Welcome to the upper hand, where Chuck and Chris talk Hand surgery.
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Oh, hey, Chris.
Hello, Charles.
Trying to shake it up. Make it a little different.
I think you totally threw people off there. I think they were, they thought they were listening to NPR.
What podcasts are we listening to? All right. Well, I'm excited to be with you today.
This week will not be Chuck's election-election update, like last week's.
Yeah, if we lost you early last week. Welcome back.
Hey, why don't we talk about the Supreme Court that'll get people.
Oh yeah, great. I hope you've had a good week, and I am excited to be back with you. And what better way to start this podcast than a review. This one is from DMM314. And it says great listening for physicians and therapists interested in upper extremity care. Love the interaction of Chris and Chuck, need more nerve. It pains me to read that one. But I have to share.
Well, you know, when we are structuring the episode, It is no accident that I had you read that one, because you would have thought that I planted that last sentence in there. So thank you to DMM314 for acknowledging the importance of the nerve portion of our podcast and I'm hoping that we will finally get some more down the line.
We do, we have a little template of episodes and we have a few guests we want to invite but we do need to circle back for nerve I'll admit it we need to need to respond to the clamor for more nerve.
You have to give the people what they want. popular vote indicates that more nerve is needed.
I'm fine with that. But we're gonna hit some sports as well. Because that is very popular also.
Ahh you know listener survey says nerve more but yeah, we'll do some sports too.
True. Yeah. Speaking of listener survey, please, please, please go fill it out. If you haven't done so already. I thought one interesting fact is, you know, we gave we allowed for three categories of age, because we're just curious as to who's listening. And so one category was old, like Chuck, which is really old.
I would not fix your distal radius, Chuck.
You might just put me out of my misery if I came in with a distal radius fracture, is that an option? The second category was young, like Chris, and the third category was really young. And the biggest responders, the biggest group of responders to our survey, at least were even younger than Chris, which I thought was great. And we're appreciative. And maybe you guys just really want a mug?
I think so. But we also, you know, I think that one thing that we should say is that if you're if you appreciate, you know what, what we're doing, you know, I think that our fellowship is, is a great opportunity to, you know, to check out if you are in the resident category, if you're interested in hand surgery. You know, we have great discussions like this every Monday morning, although it's a little harder on a Monday morning, and
liveliness. But one of the strengths of our group really is the you know, the collegiality and how much we enjoy talking about things. So, if you're younger than me, and you want to check out the WashU fellowship, please do.
I love that. I am going to blow your mind for a second here Dr. Dy. I, I don't think I'm thought of especially as a cultured, poem reading individual. I know, I know, you may think of me that way and appreciative of the arts, I think you probably should give me a little credit more credit than you do. But this is really interesting. So in my family, we had a poet many years ago. Clearly that gene was not passed
on. But my great grandpa great, great grandfather named Samuel Allman wrote a poem, which honestly is a big deal. It's called Youth. And given all the ageism you demonstrate towards me, I want to read the first line of that poem, if you will humor me.
Yes, please.
Youth is not a time of life. It is a state of mind. It is not a matter of rosy cheeks, red lips and supple knees, it is a matter of the will a quality of the imagination, vigor of the emotions, it is the freshness of the deep spring of life. So I know that you realize that that articulate... gene was not passed on to me, but I just had to get that in here, had to get it in.
You know, are you going to try to make the argument that activity level is more important than age in terms of indications for surgery, I feel like you're going in that direction
He's really old, but
Your fountain of youth, in your, in your hobbies and your passions will definitely push me towards surgery.
My goal is to change your mind and make you think I'm a surgical indicated patients.
Just say you're an elite athlete.
No one will believe that. All right, can you share with our listeners a case something of interest that you have, you know, seen or want to share?
Well, you know, I mentioned a few weeks ago that I'd done my first wide awake nerve repair, which was unexpected. And I asked the patient if he wanted me to repair it, and he said, Sure. And on top of some other tendons, we repaired that and you know, the wide awake protocol really helped move things along for him. So not to make this too much of a wide awake commercial, but, you know, he is doing well, I would say an
optimistic patient. But you know, doing the tendon you know the, the tendon repairs, and the nerve repair and local and seeing how well he's flown through, I probably will start to open up some indications a bit more. Have you changed indications for wide awake surgery at all, even in the last few months,
I haven't necessarily gotten more aggressive about what I do under local only I have gotten more aggressive about how frequently I offer it. And so that will continue. And I think the more I do, the more likely I am to expand my indications as you might predict. You know, as I as I sit here and think about our topic of the day, which is really some of the surgical pearls. In our approaches to
distal radius fractures. It makes me think about people who have impacted our field, and one of my favorite sayings, which I attribute to Paul Mansky, but it's not Paul Mansky's quote, but you know, life is not about creating opportunities, but rather recognizing them. And so certainly Don Milan has popularized WALANT surgery, and we owe him a great debt of
gratitude for that. George Orbay and the volar plate, which we have mentioned before, and will probably mention again, during this episode, and then our previous guest, Charlie Eaton with needle aponeurotomy, I think those three individuals, again, have just done a great deal to advance our field, whether by their own thought or just advancing what others have also discussed.
