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Repair of Pronator Quadratus With Partial Muscle Split and Distal Transfer for Volar Plating of Distal Radius Fractures
SURGICAL TECHNIQUE
Repair of Pronator Quadratus With Partial Muscle Split and Distal Transfer for Volar Plating of Distal Radius Fractures Hui-Kuang Huang, MD,*†‡§ Jung-Pan Wang, MD, PhD,*† Ming-Chau Chang, MD*† Flexor tendon injury is a rare, but serious, complication after volar plate fixation for distal radius fractures. The plate position and prominence at the watershed line are contributing factors that cause flexor tendon injury. With the standard volar approach, the pronator quadratus (PQ) is typically elevated off the radial attachment. The distal part of the plate is often visible after repair of the PQ. We describe a “PQ-splitting” technique for covering the distal edge of the plate if primary PQ repair cannot completely cover the distal part of the plate. We also report the outcome of our series. This method can potentially prevent direct gliding of flexor tendons on the distal part of the plate and prevent flexor tendon attrition on the plate prominence. (J Hand Surg Am. 2017;42(11):935.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal radius fracture, flexor tendon rupture, pronator quadratus, tendon attrition, volar plate.
F
are commonly encountered in clinical practice, and volar plate fixation for these fractures is frequently used. Flexor tendon injury is a rare, but serious complication, after volar plate fixation. Soong et al1 and Kitay et al2 have proposed that the plate position and prominence at the watershed line is a contributing factor that causes flexor tendon injury. With the standard volar approach, the pronator quadratus (PQ) is typically elevated off the radial attachment to RACTURES OF THE DISTAL RADIUS
From the *Department of Surgery, School of Medicine, National Yang-Ming University; the †Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei; the ‡Department of Orthopaedics, Chiayi Christian Hospital, Chiayi; and the §Chung Hwa University of Medical Technology, Tainan, Taiwan. Received for publication July 27, 2016; accepted in revised form August 20, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jung-Pan Wang, MD, PhD, Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd., Taipei 112, Taiwan; e-mail: [email protected]. 0363-5023/17/4211-0022$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.08.018
facilitate plate fixation. Plate irritation of the flexor tendons is a problem, no matter what type of volar plates are used. A PQ repair is suggested by some authors to provide potential shielding between the flexor tendons and the plate, although no comparative studies have shown lower rates of flexor tendon rupture after repair.3 The PQ-sparing method is also preferred by some surgeons to minimize dissection and preserve more of the PQ function.4,5 However, in both PQ elevation/repair and the sparing method, the distal part of the plate frequently cannot be covered by the PQ if the plate has to be placed more distally to improve the fixation. The flexor tendons will glide on the distal prominent part of the plate, which could possibly lead to tendon attrition or rupture. Usage of the PQ to cover the distal part of the plate during repair may be a reasonable way to protect the flexor tendons if the plate position and prominence cannot be changed. We report a “PQ-splitting” technique for covering the distal prominent part of the plate to provide a potentially protective effect if the plate has to be applied more distally on the watershed line to improve the fixation.
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
935.e1
935.e2
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
FIGURE 1: The PQ is pulled gently to evaluate the possiblity of advancement and covering the distal part of the plate.
INDICATIONS Distal radius fractures treated with volar plate osteosynthesis via the standard volar Henry approach with PQ elevation off the radial attachment. CONTRAINDICATIONS 1. Patients with impaired function of the pronator teres muscle or if the pronator teres muscle has been used for tendon transfer. 2. Distal radius and ulna fractures treated with volar plate osteosynthesis for both fractures. 3. The PQ is severely damaged. SURGICAL TECHNIQUE Under general anesthesia, all patients are placed in the supine position and a radiolucent hand table is used. The arm pneumatic tourniquet is used for all patients. The incision is made radial to the flexor carpi radialis, going through the interval of the flexor carpi radialis and the radial artery. The PQ is elevated off its radial attachment. Elevating the PQ using a piece of the distal radial-sided fibrous attachment of the PQ, if possible, facilitates suture holding if PQ repair is planned after osteosynthesis. Then the fracture reduction and volar plate osteosynthesis is performed. After osteosynthesis is done, the PQ can be gently pulled radially and distally by grasping with the tissue forceps (Fig. 1). If the PQ can cover the distal part of the plate, then we just suture the PQ along the radial aspect to cover the distal part of the plate. If the distal part of the plate cannot be covered, then PQ splitting is performed. We split the distal PQ to make an 8- to 10-mm muscle flap that can be easily pulled distally and radially to cover the distal part of the plate (Figs. 2, 3). If the coverage is not satisfactory, more elevation of the distal PQ muscle flap off the interosseous J Hand Surg Am.
