OPER ATIVE TECHNIQUE

Volar Plating with Anatomically Designed Plateand Fixed-Angle Screws

Key contributors:Dr. David L. NelsonDr. David S. Ruch

Introduction

Features and Benefits

Anatomical Landmarks

Pre-operative Preparation

Volar Plating of Distal Radius Fractures Operative Technique

(A) Reduce the Fracture Before Placing the Plate

(B) Use the Plate to Reduce Dorsal Fragment

Postoperative Management

Sterilization

Ordering Information

1

2

3

4

4

7

10

11

12

13

Orthofix wishes to thank the following surgeons for their contribution to the development of this technique:

Dr. David L. NelsonBoard Certified Orthopedic SurgeonHand Surgery SpecialistPrivate Practice Greenbrae, CA

Dr. David S. RuchProfessor Director Orthopedic Hand SurgeryDuke University Medical Center

O P E R ATIVE TECHNIQUE 1

INTRODUCTION

The Orthofix Contours VPS combines locking screw technology with an anatomicallydesigned plate to achieve fixed-angle screw placement with superior buttressing forvolar and dorsal fracture displacement. The advantage of the fixed-angle design of theContours VPS over the variable-angle fixed-angle designs is that, once the first screwis place in an extra-articular, subchondral location, all the other screws should also beproperly in subchondral bone, but not in the joint.

The Contours VPS anatomic design is based on cadaveric dissection, prepared bones,and digitized data gathered from the Hamann-Todd Osteological Collection. The volarsurface geometry of the distal radius has substantial variability, most notably in theprominence of the lunate facet (called the lunate facet tuberosity, LFT), the volar radialtuberosity (VRT), and the volar radial ridge (VRR). The Contours VPS is designed toaccommodate the broad variances between patients caused by these structures for amore aligned bone-plate interface. The unique design of the Contours plate providescoverage for even the most difficult distal radius fractures, and avoids the need for multiple implants.

Contours VPS reduces the risk of improper plate and screw placement, and providessuccessful, reproducible outcomes.

Proximal row converges ondistal for superior support

Bending crease to adjust angle of the radial styloid screw

Distal row follows adownward angulation similar to the joint surfaceto reach subchondralbone without enteringthe joint space

Distal K-wires angleto match screw direction and verifyplacement of plate

Medical gradeanodized titanium

Non-Locking shaftscrew placementoptions Oblong hole allows

for optimal initialpositioning of the plate

Radial styloid screwcan capturedifficult radial styloid fractures

O P E R ATIVE TECHNIQUE2

Screws color coded by characteristics

Measurement guide

Screw Tray Caddy

Instrument Tray • Threaded drill guide can be used as an

intra-operative handle for the plate. • Threaded benders protect the integrity of

the screw hole when adjusting at thebending crease.

• Ruled depth gauge for easy screwlength determination.

Slightly elevated seat for easy grasp with screwdriver

No misplaced screws - all screws have dedicated holes with matching depth.

SURGICAL ANATOMY

The volar surface geometry of the distal radius has substantial variability, most notably in the prominence ofthe lunate facet (called the lunate facet tuberosity, LFT),the volar radial tuberosity (VRT), and the volar radialridge (VRR).

The area of fibrous tissue proximal to the volar joint lineis referred to in this technique as the Fibrous TransitionZone (FTZ). This area represents the most proximalinsertion of the volar extrinsic ligaments.

Scaphoid facet

Volar joint line

Volar radial ridge

Volar radial tuberosity

FibrousTransitionZone

FibrousTransitionZone

Pronator quadratus (PQ)muscle

Distal plateplacement

Volar joint line

Fibrous Transition Zone:area of fibrous tissueproximal to the volar joint line. This arearepresents the mostproximal insertion of thevolar extrinsic ligaments.

Lunate facettuberosity

O P E R AT IVE TECHNIQUE 3

O P E R ATIVE TECHNIQUE4

(figure 1)

PRE-OPERATIVE PREPARATION

Contours VPS is designed to allow immediate motionwithout casts or splints. If the surgeon feels the specificcase can sustain normal hand therapy loads, the bestfinal range of motion and function will be achieved by starting hand therapy as soon as tolerable, usuallywithin 3 days of surgery. Prior to surgery, discusspost-operative hand therapy with the patient andmake arrangements for the first visit.

Perform a closed reduction, both to assess fracturefragment stability/movement and to make open reduction easier. Confirm with the C-arm.