Agree, Agree completely. And I think that if you know, anybody is looking for an area to make a difference, see where we struggle in terms of you know, the, you know, if you're a trainee, and you're in clinic, and you're listening to us fumble through a conversation, question dogma, a good paper, a good that, that questions, dogma can go a long way and change how we do things.
And a lot of times, you know, the, for example, the wide awake stuff that Don Milan does, that was a necessity because he couldn't get theater time. And perhaps there's going to be some interesting innovation that comes out of COVID. Because we're all struggling to do things in a different way. Perhaps our efficiencies will get greater.
Yeah, I think that's well said. And it will be interesting to see, we may not know, what we have learned and what has changed in our surgical practices until well past COVID. Whenever that may be, but I think it's a great point, necessity, and, and creativity. And that's why engaging all aspects of, of people of different age and different backgrounds and different ethnicities is so important. Because, you know, people think differently. And that's what we
need. We don't need uniform thought that's just, we need, you know, an education that provides a background, and a set of tools and a set of knowledge to assure competency, but then we need creativity in our field to really make advances.
And that's where it's nice when you get to either train somewhere or end up working somewhere that's different than where you, than where you started your residency.
Yeah, that is so important. We talked about that. We talked about that for hiring, you know, if you just you know, we know our own fellows best, but it's tricky hiring your own fellows because you don't want to become inbred. It's just such an interesting thing. Because we bring someone in who has a different background, they just think about things differently. And that's a win for sure.
I'm glad you your last faculty hire too wasn't a former fellow.
We were desperate, we were desparate.
Thanks for keeping me on board, Chuck. So that being said, we usually have a grab bag session and we welcome any questions, feel free to post them on social leave them in a review or send it to us at handpodcast@gmail.com. But in lieu of a listener posted question, I'd like to ask Chuck to share the Goldfarb pearl of the week.
Yeah, so here's my pearl of the week which has been a question but not an official submitted question. But you know, there's a lot in the literature and this is a little controversial, but I'm going to share my personal beliefs. There's a lot in the literature about the percutaneous treatment of scaphoid fractures, and some of that it relates to Joe Slade and his groundbreaking work he did many years ago regarding the treatment of scaphoid fractures.
And I know that there are plenty of people out there, I believe that still do percutaneous scaphoids. And so I will just say that I don't like it. I don't do it. I don't think it's the right thing to do for a couple of reasons. First of all, whether you go dorsal or volar, we know that there are tendons in play for certain, and perhaps
cutaneous nerves. And the other reason I don't do it is because we can make such a small incision, especially for a dorsal approach, and really know exactly what we're seeing, keep the important stuff safe, and really put the K wire starting point exactly where it needs to be. So the morbidity is minimal. And the precision for the surgery is so great when we do a
little mini open. So my pearl of the week is really just an opinion of the week, but I really like a mini open rather than, and by mini open I mean, a centimeter and a half, rather than a percutaneous treatment of a scaphoid fracture. Does that resonate?
Yeah, I think to summarize, you know, percutaneous scaphoid fracture fixation in my book would be it's all good until it's not. Because it might work well, lots of times. But you know, there can be some potentially devastating issues. And I hope that a listener feels strongly about this and wants to prove Chuck wrong. That could be another recurring segment, prove Chuck and Chris wrong. We would welcome that.
Yeah, that would be great. That'd be great. And you can certainly take a first stab at that over Twitter. And I think Chris and I are delving a little bit into Instagram. I'm a, I've always been on Instagram. Not always, but I've been on Instagram for a while, but just as a passive observer, and I've started a new account. And for my congenital work, but I you know, now I think Chris has as well. And so, you know, I think we might need to make an upper hand Instagram account. What do you think?
We've been gently prodding our social media director to do that.
I think I think it'll be easier. I think it's really easy to do, given you can link the two but yeah, maybe I don't know, we haven't talked about that. I'm not trying to put any pressure on you. You have a few things on your plate.
Also. Chuck, you are on the gram, you are @thecongenitalhand. Is that right?
Yeah. So I couldn't just do congenital hand, which is my Twitter handle. So it's the congenital hand
because there're so many people out there dying to share content about congenital hands. I mean, you know.
It's a huge area of interest on on every social media platform.
Yes, so I have. I have rejoined because a wise older partner of mine told us that Instagram is where, you know, the younger trainees are flocking to. And honestly, our listener survey suggests that people that listen to the podcast are even younger than me. So reluctantly, I have dusted off my Instagram account after four years of inactivity in the name of our podcast and promoting some of our some of our fellowship material. So.
And I saw your post from this morning a little Christmas tree farming.
Yeah, you know, we it was it was more of a, you know, a photo opportunity. You know, nothing quite like family photos. I didn't I managed to avoid sharing a picture of myself in those wonderful Christmas tree pajamas. You'll have to wait with bated breath for that one.
Oh, god please no, just leave it with the kids.
I figured that, you know, you got to give the people what they want. So
Yeah what we, don't give us what we don't want.
It might break Instagram. So that's kind of why I held back. So
Viral
Viral the wrong way.