r
FIGURE 2: Illustration of PQ split.
membrane by using the elevator is done to achieve total coverage of the distal part of the plate. The distal PQ flap can then be advanced distally and radially and sutured to the border of brachioradialis tendon (Figs. 4, 5). The PQ proximal to the split can be repaired to the previous attachment as best possible. POSTOPERATIVE MANAGEMENT We apply a below-elbow orthosis with the wrist in neutral position for 2 weeks. Weight-bearing forearm rotation exercises are restricted until external bridging of callus across the fracture lines is noted. PEARLS AND PITFALLS 1. Utilizing coagulation cautery in splitting the PQ facilitates hemostasis of the dissected small intramuscular vessels. 2. In our experience, elevating the distal PQ muscle flap up to the radial border of the ulna is often Vol. 42, November 2017
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
935.e3
FIGURE 5: Good coverage of the distal part of the plate and the repaired proximal PQ.
FIGURE 3: The PQ is split and the distal part of the muscle flap is transferred to cover the distal part of the plate.
sufficient for complete coverage of the distal part of the plate. 3. Maintain intact fascia on the PQ flap to facilitate the holding power of suture repair. Also, elevation of part of the distal and radial-sided fascia/periosteum connecting to the PQ is better for sutureholding and repair. 4. In our experience, if less than 1 cm length of the distal plate is revealed through traction by pulling on the PQ muscle, the split distal PQ muscle flap will easily be able to cover the distal part of the plate. POSTOPERATIVE ASSESSMENT Follow-up is done every 2 weeks for the first month after surgery and once every month thereafter until 3 months after fracture healing. Functional outcomes were evaluated at the time of follow-up. Functional evaluation included the visual analog scale for pain (0, no pain; 10, worst pain) during activity and active range of motion. The shortened Disabilities of the Arm, Shoulder, and Hand questionnaire and the Mayo Wrist Score were used for functional evaluation.6,7 All patients had a final follow-up by telephone for evaluation of level of activity and complications. RESULTS AND COMPLICATIONS There were no complications. All 64 patients had uneventful union with the presence of bridging callus within 8 weeks after the surgery.8,9 In the final telephone follow-up at a mean of 24 months (range, 12e38 months), there were no flexor tendon
FIGURE 4: Illustration of PQ flap distal advancing transfer.
J Hand Surg Am.
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ruptures and all patients were able to return to their previous full level of activity with no or mild pain. The pain, functional outcomes, and range of motion continued to improve from the 3- to 12-month periods. DISCUSSION Surgeons may desire to repair the PQ when using the volar approach for distal radius fractures osteosynthesis if the PQ is elevated, but the distal part of the plate is often left uncovered after the repair. We perform a partial PQ split based on the reported technique of PQ pedicled vascularized bone graft in treating scaphoid nonunion.10,11 In the procedure, pedicled PQ vascularized bone graft is transferred to the scaphoid, and the distal part of the pedicled PQ flap can reach far to the nonunion site of the scaphoid and still maintain the circulation. With the same method, it would be easier to just reach the distal part of the radius to cover the distal part of the plate and still maintain the circulation to keep the viability of the split PQ flap. Also with this method of partial PQ splitting and distal advancing transfer in treating scaphoid nonunion, wrist and hand function is not impaired.12e14 Haberle et al15 reported a prospective randomized trial showing no significant difference in pronation strength and function in groups with or without PQ repair after volar plating of distal radius fractures. The PQ repair might improve pain and recovery of function in the early postoperative period, but in the long term, the improvement may not be significant.16 Nevertheless, repair of the PQ as much as possible is still suggested.16e20 Also, partial wrist denervation by neurectomy of the anterior and posterior interosseous nerve can provide pain relief for the wrist, and wrist and hand functioning would not be impaired.21 The PQ split method would be possible to have neurectomy of some distal branches of the anterior interosseous nerve because part of the PQ muscle is transversely divided. There may be a benefit on pain improvement after neurectomy and PQ repair and function is not impaired. Hohendorff et al22 reported a method of PQ elevation with a part of a fibrous portion of the roof of the first extensor compartment and the palmar limb of the brachioradialis tendon insertion that can adequately cover the distal part of the palmar plate without volar subluxation of the tendons in the first extensor compartment.23 But in cases in which part of
J Hand Surg Am.