VOLAR PLATING OF DISTALRADIUS FRACTURES

1. Place patient in supine position with hand extendedon arm board. Prep hand, and apply finger traptraction if desired.

2. Make an incision using the flexor carpi radialis(FCR) approach, with distal extension as necessary.The FCR tendon is palpable radial to the palmarislongus, and is approximately centered over theradius. The skin incision should be centered overthe FCR tendon and of approximately 10 cmlength. Generally, exposure may be facilitated byincising the septum between the FCR and the flexor pollias longus (FPL). Care should be taken toavoid the palmar cutaneous branch of the median nerve. (figure 1)

Palmer cutaneousbranch of median nerve

Optional distal extension to improve exposure of the radial styloid

Radial artery

Median nerve

3. Incise the fascia over the FCR and mobilize thetendon ulnarly to protect the radial nerve. Dividethe floor of the FCR sheath, continuing the dis-section distal to the skin incision for about 1/2 cmdistal to the wrist crease. Take care to avoid boththe median nerve (in some cases it may be veryclose to the field) and the radial artery (in somecases a branch of it may cross just below the FCRtendon, distally). The floor of the FCR distallyforms a thick septum between the FCR and theFPL. Failure to obtain enough distal exposure ofthe radius is usually due to inadequate division ofthis septum far enough distally. Radial columne x p o s u r e may be facilitated by releasing the brachioradialis (BR) insertion from the radial styloid. (figure 2)

4. Mobilize the FPL ulnarly, releasing the musclefibers from the radius. The median nerve is ulnarto the area of dissection, and the mobilized FPLwill protect the nerve. The pronator quadratus(PQ) will be directly visualized with the distalportion usually obscured by the pre-muscular fatpad. The distal portion of the pronator quadratusis often torn. (figure 3)

(figure 3)

(figure 2)

F P L

P Q

F C R

Radial artery

Mediannerve

O P E R AT IVE TECHNIQUE 5

Radial arteryMediannerve

F C R

FPL

5. Incise distally 1 to 2 mm distal to the PQ distal border and release the PQ muscle from its radialattachment. Preservation of 1-2 mm of fibrous tissue radially may facilitate repair of the PQ at theend of the case. (figure 4)

6. Reflect the PQ, clearing off enough of the radius to visualize from the volar radial tuberosity and volarradial ridge on the radial side to the distal radialulnar join (DRUJ) on the ulnar side, and the entirefracture site. Failure to visualize the entire width ofthe radius is generally due to lack of adequaterelease of the septum between the FCR and theFPL distally. Take care to protect the radial arteryon the radial side and the median nerve on themedian side. Distal exposure is dependent upon thefracture characteristics. In the presence of smalldistal fracture lines the FTZ may need to be elevat-ed to achieve exposure of the fracture. Careshould be taken to avoid complete detachmentof the volar extrinsic ligaments of the wristfrom the palmar lip of the radius. ( f i g u re 5)

7. Choose either the long or standard Contours VPSplate system based on the length of the fracture.For longer shaft fractures, use the long plate. Usethe purple plate for the right wrist and the bronzeplate for the left wrist.

Brachioradialismuscle

Volar radial tuberosity

O P E R ATIVE TECHNIQUE6

(figure 5)

(figure 4)

Long Standard Color-coded plates

Bronze = Left Plate Purple = Right Plate

F C R

SURGICAL OPTION A:REDUCE THE FRACTURE BEFORE PLACING THE PLATE

A1. This technique requires the fracture to be easilyreducible and stable, either by itself or by theplacement of K-wires. If this is the technique chosen, free up the fracture fragments andreduce. If they are not stable, place K-wires asneeded. (figure 6)

A2. Examine the fracture configuration and decideon the most appropriate plate. The plate may not extend across the entire width of the radius.All that is required is the distal fragment be firmlyheld by the distal screws. Care must be taken tocapture both any radial styloid fragment and anyulnar/dorsoulnar fragment. If there is a large central area of fracture lines, the plate mustextend radially and ulnarly far enough to allowsecure purchase of the distal fragments.

A3. Place the plate as distally as possible, to engagethe strong subchondral bone but still proximalenough to be out of the joint. Temporary fixationand alignment of the plate is accomplished bydrilling a wire into a distal K-wire hole. Thread thedrill guide into a distal K-wire hole and drill a K-wire through the guide and check its placementwith fluororoscopy. (figure 7)

There is a choice of two techniques from this point: (A) Reduce the fracture first, then place the plate;(B) Place the plate and the distal screws first, reducing only the intra-articular fragments (if present), then secondarily use the plate to reduce the extra-articular component.