Alright, well, let's jump into the technical part of distal radius fractures. And we ended our last episode talking about some of the indications of treatment of a distal radius fracture from a volar approach. But let's, if it's okay with you. Let's jump right into the how we do it.
Yeah, so what we can do is, um, you know, kind of gently prod each other on the fine details, you know, like we were, you know, like you were a resident and working with, with one of us kind of asking, Why exactly, do you do the things you do?
All right. What Why don't we start with your approach? How do you think about your approach? Do you cross the wrist crease? How do you address the palmar cutaneous branch? How do you address the FCR tendons? So how did you get down to the radius.
So I make a skin incision over the volar aspect of the distal forearm centered over the FCR. And you can typically palpate that and sometimes see it and skinnier
patients. Skin incision directly over that, and then I will identify the volar FCR sheath, divide that sheath, retract the FCR tendon in the midline, or ulnar direction and divide the dorsal FCR sheath acknowledging the fact that you need to keep in, in line with the in situ c urse of the FCR not the r tracted course because if you d , you're going to get a little t o close to the palmer c taneous branch in the median n
rve. I know there are a number o studies demonstrating that y u know that palmar cutaneous b anch can either be within that s eath or even a little bit r dial to the sheath. So you a ways have to look out for it b cause injury to that nerve can b , can be devastating in some c ses, and honestly, just a noying in many others. How do y u do it from there?
Yeah, I think I would, I would echo two points. First, let's talk briefly about the palmar cutaneous branch, there's two studies that look at that. The first was by a former fellow of ours, Kevin Lutsky, with his group in Philadelphia. And that was, I think, the first paper that really emphasize it, hey, if you're going through the FCR sheet, be aware that the palmar cutaneous branch and median nerve can be on top of, can be in, or can be directly beneath
the FCR tendon. And there's a more recent study by the folks from New York, Luke Catalano and Steve Glickel, and Alton Barron which really highlighted the same thing. And so I the message, there is clear, if you're going to do anything with the FCR tendon, you, you cannot do it blindly or wildly, you have to be aware of that nerve.
So do you go looking for that nerve? Or do you just say, you know, look for it in the field? And if we don't see it great.
Yeah, I typically look for it in the field. Although if there's something about the patient that makes me particularly concerned, or if I want to show the anatomy to a resident, it's really two spreads of the scissors. And I think the key is, it's five centimeters proximal to the wrist crease, typically where you can find it most easily at the branch point. And it's really not hard to find. And once you find it, it's easier to keep it safe. But I don't make that a routine.
Yeah, yeah. And sometimes one of the things I like to emphasize to the residents who are rotating with us who are not going into hand is that look, there are certain structures that you are going to encounter on call either as a resident or as an attending, that you need to know how to find things quickly. So you know, you need to know how to find the median nerve quickly. And at that level, it is yep,
subcutaneous. So it's good to show that to them, and then show them where that palmar cutaneous branch is coming off of the radial side of the median nerve. And like you said, If you choose to go find it, it is a couple of spreads of the tenotomies, and it's a good thing to demonstrate.
Yeah, and the second thing is, I really dislike crossing the wrist crease. So it's easy enough to cross the wrist crease and go over the thenar eminence. And certainly I do that, you know, clearly, we do that with volar approach to the scaphoid. But anytime you cross that wrist crease, even if you do it at an angle, which of course you should to minimize the risk of significant scarring and a contracture, it just causes pain and a slower recovery. And the same holds on the ulnar side of
the wrist. If I'm decompressing, which I rarely do. But if I'm decompressing the distal ulnar tunnel, I really don't like to cross the wrist crease there either. I just think that's really important to me. Although if you have to do it, you have to do it.
Yeah. And that that does tend to be an area of painful and prominent scars. You know, for example, if you are crossing the wrist crease for even an extended carpal tunnel, even taking it at a zigzag to avoid crossing it perpendicular and to keep yourself away from the palmar cutaneous branch. That is the area that patients
will complain about. And then with regards to the approach for distal radius fracture, you know, if you are that distal, you do need to be mindful of the palmar branch or the radial artery coming over the FCR if you are getting that distal. So how do you how do you then proceed deep to that after you've gotten the dorsal FCR sheath divided?
I typically retract the FCR tendon radially. Although People always ask Can you retract it ulnarly, of course you can, it doesn't really matter to me which way we retract it. Sometimes it lends itself one direction or another, but I typically retract it radially. And then I use a finger or a raytech to elevate the soft tissues, including the FPL tendon and sometimes the FPL muscle belly to expose expose
the pronator quadratus. And then from there, I tend to make a linear or longitudinal incision in the pronator quadratus, leaving a little cuff on the radial side for potential repair. And then I use Hohmann retractors from there. I don't make an L shaped incision in the pronator. I just haven't found that necessary. I tried to elevate the pronator sub periosteally if there's periosteum available, and then I use Hohmann retractors, as I said, How do you approach the deep the deeper side?
