is round and self-tapping.
has been possible to design the head with a low profile. In addition the screw cannot be tightened if each nail of the driver is not placed in each slot. With the standard hexagonal socket head the socket may be destroyed when the screw is tightened if the screwdriver is not inserted into the hole correctly. The other feature of the screw is that it is cannulated so that the screws can be inserted correctly and safely by using a guidewire into the subchondral bone of the distal fragment. A 1.1-mm diameter guidewire can be introduced into the subchondral bone and the radial styloid process under fluoroscopy. Subchondral screw fixation is performed easily and accurately with safety (Fig. 3). Mechanical properties of the plate were tested using a tension-testing machine (SHIMADZ Co., Ltd., Kyoto, Japan). The mechanical properties of the Ti-6AL-4V plate are in accordance with the world mechanical standard ASTM F136-98.
Postoperative Management scopic control through the hole after the plating was completed. Both the screw hole and head are shaped conically and this allows for the screw to be inserted at a maximum of 10° from the vertical in any direction. The screws are self-tapped cancellous in type, with a low-profile head and a round tip for avoiding damage to soft tissues. The screw has a conically shaped head and 3 slots and a hole for a guidewire (Fig. 2). Because the socket head is not hexagonal, it
A bandage was required for postoperative immobilization for 7 to 10 days after surgery. Active exercises of the finger and the wrist were commenced on the day after surgery.
Radiographic Examination and Clinical Evaluation The palmar tilt, radial inclination, and radial length were measured radiographically 3 times: before sur-
Figure 3. A C1.2 fracture in a 28-year-old woman. (A) Posteroanterior and (B) lateral radiographs after plating. Four screws were inserted into the radial styloid and the subchondral bone of the distal fragment. Subchondral fixation was obtained.
Kamano et al / Palmar Plating System for Colles’ Fractures
753
Table 1. Radiographic Parameter Palmar tilting angle (°)
Before Surgery
After Surgery
⫺21.4 ⫾ 11.1
8.4 ⫾ 4.2
p value Radial inclination (°)
p ⬍ .001
15 ⫾ 4.8
p value Radial length (mm) p value
Final Follow-Up Evaluation 7.4 ⫾ 4 ND
22 ⫾ 3.3 p ⬍ .001
4.9 ⫾ 2
21 ⫾ 2.8 ND
9.9 ⫾ 2.9 p ⬍ .001
Ulnar variance (mm)
9.5 ⫾ 3.0 ND
0.6 ⫾ 1.5
p value
1.1 ⫾ 1.5 ND
Mean ⫾ SD. ND, no difference.
gery, immediately after surgery, and at the final follow-up evaluation. The ulnar variance was measured 2 times: immediately after surgery and at the final follow-up evaluation. The paired Student t test was used to compare each radiographic parameter. Subjective and objective data were graded by using the demerit point system of Gartland and Werley,10 which has been modified by Sarmiento et al.11 At the final follow-up evaluation each extensor tendon was checked clinically. Any other clinical signs of problems relating to our surgical approach were also reviewed at the final examination. All surgeries were performed by 2 of the authors (M.T., M.K.). Each radiographic parameter was measured by a physician who also performed the clinical evaluation (M.K.).
of 35° to 57°, 16° radial deviation (86% of the opposite side) with a range of 12° to 20°, 29° ulnar deviation (88% of opposite side) with a range of 15° to 35°, 80° pronation (90% of the opposite side) with a range of 70° to 90°, and 80° supination (90% of opposite side) with a range of 70° to 97°. At the final follow-up evaluation none of the patients had clinical evidence of damage to the extensor tendons. There were no injuries to the radial artery or to the median nerve. There were no symptoms caused by to the trans-FCR approach. One patient developed a chronic regional pain syndrome. Early recognition of the syndrome and oral medication resulted in resolution. One patient with diabetes had a mild skin infection that resolved with antibiotics.
Results
Discussion
Bony union was achieved in all patients. There was no statistical significance between each parameter immediately after surgery and at the final follow-up evaluation. All radiographic parameters are shown in Table 1 According to the modified Gartland and Werley10 rating scale there were 12 excellent and 28 good results. The mean grip strength recovered 78% (range, 60%–100%) as compared with the opposite side. The wrist range of motion was assessed with a goniometer at the final follow-up evaluation and averaged 57° extension (88% as compared with the opposite side) with a range of 45° to 65°, 48° flexion (79% compared with the opposite side) with a range
The first report concerning palmar plating for Colles’ fractures was by Georgoulis et al2 in German in 1992. In the English literature Orbay6 first mentioned the safety and the effectiveness of volar plating for unstable Colles’ fractures in 2000. Subsequently several investigators have reported palmar plating for dorsally displaced fractures of the distal radius.1–7 The great advantage of palmar plating is its simplicity and safety in approaching the distal radius. Difficulties with the dorsal approach and dorsal plating have discouraged surgeons from internal fixation. The most serious complication of dorsal plating is extensor tendon rupture. Several investigators have
8–10 3–4 0 0 12 28 19 12 79 78 27 29 17 16 57 48 59 57 21 22 5 8
— 9.9
8–10 4 8 8 78 — — 62
Flexion Extension
61 12 23 0
Ulnar Deviation Radial Deviation Radial Length (mm) Radial Inclination (°) Palmar Tilt (°) Reporter
Constantine et al (20 patients) Orbay and 5 Fernandez (31 patients) Kamano (40 patients)
Fair Good Excellent
Modified Gartland and 10 Werley (No. of Cases)
Grip Strength Compared With Opposite Side (%) Final Wrist Motion (° Average) Radiographic Parameter (Average)