The choice of surgical technique depends on surgeon preference and fracture configuration.

(figure 7)

(figure 6)

O P E R AT IVE TECHNIQUE 7

O P E R ATIVE TECHNIQUE8

A4. Next, pre-drill with the 2.5 mm drill bit and placethe 3.5 mm proximal shaft screw in the oblonghole. Utilize the the depth gauge to determineproper length of the screws. Confirm properplate position and apply proximal shaft screws as needed. (figure 9)

Due to the design of the Contours VPS screws(rounded tips, micro cutting flutes and threadsextending to the tip), full bicortical purchase can be obtained without extending more than 1 mmbeyond the far cortex. These screws shouldengage both cortices, as their security comesfrom bicortical purchase. Check the screwlengths with fluoroscopy. (figure 10)

The tilted lateral view is taken with a pad underthe hand to incline the radius 22% toward thebeam. It eliminates the shadow of the radial styloid and provides a clear tangential view of thelunate facet. It is useful to assess residual depressionof the palmar lunate facet and possible hardwarepenetration into the articular surface. (figure 8)

Use both the oblique lateral (called the “facet lateral” because it properly profiles the lunatefacet) and the oblique PA (called the “facet PA”).The precise angle of the oblique depends on theangle of the facet you are interested in examining.Screw placement should be 4-5 mm from thejoint line as the strong subchondral bone providesthe most secure screw purchase.

(figure 8)

(figure 9)

(figure 10)

220

Eliminates radial styloid shadow

A5. Once proper plate placement has been determined, choose the appropriate distal fixationscrew style. The Orthofix Contours VPS providesfour choices:a. 2.0 mm microthread screws for the smallest,

most fragile fragments b. 2.4 mm locking screws for small fragments c. 2.7 mm locking screws for larger fragments,

and d. 2.4 mm non-locking lag screws.

The radial styloid is normally the largest fragmentand a 2.7 mm locking screw is used for greatestsecurity. The 3.5 mm cortical screw is for placement in the radial shaft.

Use the depth gauge to determine the properscrew length. (figure 11)

2.4 mmNon-Locking

2.0 mmLocking

M i c r o t h r e a d

2.4 mmLocking

2.7 mmLocking

3.5 mmNon-Locking

Cortical Shaft ScrewDistal Screws

(figure 11)

O P E R AT IVE TECHNIQUE 9

A6. Drill the correct size hole:

Note: the distal screws should be about 2 mm short of the dorsal cortex, for two reasons.a. The dorsal cortex provides little support. The

security of the fixation comes from the screwplacement into the subchondral bone.

b. Screw prominence dorsally will impinge on theextensor tendons, which lie close to the boneand are held there by the extensor retinatulumand its vertical septae. Although the OrthofixContours VPS pins and screws are rounded toavoid tendon injury, post-pointing must beavoided. Check the length of the screws withfluoroscopy, keeping in mind that Lister’stubercle may prevent you from visualizing thedorsal cortex and give a false impression of thelocation of the dorsal far cortex. ( f i g u re 12)

Screw size Drill size2.0 mm microthread 1.6 mm2.4 mm locking screw 2.0 mm2.4 mm non-locking screw 2.0 mm2.7 mm locking screw 2.0 mm

(figure 12)

Shadow of Lister’s tubercle

Surgical Option B:Use the Plate to Reduce Dorsal Angulation

B1. This operative approach uses the plate to reducethe dorsal bending displacement (tilt). Apply theplate distally and verify there is no intraarticularpenetration (figure 13)

Place the distal screws as noted in step A6 above.The screws should be secure and extend at leasthalf the width of the radius, or the reductionm a n e u v e r will fragment the distal bone. As thescrews are inserted, make sure the proximal shaftof the plate is aligned correctly over the radius.Once all the distal screws are placed: (figure 14)

a. The fracture line should be sufficiently mobile

b. Reduce the distal fragment simultaneously as if doing a closed reduction and by lowering theplate down to the radial shaft. Never use theshaft as a simple lever, without simultaneouslyperforming the above two points, or the distalfragment can be further fragmented. Place theshaft screw in the oblong hole and check it’slength. (figure 15)

c. Confirm reduction distal, to proximal, andplace remaining screws as needed. Confirmscrew length.

(figure 13)

(figure 14)

(figure 15)

O P E R ATIVE TECHNIQUE1 0

O P E R AT IVE TECHNIQUE 1 1

8. Examine the plate to be sure it is not palpableexternally, that the volar radial tuberosity does nothold the plate off the radius.