So I'll typically pull the FCR tendon and retract it ulnarly. So I almost always do it that way. I can't remember one where I went radially although that question does come up. I'll then take a Freer elevator and then use that to dissect to the radial aspect of the shaft of the radius and then replace that with a Hohmann retractor that I parked there and that allows me to retract the radial artery out of the
way. So with that placed, I then take a raytech around my finger and bluntly dissect the long flexors off of the pronator quadratus and replace that with an Army Navy type retractor, reminding whoever's doing the retracting that you're pulling on the median nerve as well. So
be mindful of that. And then for the pronator quadratus, I mean, I'd like your thoughts on this, I kind of go back and forth in terms of when pronator quadratus repair is indicated if ever, if it is a situation in which I think I'm going to repair the pronator quadratus, I will divide the brachioradialis tendon longitudinally, so splitting it longitudinally along the radial shaft of the
radius. And then that'll allow me to A, release to brachioradialis, but then I can then take that volar limb of the BR and elevate it with the pronator quadratus. So at the end of the case, if I wanted to repair it, I have a more reliable tendon cuff on the pronator quadratus to put back if I wanted to.
That's super interesting. Couple of comments. First, I appreciate your comment about avoiding over retraction on the median nerve. I will remember early early in my career. So we're talking 2003, 2004, when I first started doing this procedure, that I am guilty of having over retracted on a patient's median nerve and crps developed, and that scarred me as it should have. And I've been super careful of that ever
since. And I hope the listeners, especially younger listeners will never have that happen to them. Second of all, it's interesting what you say about repairing the pronator, I tend to repair the pronator if it's easy to repair, and if it's easy to repair, I don't need the assistance of the BR to do that. And so I'm repairing fascia to fascia, I think is just for me I, putting a couple of monocle sutures in is easy when it comes
together nicely. I don't think it's necessary because I don't really think it protects against future tendon issues. Because the part of the plate that sits distal to the pronator is the part of the plate that's going to cause the problem. So I'll do it if it's easy. And if it comes together nicely, I don't think patients lose anything when we don't do that repair.
That brings up a good point. I mean, so what is the part of the plate and this will be manufacturer dependent and as well as physician dependent, you know, where you put the plate, but I typically find that it's that distal row on the radial, you know the too radial, most distal row screws, if you have, you know, either the plate too distal, or you have prominent screw heads because they haven't locked into the locking
mechanism. Well, that's the area of the plate that is going to potentially cause FPL and other flexor tendon issues, and that is the part of the plate that you want covered. If any part of the plate.
Yeah, the manufacturer you know, I've for many years, I have said that, you know, the plates are very, very similar. And clearly they're very similar, but there are differences. And I prefer a thin plate. And I prefer a plate that I don't like the plates that have a big angle volarly, you know, going from straight to angled volarly because at the morphology the distal radius is
somewhat variable. And I think the one principle I have is unless the fracture really calls for it, don't go distal to the watershed line. And so the pronator comes right up adjacent to the watershed line definitely doesn't cross the watershed lines, and there's a gap between them or sometimes the pronator is right at the watershed. And I think avoiding going distal to that is the key. And you're right. When screws sit nicely into the plate, it makes it easier to remove the screw
issue. But it's tricky. And I think there are benefits to certain plates at certain times. I'm not sold on any of them necessarily or or against any of them necessarily. But the plate matters.
Yeah, I agree. And, you know, one interesting study that I read as part of this JBJS update was one study that looked at the actual kind of volar cortical angle of the distal radius in an uninjured distal radius setting. And there's a wide range that you have there. And that range exceeds what most manufacturer's plates have. So there are situations which many of us use the plate as a reduction guide. And that can be
a little bit tricky. If the plate doesn't match the patient's physiologic anatomy, or they've already had a dis radius fracture and have refractured and all your markers are off there. I think that's where sometimes we can get in trouble is if we don't endeavor to get a, almost a reduction you exactly want from the get go and then you rely on the plate to help you.
Right. And that, of course is the danger of just using a standard volar plate rather than a fragment specific play, which we can talk about. And I have traditionally been a person who likes the volar plate for almost every distal radius fracture. I don't do fragment specific fixation very often, but I will obviously and I will go dorsal sometimes, but you're right, I think depending on the hardware can be helpful and can make osteotomies you know, more straightforward,
but for a fracture itself. I don't like necessarily to depend on the hardware as much. You know, easier said than done, but I don't I don't like to depend on it. So do you as a matter of routine release the brachioradialis tendon at the floor of the first compartment?
Not as a matter routine if I know, you know, there's a lot of shortening on the initial x rays. You know, if I think that that's going to be something that's gonna hold us back, I have a low threshold to release it. But I would say it's probably one out of 10 times, sometimes I just want to show the anatomy of the brachioradialis to the trainee, and then we'll release it along the way.
Yeah, I see it the same way you do. And certainly some of our partners always release it, just like they never repair the BR, I'm sorry, never repair the pronator quadratus, but I'm a little flexible there, I will release it, especially if I'm struggling with the styloid fragment, if it's a separate fragment, obviously, if I'm considering a radial column plate, I would release it for exposure, but I don't make it a matter of routine.
