Volar plating in DER

1. Volar Plate Fixation of a
Distal Radius Fracture
Prepared by Dr Madan Mohan
Based on
Orthop Clin N Am 47 (2016) 235–244

2. •When surgery is indicated to treat distal
radius fractures, volar locked plates have
recently become the treatment of
choice.
•This procedure was first introduced by
Orbay and Fernandez in 2002.

3. Advantages
The purported advantages of volar locked plates include
• A stable periarticular reduction affording earlier return to function,
• A decreased need for postoperative immobilization,
• A consistent surgical approach, and
• A hardware complication profile relative to late tendon injury that can
be minimized with thoughtful screw and plate positioning

4. Goals of Treatment
• Volar tilt (11 degrees +/- 5 degrees)
• Radial height (14 +/- 1 mm)
• Radial inclination (22 degrees +/- 3 degrees)
• Ulnar variance (0.7 +/- 1.5 mm)
• Articular step-off (<2 mm )

5. Method of measuring
the radiographic
parameters of the
distal radius
fractures. (A) Volar
tilt (VT). (B)
Radial height (RH). (C)
Radial inclination (RI).
(D) Ulnar variance
(UV).

6. Concept of Volar Locked Plate
• The volar locked plate was intended to serve as a fixed-angle
buttressing construct for the subchondral surface of the distal radius
using a more generous soft tissue envelope provided by the volar side
of the distal forearm
• Initial designs included only 4 screws or pegs in the distal row, which
were designed to capture the radial styloid, the central articular
surface, and the volar-ulnar corner of the distal radius

7. Variable-angle locked plates afford more flexibility in
both plate positioning as well as subchondral screw
positioning

8. The Importance of Maintaining Reduction
• Persistent radial shortening and/or distal radioulnar joint (DRUJ)
incongruency has been shown to be a troublesome problem
• Common sequelae include altered carpal kinematics, Keinbock
disease, scapholunate instability, and ulnar impaction
• An additional concern with altered kinematics with distal radius
fractures is the high incidence of primary and secondary TFCC tears,
which have been reported to be as high as 45% to 57% after a distal
radius fracture

9. Potential Factors Influencing Reduction Maintenance
• A screw length greater than 75% of the bicortical distance
provides excellent stability and minimizes the chance for
extensor tendon rupture by obviating the need for bicortical
drilling and eliminating the possibility of dorsal screw
prominence while still maintaining adequate subchondral
screw support.
• The number of screws in the distal row did not show a
significant influence on the stiffness or stability of the final
construct

10. The plate be placed as distal as possible
without crossing the watershed line to
place the screws as close as possible to
the subchondral bone.

11. •Orbay and Fernandez suggested that the buttress
effect of the volar locked plate is the critical
biomechanical advantage to this technique when
compared with more traditional methods of fixation
•The buttress exists in a static location regardless of
the number of screws in the distal row. This implies
that it is the position of these screws, and not the
number or the length of the screws that dictates the
capability of the construct to reproducibly maintain
the reduction of the distal radial articular surface

12. THE DISTAL DORSAL CORTICAL DISTANCE
• This tool can allow the surgeon to make intraoperative adjustments
based on a fluoroscopic 20degree true lateral view that allows
visualization of the most distal screw and the dorsal rim of the radius
in profile
• On the preliminary and final postoperative radiograph, the DDD was
measured from the tip of the most distal screw in the construct to the
edge of the dorsal rim of the distal radius
• Based on these numbers, the difference in the DDD with time was
measured to reflect the amount of settling

13. Case of a DDD placed
within the optimal distance.
(A) Immediate postoperative
lateral radiographic view
demonstrating an initial DDD
of 5.5 mm. (B) One-year
follow-up lateral
demonstrating a DDD of 5.2
mm, showing 0.3 mm of
settling, and a concordant
0.84 degree loss of volar
tilt.

14. Case of a DDD placed
outside the optimal distance. (A)
Immediate postoperative lateral
radiographic view demonstrating
an initial DDD of 9.6 mm. (B)
One-year follow-up lateral
demonstrating a DDD of 5.9 mm,
showing 3.7 mm of settling, and
a concordant 8 degree loss of
volar tilt.

15. The conclusion was that a DDD of
less than 6 mm was found to be the
critical value for maintaining fracture
reduction and avoiding loss of volar
tilt, radial shortening, and DRUJ
incongruency