reported this complication when using dorsal plating.12–15 In the treatment of dorsally displaced fractures with palmar plating a buttress effect cannot be expected. To prevent loss of reduction or to minimize it, a fixed-angle screw-and-plate system was developed that involves an AO/ASIF titanium volar distal radius T plate (Synthes, Paoli, PA). All distal screws have a fixed angle for supporting the subchondral plate of the distal fragment. Constantine et al1 reported the clinical results of the plate in 2002. They treated 20 cases (AO type A, 4 cases; type C, 16 cases) of unstable dorsally displaced fractures of the distal radius by using a volar Henry approach. An 8to 10-cm skin incision was made in line with the radial border of the FCR tendon. There were 8 excellent, 8 good, and 4 fair results using the modified Gartland and Werley9 scale. Orbay and Fernandez5 also used a fixed-angle internal device (DVR Plate; Hand Innovation, Miami, FL) and reported their results in 2002. They treated 31 dorsally displaced unstable fractures of the distal radius using the extended FCR approach. An 8to 10-cm skin incision was made over the FCR tendon. Distal pegs, introduced in the immediate subchondral plate of the distal fragment, fixed the distal fragment. The overall outcomes according to Gartland and Werley10 scales showed 19 excellent and 12 good results. Comparison of the clinical results with these 2 studies is shown in Table 2. There were no differences in the average grip strength between our cases and the 2 other studies. The average extension-flexion arc of the wrist in our patients was the smallest of the 3 studies. In the final outcome there were no fair or poor results in our patients; however, there were 4 fair results in the study by Constantine et al.1 As compared with the results from the study by Orbay and Fernandez,5 the percentage of good results was higher in our patients. The basic concept of fixation in the 2 previous studies was subchondral support. Distal pegs or screws introduced under the subchondral plate of the distal fragment support the distal fragment. To prevent loss of reduction the pegs or screws should be introduced as closely as possible to the subchondral plate. Although each peg is fixed at a different suitable angle according to the shape of the distal radius, it is not easy for all pegs to be introduced close to the subchondral plate. Especially in the plate used by Constantine et al1 (AO/ASIF titanium volar distal radius T plate [Synthes]), all screws are fixed at the same angle. Thus all screws are inserted in fixed
Skin Incision (cm)
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Table 2. Comparison of Clinical Results
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directions and there is a possibility that some screws may be introduced into the radiocarpal joint when it is necessary for the plate to be situated distally. Recently a case was reported in which all the distal locking screws did cut through the subchondral bone and penetrated into the joint.8 As compared with the concept of subchondral support, our concept of fixation is subchondral fixation. By using a guidewire one can insert a cannulated screw into the subchondral bone correctly and easily. There is an extremely small possibility that a screw will be inserted into the radiocarpal joint. The plate we used is thin and small with adequate mechanical properties. One can cover the plate with the pronator quadratus, totally avoiding mechanical damage to the median nerve and the flexor tendons if the muscle is not damaged at the time of fracture. In our patients the muscle was injured partially in 7 of 16 patients with A3.2 fractures. Total coverage was impossible in only 2 patients. Compared with the surgical approaches previously reported1,5 our plating system is less invasive. Our plate system, however, has only 1 size and 2 variations for the right and left hand. Our plate is not indicated when a fracture extends to the proximal radius. Although having such limitations, the palmar plating system we developed makes fixation of the distal radius easy, safe, and effective in the treatment of unstable Colles’ fractures. This is a preliminary report, however, further investigation is necessary.
References 1. Constantine KJ, Clawson MC, Stern PJ. Volar neutralization plate fixation of dorsally displaced distal radius fractures. Orthopedics 2002;25:125–128. 2. Georgoulis A, Lais E, Hertel BP. Die volare Plattenosteo-
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synthese bei der typischen und a typischen distalen Radiusfraktur. Akt Traumatol 1992;22:9 –14. Kamano M, Honda Y, Kazuki K, Yasuda M. Palmar plating for dorsally displaced fractures of the distal radius. Clin Orthop 2002;397:403– 408. Kamano M, Honda Y, Kazuki K, Yasudab M. Palmar plating with calcium phosphate bone cement for unstable Colles’ fractures. Clin Orthop 2003;416:285–290. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205–215. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5:103–112. Schutz M, Kolbeck S, Spranger A, Arndt-Kolbeck M, Haas NP. [Palmar plating with the locking compression plate for dorsally displaced fractures of the distal radius—first clinical experiences.] Zentralbl Chir 2003;128:997–1002. Sommer C, Babst R, Müller M, Hanson B. Locking compression plate loosening and plate breakage—a report of four cases. J Orthop Trauma 2004;18:571–577. Orthopaedic Trauma Association. Orthopaedic Trauma Association Fracture and Dislocation Compendium. J Orthop Trauma 1996;10(suppl 1):16 –30. Gartland JJ Jr, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg 1951;33A:805–907. Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures. J Bone Joint Surg 1975;57A:311–317. Carter PR, Frederick HA, Laseter GF. Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surg 1998;23A:300 –307. Kambouroglou GK, Axelrod TS. Complications of the AO/ ASIF titanium distal radius plate system ( plate) in internal fixation of the distal radius: a brief report. J Hand Surg 1998;23A:737–741. Lucas GL, Fejfar ST. Complications in internal fixation of the distal radius [letter to the editor]. J Hand Surg 1998;23A: 1117. Ring D, Jupiter JB, Brenwald J, Büchler U, Hastings H II. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 1997;22A:777–784.