And it's also I think it's a good landmark to have sometimes, because if the fractured fragment on that radial side is rotated, or even kind of pronator supinated, and you're trying to put a radial column plate on, having that intact and looking at that flat tendon can help you judge rotational alignment. And also, if you're trying to put a radial column plate on, tells you kind of where the flat surface or the radial side of the radius is to
put the plate on. So it can be a useful guide, but again, low threshold to release it. So question for you, how do you get the reduction? So you know, a lot of people do this differently. Are you typically lining it up, holding it there and then having a plate placed? Or are you using a K wire to assist reduction? How do you do that?
Yeah, I think this is a great conversation How many times have you irradiated your thumb holding point we may see this somewhat differently. And obviously there are differences based on the type of fracture, but my routine is, is very much the same each case, I achieve a manual reduction, both through, first of all, you know irrigation. And if there's a big step off, you know, clean out the fracture site, but mainly manual reduction, including flexion of
the wrist. Once I've done that, and I feel pretty good about what the volar cortex looks like I bring the C arm in, I contin e to flex the wrist and hold y thumb on the fracture, and I g t a C arm. Mainly looking t the lateral, I do an anatomi lateral view. So trying to atch the inclination of the dis al radius with my angle of the ray. And then I'll get one ry to get one, you know, PA view And then if I'm happy there, I slide the plate in leaving
the wrist flexed. And my first crew goes in the sl ding hole proximally. So the bigger screws for mos plate manufacturers, and the I put one distal screw and again, variable based on fractur type. I don't like K wires, don't, nothing against K wires in this situation, but that's ust not my routine. So that's t e basic approach that I have usi g wrist flexion and the manual r duction as my ke that reduction the whole time? I say that but honestly it is a consideration, right?
So, you know, I pass down a lot of surgery to trainees, one thing I never pass down is control the C arm. Because I think that is incredibly important and great imaging depends on having done it before. And so I control the imaging, I control my own radiation and I keep their hands away. And I think that serves many purposes, you know, including keeping their hands away. And I try to do one single shot for each picture and I do pretty well at that. But you're right I am radiating myself.
So I when I started in practice, you didn't give me any trainees. So, I had to do things myself. So, and also I saw this was the way that I had seen a lot of distal radius fractures
done in residency. So, I do like using a K wire, but I do get a manual reduction as you mentioned, I think that the keys for the manual reduction are as you mentioned, you know flexing your wrist, but first using extension of the wrist to disengage you disengage the fragment using your thumb or whatever instruments you want to act as a lever arm and then reducing their fracture holding it flexed and then honestly having whoever is on you know able to do it, pull traction and
ulnarly deviate the wrist to help get that length and inclination restored. And then while I am holding the reduction, you know, for example with my thumb and somebody else is flexing the wrist, you know, pulling traction and ulnarly deviating I will put a percutaneous wire on the, through the radial styloid and oblique retrograde angle, and then on the far side enga ing the metaphysis of the dista radius across the fractur
. Now I understand what you're oing to say about the proximit of the superficial radial n rve and whether that's I know ou were worried about it. But y u know, I think that knowing the pattern of the anatomy there, if you are truly in on the radia on the most radial aspect of he styloid you should be dista to the branch point of the sup rficial radial nerve. And th t is something that I worr about getting burned on. B t I found that having that re uction held by the K wire fre
I like a couple things you said a lot. First of all, it is overly simplistic to think that you can flex the wrist and put dorsal pressure on the volar cortex with your thumb and obtain a reduction in every patient. So I like the concept of properly applied traction, and ulnar deviation. And those are really important steps. So thank you
for mentioning those. Second of all, I like how you emphasize that when you use a K wire, or maybe you always use the K wire, but you're you're doing it through the radial styloid you're not necessarily using a K where through your plate. Did I interpret that correctly?
Correct.
Okay. And I do that sometimes, because I think especially when you have a fracture, a two or three part fracture, when that radial styloid is its own independent piece and is not really tied in, that can be huge. And I totally agree that doing that percutaneously is a very reasonable thing to do. Yeah, I think those are the key steps.
And we you know, occasionally I'll worry about inter articular components, I did a study a long time ago, looking at whether you can assume that volar cortical alignment and good C arm, radiographic appearance, give you good information about interarticular displacement. And the lesson I took from that is it does and so while I put a scope in a wrist last week to make sure I was happy with the reduction, I don't do that very often.
Yeah, I I follow that. And I think that adding a scope, adding a scope tends to be more technical triumph, although I know that there are a lot of advocates for the scope. And some of it is honestly, my, my facility with the scope is not that of other people. You know, one thing that other people will use as a, you know, actual traction setups, one of our partners will use a traction setup off the end of the hand table, which and I did not see in training, but I can see the
value. It's just another thing to add to the setup, which I don't think you absolutely need.
It's so interesting that you say that because I was talking about that during, I had a couple distal radiuses, distal radii, this week, I was referencing a previous giant in orthopedic surgery at Washington University, Dr. Ford, and Dr. Ford had a board the Ford board. And it was a essentially a plywood construction that took the place of a hand table. And you basically rested the hand on this table, it had finger traps and a weight built in. And so it did exactly what you were
suggesting. And those types of setups can be really useful, especially when you have limited hands. And for those who like pinning distal radius fractures, it can really make things very simple and straightforward. I do still think there's a role for pinning selected destroy radius fractures. Not really what we're here to talk about today. But But I think traction setups can be useful, especially when hands are limited.