r
the distal PQ was damaged from the trauma, and for some surgeons who prefer to use the PQ-elevating method, the PQ-splitting method can be a choice if there are difficulties in simply advancing PQ to cover the distal part of the plate. REFERENCES 1. 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(4):328e335. 2. Kitay A, Swanstrom M, Schreiber JJ, et al. Volar plate position and flexor tendon rupture following distal radius fracture fixation. J Hand Surg Am. 2013;38(6):1091e1096. 3. Tahririan MA, Javdan M, Motififard M. Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures. Indian J Orthop. 2014;48(4):399e403. 4. 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(1):2e6. 5. 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 [in French]. Chir Main. 2009;28(4):224e229. 6. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire: validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44. 7. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP III, Linscheid RL. Scaphoid malunion. J Hand Surg Am. 1989;14(4): 679e687. 8. Duwelius PJ, Schmidt AH, Rubinstein RA, Green JM. Nonreamed interlocked intramedullary tibial nailing. One community’s experience. Clin Orthop Relat Res. 1995;315:104e113. 9. Panjabi MM, Walter SD, Karuda M, White AA, Lawson JP. Correlations of radiographic analysis of healing fractures with strength: a statistical analysis of experimental osteotomies. J Orthop Res. 1985;3(2):212e218. 10. Braun RM. Proximal pedicle bone grafting in the forearm and proximal carpal row. Orthop Trans. 1983;7:35. 11. Lee JC, Lim J, Chacha PB. The anatomical basis of the vascularized pronator quadratus pedicled bone graft. J Hand Surg Br. 1997;22(5): 644e646. 12. Pistre V, Reau AF, Pelissier P, Martin D, Baudet J. Vascularized bone pedicle grafts of the hand and wrist: literature review and new donor sites [in French]. Chir Main. 2001;20(4): 263e271. 13. Noaman HH, Shiha AE, Ibrahim AK. Functional outcomes of nonunion scaphoid fracture treated by pronator quadratus pedicled bone graft. Ann Plast Surg. 2011;66(1):47e52. 14. Lee SK, Park JS, Choy WS. Scaphoid fracture nonunion treated with pronator quadratus pedicled vascularized bone graft and headless compression screw. Ann Plast Surg. 2015;74(6): 665e671. 15. Haberle S, Sandmann GH, Deiler S, et al. Pronator quadratus repair after volar plating of distal radius fractures or not? Results of a prospective randomized trial. Eur J Med Res. 2015;20:93. 16. Tosti R, Ilyas AM. Prospective evaluation of pronator quadratus repair following volar plate fixation of distal radius fractures. J Hand Surg Am. 2013;38(9):1678e1684. 17. Fan J, Chen K, Zhu H, et al. Effect of fixing distal radius fracture with volar locking palmar plates while preserving pronator quadratus. Chin Med J (Engl). 2014;127(16):2929e2933.
Vol. 42, November 2017
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
18. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol KA. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures. J Orthop Trauma. 2013;27(3):130e133. 19. Nho JH, Gong HS, Song CH, Wi SM, Lee YH, Baek GH. Examination of the pronator quadratus muscle during hardware removal procedures after volar plating for distal radius fractures. Clin Orthop Surg. 2014;6(3):267e272. 20. Ahsan ZS, Yao J. The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating. Hand (N Y). 2012;7(3):276e280.
J Hand Surg Am.
r
935.e5
21. Weinstein LP, Berger RA. Analgesic benefit, functional outcome, and patient satisfaction after partial wrist denervation. J Hand Surg Am. 2002;27(5):833e839. 22. Hohendorff B, Surberg D, Maier J, Burkhart KJ, Muller LP, Ries C. Repair of the pronator quadratus muscle with a part of the brachioradialis muscle insertion [in German]. Handchir Mikrochir Plast Chir. 2015;47(3):149e154. 23. White GM, Weiland AJ. Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease: a case report. J Hand Surg Am. 1984;9(5):704e706.