9. Confirm that all screws are properly placedwith their length appropriate to the locationto avoid dorsal screw penetration through thefar cortex and ex t e n s o r tendon rupture.

10. Check the DRUJ stability. If unstable, considerpinning the DRUJ or perform a soft tissue repair.

11. If possible, repair the PQ, utilizing the fibrous edgep r e v i o u s l y preserved to hold the suture securely.(figure 16)

12. Close the skin.

Perform a final check for plate prominence and DRUJ instability.

POSTOPERATIVE MANAGEMENT

Contours VPS is designed to allow immediate motionwithout casts or splints if the surgeon feels the specificcase can sustain these loads. To obtain the best finalrange of motion and function, Contours VPS p a t i e n t sshould begin hand therapy as soon as tolerable, andusually within 3 days of surgery.

A block may be used to assist in post-operativepain control and contribute to earlier ROMtherapy.

(figure 16)

F C R

O P E R ATIVE TECHNIQUE1 2

The Contours VPS Plate and Bone Screws are supplied NON-STERILEand require sterilization prior to use. The recommended, validatedsterilization cycle is:

The Contours VPS Plate and Bone Screws are intended for SINGLE USE ONLY.

Method Cycle Temperature Exposure Time Steam Pre-Vacuum 132 -135 °C Minimum 10 minutes

(minimum 4 pulses) (270 -275 °F)

Steam Vacuum 132° C (270 °F) 10 minutes

STERILIZATION

Ordering Information

VPL0309VPL0310

Catalog # Thread Diameter Screw Length3.5 mm Non Locking Cortical Screws

PSC3512TPSC3514TPSC3516TPSC3518TPSL3520T

3.5 mm3.5 mm3.5 mm3.5 mm3.5 mm

12 mm14 mm16 mm18 mm20 mm

Catalog # Thread Diameter Screw Length2.4 mm Non-Locking Screws

PSC2414TPSC2416TPSC2418TPSC2420TPSC2422T

14 mm16 mm18 mm20 mm22 mm

Catalog # Thread Diameter Screw Length2.4 mm Locking Screws

PSC24P12TPSC24P14TPSC24P16TPSC24P18TPSC24P20TPSC24P22TPSC24P24T

2.4 mm2.4 mm2.4 mm2.4 mm2.4 mm2.4 mm2.4 mm

12 mm14 mm16 mm18 mm20 mm22 mm24 mm

Catalog # Thread Diameter Screw Length2.7 mm Locking Screws

PSC2714TPSC2716TPSC2718TPSC2720TPSC2722TPSC2724TPSC2726TPSC2728T

2.7 mm2.7 mm2.7 mm2.7 mm2.7 mm2.7 mm2.7 mm2.7 mm

14 mm16 mm18 mm20 mm22 mm24 mm26 mm28 mm

Catalog # Thread Diameter Screw Length2.0 mm Locking, MicroThreaded Screws

Catalog # Left Contour LengthLeft Plates

LeftLeft

StandardStandard

StandardLong

Catalog # DescriptionInstruments

VPR0321VPR0322

Catalog # Left Contour LengthRight Plates

RightRight

StandardStandard

StandardLong

PSC2014TPSC2016TPSC2018TPSC2020TPSC2022TPSC2024T

2.0 mm2.0 mm2.0 mm2.0 mm2.0 mm2.0 mm

14 mm16 mm18 mm20 mm22 mm24 mm

Steri-Tray, Empty3.0mm Hex Driver

Bender, Straight PlateBender, Threaded Plate

Drill Guide, 2.5 mmK-Wire, 1.1 x 150 mm

Hex L KeyDepth Gauge, Distal

Depth Gauge, Proximal1.5 Hex Driver (Tip Only)

1.5 Hex DriverDrill Guide, 1.6 mmDrill Guide, 2.0 mm

Drill Bit, 1.6 mmDrill Bit, 2.0 mmDrill Bit, 2.5 mm

VP601DH0411DH0412DH0413DH0416DH0421DH0422DH0426DH0427DH0437DH0439DH0432 DH0433DH0434DH0435DH0436

2.4 mm2.4 mm2.4 mm2.4 mm2.4 mm

w w w . o r t h o f i x . c o m

C V- 0 7 0 2 ( A ) -O P T-US © Orthofix Inc. 1/2007

For more information contact your local representative or call 1.800.266.3349 (B o n e F i x )