So you mentioned putting in the oblong screw in the shaft? How do you fine tune the proximal to distal position of the plate, and when are you satisfied with the position of that plate.
So it's really important if you are going to use the oblong hole, that your initial placement of the plate is both centered on the shaft but also has a general approximation of the proximal, distal. And for me, that means putting that plate right up towards the watershed line, but not passing it, making sure the reduction is not, you know, you're not shortened with your reduction, because then you'll you know, you won't ever have it right. And I think it's experience. And sometimes I do
better than others. But I like that approach. And it works for me. And obviously I know it works for many people, but it does require experience and you don't want to drill a bunch of holes and realize you don't have the plate in the right place.
Yeah, and I think that as I've, you know, even my early years of practice, as I've gotten better at this and done more, I think it shows you the importance of that initial reduction. Because I don't want to rely on the plate too much. I know there are a lot of bells and whistles built into these plates to help you. But I think it's important to get that reduction as close as you can
initially. How do you proceed distally with your sequence of screw fixation, you know, are you using a cortical screw to help bring a plate down the bone? Is that something that no longer has a role in your practice?
So great questions. I'll throw in a little history for those who like history. So as I think we mentioned long ago, and we've mentioned today already, George Orbay really revolutionized the treatment of distal radius fractures by popularizing the volar approach, and also by his plate, the hand innovations plate and that original plate there were locking screws which is part of the evolution or revolution. There were locking pegs and there were non locking screws. As I recall, I think all
three were options. I will say, so that was published I believe in March of 2002. In February of 2002, the Cincinnati group published a paper about volar plates for dorsally displaced distal radius fractures. And so the Cincinnati group obviously did it first, but they use the old fashioned, I think it was synthes plates, which were not fancy at all, and didn't have the benefits of the locking technology that Orbay really did
so much to advance our field. So for me, I will still use a non locking screw, getting back to what you alluded to earlier in those patients where I am going to use the plate to help with my reduction, so pulling down that distal fragment towards the plate. And that does require bicortical fixation. So we do that very carefully to avoid plunging, and often it's a
temporary screw. So I'll do a non locking screw assist with my reduction, if I'm struggling, add a couple of locking screws and then replace that non locking screw with a shorter locking screw. Do you see it differently? Do you ever use that non locking screw to assist your reduction or is that something you rarely consider
I do it but I'm not relying on it, I will use it to help get that plate tucked in a little bit better just to fine tune it. But I there, I know there are surgeons who really bank on that, that screw fixation to really bring it down and align things. And I don't love that, mainly because there are a couple of things that are out of your control as a surgeon, one of them is bone uality. And in some, in a se ment of population, you know, he bone is not great for this
or this fracture. So even if I think I have reasonable bite w th that screw, I will, as you al uded to earlier, I'll have my humb on the volar cortex someti es. And then while that screw s going in, I will then take finger and push dorsally. To ry just kind of bring that bone little bit closer, obviously t e wrist is flexed too, and he ping to engage that because I do 't want to rely on the screw to do much because you know you' e in an area where the bone qua ity may be suspect and you don't
want to get burned. And I ag ee with swapping out that scre at
So we have I think you said all that very well, we have excellent residents and fellows, we're very fortunate in that regard. And when we have residents on our service, you know, they've been doing bigger things they've been doing femur fractures and the like. And, you know, feeling that second cortex is so easy in
those situations. But when you have a old patient like me, or maybe even slightly older, and that dorsal cortex is thin, and you don't get the feedback, and you haven't put screws in a lot of distal radius fractures, it can be really tough to feel that second cortex. Plus, you know, it can be displaced. And so I have no problem using a manual support dorsally both to help the reduction, but also to help feel that drill. And I don't think you need to go through
that cortex. And you shouldn't go through that cortex when at all possible. But I think it's okay, it's okay to have your hand dorsally, finger dorsally to feel the drill that really can be helpful.
Yeah, one of our you know, the, the importance of the dorsal ulnar corner fragment is, is different, I think in different patient populations, perhaps less important in an older patient population. But there are, you know, a number of publications about that particular fragment, one of which came from one of our
partners, David Brogan. And he mentioned in that, you know, in the postmenopausal female population, which they studied, that the size of that fragment in terms of the width from volar, to dorsal, it's about 24%. So if you want to get fixation in there, you can't typically use kind of the 75% or, you know, that length of screws. So it's a question of whether you, as a surgeon feel that that's an important fragment to fix. Because obviously, going bicortical with your screw fixation there can
have some potential risk. Now, if you're truly more on the dorsal ulnar corner, you're a little bit further away from the EPL. But you know, still, I would argue that you if you're trying to really secure that fragment, there are other structures at risk, including the sigmoid notch.