Vol. 42, November 2017
Repair of Pronator Quadratus With Partial Muscle Split and Distal Transfer for Volar Plating of Distal Radius Fractures Hui-Kuang Huang, MD,*†‡§ Jung-Pan Wang, MD, PhD,*† Ming-Chau Chang, MD*† Flexor tendon injury is a rare, but serious, complication after volar plate fixation for distal radius fractures. The plate position and prominence at the watershed line are contributing factors that cause flexor tendon injury. With the standard volar approach, the pronator quadratus (PQ) is typically elevated off the radial attachment. The distal part of the plate is often visible after repair of the PQ. We describe a “PQ-splitting” technique for covering the distal edge of the plate if primary PQ repair cannot completely cover the distal part of the plate. We also report the outcome of our series. This method can potentially prevent direct gliding of flexor tendons on the distal part of the plate and prevent flexor tendon attrition on the plate prominence. (J Hand Surg Am. 2017;42(11):935.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal radius fracture, flexor tendon rupture, pronator quadratus, tendon attrition, volar plate.
F
are commonly encountered in clinical practice, and volar plate fixation for these fractures is frequently used. Flexor tendon injury is a rare, but serious complication, after volar plate fixation. Soong et al1 and Kitay et al2 have proposed that the plate position and prominence at the watershed line is a contributing factor that causes flexor tendon injury. With the standard volar approach, the pronator quadratus (PQ) is typically elevated off the radial attachment to RACTURES OF THE DISTAL RADIUS
From the *Department of Surgery, School of Medicine, National Yang-Ming University; the †Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei; the ‡Department of Orthopaedics, Chiayi Christian Hospital, Chiayi; and the §Chung Hwa University of Medical Technology, Tainan, Taiwan. Received for publication July 27, 2016; accepted in revised form August 20, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jung-Pan Wang, MD, PhD, Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd., Taipei 112, Taiwan; e-mail: [email protected]. 0363-5023/17/4211-0022$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.08.018
facilitate plate fixation. Plate irritation of the flexor tendons is a problem, no matter what type of volar plates are used. A PQ repair is suggested by some authors to provide potential shielding between the flexor tendons and the plate, although no comparative studies have shown lower rates of flexor tendon rupture after repair.3 The PQ-sparing method is also preferred by some surgeons to minimize dissection and preserve more of the PQ function.4,5 However, in both PQ elevation/repair and the sparing method, the distal part of the plate frequently cannot be covered by the PQ if the plate has to be placed more distally to improve the fixation. The flexor tendons will glide on the distal prominent part of the plate, which could possibly lead to tendon attrition or rupture. Usage of the PQ to cover the distal part of the plate during repair may be a reasonable way to protect the flexor tendons if the plate position and prominence cannot be changed. We report a “PQ-splitting” technique for covering the distal prominent part of the plate to provide a potentially protective effect if the plate has to be applied more distally on the watershed line to improve the fixation.
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
935.e1
935.e2
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
FIGURE 1: The PQ is pulled gently to evaluate the possiblity of advancement and covering the distal part of the plate.
INDICATIONS Distal radius fractures treated with volar plate osteosynthesis via the standard volar Henry approach with PQ elevation off the radial attachment. CONTRAINDICATIONS 1. Patients with impaired function of the pronator teres muscle or if the pronator teres muscle has been used for tendon transfer. 2. Distal radius and ulna fractures treated with volar plate osteosynthesis for both fractures. 3. The PQ is severely damaged. SURGICAL TECHNIQUE Under general anesthesia, all patients are placed in the supine position and a radiolucent hand table is used. The arm pneumatic tourniquet is used for all patients. The incision is made radial to the flexor carpi radialis, going through the interval of the flexor carpi radialis and the radial artery. The PQ is elevated off its radial attachment. Elevating the PQ using a piece of the distal radial-sided fibrous attachment of the PQ, if possible, facilitates suture holding if PQ repair is planned after osteosynthesis. Then the fracture reduction and volar plate osteosynthesis is performed. After osteosynthesis is done, the PQ can be gently pulled radially and distally by grasping with the tissue forceps (Fig. 1). If the PQ can cover the distal part of the plate, then we just suture the PQ along the radial aspect to cover the distal part of the plate. If the distal part of the plate cannot be covered, then PQ splitting is performed. We split the distal PQ to make an 8- to 10-mm muscle flap that can be easily pulled distally and radially to cover the distal part of the plate (Figs. 2, 3). If the coverage is not satisfactory, more elevation of the distal PQ muscle flap off the interosseous J Hand Surg Am.