I think that's right. And that's well said and I appreciate David Brogan's work in that area. I'm not a huge believer in the importance of that fragment. It's not as if I don't believe it can be important, but I don't think for me it's a major factor for most patients. We owe a debt of gratitude to Lindley Wall, one of our other partners who helped to emphasize the sufficiency of screws at what 75% of volar to
dorsal link. And so basically, we can expect a limited risk of displacement and fracture as long as you get up to that 75% point. And again, avoiding going through that dorsal cortex minimizes the risk of this surgery.
So one thing that I like to talk about with the trainees is that I tend to fix the volar ulnar, you know the distal row first because going to the radial side first makes it harder to image things. In terms of whether your screws are interarticular or not. And the group from Brown, I think it was Max Soong who did this when he w s a resident, he wrote a paper t at looked at when you can see w ether your screws are intra a
ticular or not. And that l teral tilt view that you talk a out, is truly the view that y u want. And once you start p tting things on the radial s de, like shooting up the s yloid, for example, it's just h rder to see your ulnar sided s rews. So I start with that. A d then also, because a lot of p ople think that the i termediate column is the most i portant portion of fixation.
Yeah, I love what you said a couple of comments in regard to those to your thoughts. Number one, the concept of the radial column, the intermediate column, and ulnar column, love that. Really important and I agree that intermediate column is where it's at. If you choose to fix a distal radius like I do, where you're not using k wires routinely, and you're depending on a manual reduction, and you're depending on a flexed wrist, that makes it hard to put the ulnar distal row screws in
first. And so if you do it, like I do it, and again, every fracture affects our approach, I tend to put the radial screw in first. But I think your point about visualization of the intra articular nature is really important. So I like that. And you know, the number of screws we need, I think there's no hard and fast rule. three screws, four screws depends on the fracture. So I typically use three or four distally, three proximately is that kind of your
Yeah, I think you know, there there are some standard? mechanical studies demonstrating they need at least three in the most distal row, distal to the main fracture and then maybe one within that, that next to most distal row. But again, I think it's predicated on the fracture itself and honestly, the the implant, because some of these implants have different widths, and some patients align better with the quote standard plate
versus the wider plates. You know, I was never, and I'd love your thoughts on this, I was never huge on some surgeons love kind of getting the longest possible radial styloid screw. And some plates are designed to do that. I don't think that that's where the construct is going to fail. So I don't make a huge deal out of that. And, you know, given the type of plate that I use, it's not built for
that. If your screw head ends up being prominent, because you tried to get too acute, with that that will be a problem.
Yeah, completely and totally agree. You know, the only time I use less than three screws, and I might only use one or two, but I always put distal row screws in would be a classic volar Barton's, with an anatomical reduction where you're using a buttress plate, and then maybe one or two would be all I'd use. I agree with you, I don't believe in the importance of the
radial styloid. I think what's really interesting to me is when these plates first came out, there's a lot of emphasis on getting that distal row screw set up, right subchondral so that it would help decrease the risk of dorsal collapse of the fracture. I don't hear that mentioned quite as much anymore.
I think the recognition that you need to be a little more proximal with the plate, proximal to the watershed line can make that more challenging, especially if you're using the pre you know, design plates to affect which direction your screws go in. And your ability to correct that is, is limited. So I think plate choice matters for that. And you know, you have to understand your fracture, to understand sometimes what the best plate is for that particular fracture.
Yeah, and I think your point about you know, where those screws are in the bone distally is an important one, it isn't talked about a lot. But you know, the original, fixed angle type implants relied on good subchondral bone, and particularly in a potentially geriatric and osteoporotic population. If you are not in subchondral bone, you know, there is a chance that that construct is going to fail if you are purely relying on less
than ideal metaphyseal bone. So, you know, I know that we're all getting gun shy about putting plates too distal etc. But you know, take advantage of the variable angle components of your plate and make sure that if you need to that you get into that good subchondral bone, again, without cheating your plate too distally.
I think that's well said and let's be real. I don't know that I've ever truly blamed a plate on a construct failure. You know, we don't see broken distal radius plates or broken screws, these things heal. And so really, we as the surgeon, are the critical factor to determining the success of this treatment. We're lucky we have great hardware, the hardware does differ and manufacturers might matter more than we think. But this is not a
hardware failure situation. This is really I think what it gets down to is probably not even technical. It's really about how well we understand the fracture. And that understanding doesn't have to be so sophisticated for 80 or 90% of the fracture because most of these are straightforward even if we're going to the operating room. But there's a couple of times where we'll get really difficult or deceiving fractures that make our life difficult. And I think
you've got to get it right. At that point, technically,
Do you have a preference for the metal of your implants? You know, I, I know that there are a lot of implants now that are made out of titanium for distal radius sets. And you know I was totally fine with using them most of the time. But you know, I have a preference for stainless steel, because I tend to just know how
that material feels. And I also have gone away from certain manufacturers because I don't like their locking mechanism, and having true confidence that that locking mechanism is engaged, because I've seen several different manufacturers plates that the locking mechanism I thought was engaged, and it wasn't, and that screw was backed out really early. And it only takes a couple of times to where you get burned, where you are going to switch plates.
Yeah, I don't have a huge preference. But I agree that stainless is preferable if all other things being equal, especially if you may have to take the plate out. It's just so much easier. Totally agree with that.
Yeah, you don't love those easy to strip screw heads on the titanium screws. You know, so I have pretty much routinely gone to stainless, although there are some patients who have, you know, pre known or stated nickel allergies, kind of dictate that you go towards titanium.
So why don't we finish up talking about when you consider fragment specific fixation with a volar approach? So what are your thoughts aside from the volar ulnar corner, because we know that when you have a volar ulnar corner, you need a very distal plate, and you need a fragment specific approach and threr are different ways to tackle that. Are there any other fracture patterns that make you immediately think about that?
I think a fracture that has a split, multiple splits in this the radial column, where I truly do think that I need support along the radial column, I will use a fragment specific type approach. And I think I what you're saying here is not the proprietary term fragment specific fixation, but you know, using multiple plates, perhaps orthogonal plates, sometimes with the volar plate, and sometimes with the radial column plate or both, to secure
a fragment. You know, if there, if there's a lot of comminution in that area or multiple fragmen s, I will take a small kind of 2 0, or 2-4 recon plate, and con our it to sit along the radial column. I know that there are, you know, radial styloid plates ut there, I don't typically love them. And you know, honestly, I trained with kind of contourin your own and I've become elatively facile with that. And I kind of ma
Yeah, I like I like what you said, I think you know, go either way control your own or use the pre manufactured if your manufacturer of choice has them, you know, we don't do them every day. And if you're not used to using that radial column plate, it can seem daunting, it shouldn't be, it's not daunting, you have to have the right exposure. And you have to get that plate down on the metaphyseal portion of the distal radius first and secure
it there. But it can be a game changer as far as fixation, it really can make a big difference. So when it's necessary, I would just encourage all those listening to think about that option.
And sometimes, you know, to be honest with you, it is a good thing to show trainees how to do because they're going to need to do it. And if it's a reasonable indication, I may sometimes will use a small kind of 2-0 plate along the radial side just as provisional stabilization and then opt to take it out. Because it's it you know, it is no longer necessary. But if I'm going to do that, I typically will use, design a plate or contour a plate in a way that I can leave it in if I
wanted to. And I think it is important you know with if you're using that radial column plate that you don't have prominent distal screws because that styloid is you know, subcutaneous and the first one here. And if you are too prominent with any part of the plate or the screws, it can be bothersome to patients.
Yeah, I think that's well said three concepts to close on. And I'll give my opinion on all three and then really want your honest opinion on them as well. Number one, there is no shame in supplementing a distal radius fracture with K wires and I don't do that often but I don't have a problem doing that so leaving k wires typically through the radial styloid as a supplemental fixation point and that would be for a more comminuted fracture where you
need a little more support. I typically leave those in for four weeks and just slows down my rehab a touch but I have no problem doing that. So that's number one. Number two, no shame in going dorsal as a secondary exposure, whether to look in the joint if you're not sure or whether to add a supplemental plate if you think it's necessary. And number three, no shame in using a spanning dorsal plate. Although I will say I
think that is over subscribed. I think the pendulum has really tilted towards using those type of plates more frequently than necessary. But it's a great option especially for the support of the volar ulnar corner fracture, and just really difficult comminuted fractures. So I'd love your opinion all three, k wires, dorsal supplementary approach and the dorsal spanning plate.
On the first one, I agree. If I'm at that point where it's that unstable, I'm usually putting a radial column played in any way to accomplish the same thing. But 100% agree with the thought. The second one actually did this recently, in which I made a separate accessory dorsal approach, not the full on dorsal approach to to secure a dorsal ulnar corner fragment that I thought had implications for the sigmoid
notch. And because I wanted to rotate the patient's forearm right away, I secured it with a separate inter fragmentary screw through that kind of accessory approach. So yes, 100% agree, if you think there's an important fragment or some other reason to get over there. Sometimes that can be in a malunion setting more than anything else. Yes, dorsal approach is successful. And then for the third one, I agree, I think that the spanning plate has a role and a purpose.
And you should have it available, you know, in terms of what implants are in your facility, for some of these more challenging cases, but it's not a panacea. And there are a lot of influential papers or influential speakers and papers that are getting out there and kind of using it very frequently. And I think it's probably overused. And I think that if you're a trainee, and your first thought is to go to a
spanning plate, that's okay. But you should understand there are some other ways to get out of that, which will, you know, potentially avoid a second surgery, albeit a planned surgery to remove the plate.
All right. I think on that note, we can talk about distal radius fractures for days, we probably should have another episode in the future about when and why we go dorsal and how we approach fractures from a dorsal approach. But I think we've hit the high points of the benefits of a volar approach and our personal approaches. Anything you'd like to close with?
No, except for the fact that we should probably do a rehab episode too after we've covered all the different approaches.
Yeah, so rehab episode on crps. Rehab episode on distal radius for sure. So, so critical that we get the right experienced hands on working with patients.
Have a great afternoon, Chuck.
All right. Great to see you.
Nice seeing you.
Hey, Chris. That was fun. Let's do it again real soon.
Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenitalhand. What about you?
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
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