r
FIGURE 2: Illustration of PQ split.
membrane by using the elevator is done to achieve total coverage of the distal part of the plate. The distal PQ flap can then be advanced distally and radially and sutured to the border of brachioradialis tendon (Figs. 4, 5). The PQ proximal to the split can be repaired to the previous attachment as best possible. POSTOPERATIVE MANAGEMENT We apply a below-elbow orthosis with the wrist in neutral position for 2 weeks. Weight-bearing forearm rotation exercises are restricted until external bridging of callus across the fracture lines is noted. PEARLS AND PITFALLS 1. Utilizing coagulation cautery in splitting the PQ facilitates hemostasis of the dissected small intramuscular vessels. 2. In our experience, elevating the distal PQ muscle flap up to the radial border of the ulna is often Vol. 42, November 2017
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
935.e3
FIGURE 5: Good coverage of the distal part of the plate and the repaired proximal PQ.
FIGURE 3: The PQ is split and the distal part of the muscle flap is transferred to cover the distal part of the plate.
sufficient for complete coverage of the distal part of the plate. 3. Maintain intact fascia on the PQ flap to facilitate the holding power of suture repair. Also, elevation of part of the distal and radial-sided fascia/periosteum connecting to the PQ is better for sutureholding and repair. 4. In our experience, if less than 1 cm length of the distal plate is revealed through traction by pulling on the PQ muscle, the split distal PQ muscle flap will easily be able to cover the distal part of the plate. POSTOPERATIVE ASSESSMENT Follow-up is done every 2 weeks for the first month after surgery and once every month thereafter until 3 months after fracture healing. Functional outcomes were evaluated at the time of follow-up. Functional evaluation included the visual analog scale for pain (0, no pain; 10, worst pain) during activity and active range of motion. The shortened Disabilities of the Arm, Shoulder, and Hand questionnaire and the Mayo Wrist Score were used for functional evaluation.6,7 All patients had a final follow-up by telephone for evaluation of level of activity and complications. RESULTS AND COMPLICATIONS There were no complications. All 64 patients had uneventful union with the presence of bridging callus within 8 weeks after the surgery.8,9 In the final telephone follow-up at a mean of 24 months (range, 12e38 months), there were no flexor tendon
FIGURE 4: Illustration of PQ flap distal advancing transfer.
J Hand Surg Am.
r
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935.e4
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
ruptures and all patients were able to return to their previous full level of activity with no or mild pain. The pain, functional outcomes, and range of motion continued to improve from the 3- to 12-month periods. DISCUSSION Surgeons may desire to repair the PQ when using the volar approach for distal radius fractures osteosynthesis if the PQ is elevated, but the distal part of the plate is often left uncovered after the repair. We perform a partial PQ split based on the reported technique of PQ pedicled vascularized bone graft in treating scaphoid nonunion.10,11 In the procedure, pedicled PQ vascularized bone graft is transferred to the scaphoid, and the distal part of the pedicled PQ flap can reach far to the nonunion site of the scaphoid and still maintain the circulation. With the same method, it would be easier to just reach the distal part of the radius to cover the distal part of the plate and still maintain the circulation to keep the viability of the split PQ flap. Also with this method of partial PQ splitting and distal advancing transfer in treating scaphoid nonunion, wrist and hand function is not impaired.12e14 Haberle et al15 reported a prospective randomized trial showing no significant difference in pronation strength and function in groups with or without PQ repair after volar plating of distal radius fractures. The PQ repair might improve pain and recovery of function in the early postoperative period, but in the long term, the improvement may not be significant.16 Nevertheless, repair of the PQ as much as possible is still suggested.16e20 Also, partial wrist denervation by neurectomy of the anterior and posterior interosseous nerve can provide pain relief for the wrist, and wrist and hand functioning would not be impaired.21 The PQ split method would be possible to have neurectomy of some distal branches of the anterior interosseous nerve because part of the PQ muscle is transversely divided. There may be a benefit on pain improvement after neurectomy and PQ repair and function is not impaired. Hohendorff et al22 reported a method of PQ elevation with a part of a fibrous portion of the roof of the first extensor compartment and the palmar limb of the brachioradialis tendon insertion that can adequately cover the distal part of the palmar plate without volar subluxation of the tendons in the first extensor compartment.23 But in cases in which part of
J Hand Surg Am.
r
the distal PQ was damaged from the trauma, and for some surgeons who prefer to use the PQ-elevating method, the PQ-splitting method can be a choice if there are difficulties in simply advancing PQ to cover the distal part of the plate. REFERENCES 1. 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(4):328e335. 2. Kitay A, Swanstrom M, Schreiber JJ, et al. Volar plate position and flexor tendon rupture following distal radius fracture fixation. J Hand Surg Am. 2013;38(6):1091e1096. 3. Tahririan MA, Javdan M, Motififard M. Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures. Indian J Orthop. 2014;48(4):399e403. 4. 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(1):2e6. 5. 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 [in French]. Chir Main. 2009;28(4):224e229. 6. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire: validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44. 7. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP III, Linscheid RL. Scaphoid malunion. J Hand Surg Am. 1989;14(4): 679e687. 8. Duwelius PJ, Schmidt AH, Rubinstein RA, Green JM. Nonreamed interlocked intramedullary tibial nailing. One community’s experience. Clin Orthop Relat Res. 1995;315:104e113. 9. Panjabi MM, Walter SD, Karuda M, White AA, Lawson JP. Correlations of radiographic analysis of healing fractures with strength: a statistical analysis of experimental osteotomies. J Orthop Res. 1985;3(2):212e218. 10. Braun RM. Proximal pedicle bone grafting in the forearm and proximal carpal row. Orthop Trans. 1983;7:35. 11. Lee JC, Lim J, Chacha PB. The anatomical basis of the vascularized pronator quadratus pedicled bone graft. J Hand Surg Br. 1997;22(5): 644e646. 12. Pistre V, Reau AF, Pelissier P, Martin D, Baudet J. Vascularized bone pedicle grafts of the hand and wrist: literature review and new donor sites [in French]. Chir Main. 2001;20(4): 263e271. 13. Noaman HH, Shiha AE, Ibrahim AK. Functional outcomes of nonunion scaphoid fracture treated by pronator quadratus pedicled bone graft. Ann Plast Surg. 2011;66(1):47e52. 14. Lee SK, Park JS, Choy WS. Scaphoid fracture nonunion treated with pronator quadratus pedicled vascularized bone graft and headless compression screw. Ann Plast Surg. 2015;74(6): 665e671. 15. Haberle S, Sandmann GH, Deiler S, et al. Pronator quadratus repair after volar plating of distal radius fractures or not? Results of a prospective randomized trial. Eur J Med Res. 2015;20:93. 16. Tosti R, Ilyas AM. Prospective evaluation of pronator quadratus repair following volar plate fixation of distal radius fractures. J Hand Surg Am. 2013;38(9):1678e1684. 17. Fan J, Chen K, Zhu H, et al. Effect of fixing distal radius fracture with volar locking palmar plates while preserving pronator quadratus. Chin Med J (Engl). 2014;127(16):2929e2933.
Vol. 42, November 2017
PQ SPLIT FOR COVERAGE OF DISTAL VOLAR PLATE
18. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol KA. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures. J Orthop Trauma. 2013;27(3):130e133. 19. Nho JH, Gong HS, Song CH, Wi SM, Lee YH, Baek GH. Examination of the pronator quadratus muscle during hardware removal procedures after volar plating for distal radius fractures. Clin Orthop Surg. 2014;6(3):267e272. 20. Ahsan ZS, Yao J. The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating. Hand (N Y). 2012;7(3):276e280.
J Hand Surg Am.
r
935.e5
21. Weinstein LP, Berger RA. Analgesic benefit, functional outcome, and patient satisfaction after partial wrist denervation. J Hand Surg Am. 2002;27(5):833e839. 22. Hohendorff B, Surberg D, Maier J, Burkhart KJ, Muller LP, Ries C. Repair of the pronator quadratus muscle with a part of the brachioradialis muscle insertion [in German]. Handchir Mikrochir Plast Chir. 2015;47(3):149e154. 23. White GM, Weiland AJ. Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease: a case report. J Hand Surg Am. 1984;9(5):704e706.
Vol. 42, November 2017