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• W2810961570 abstract "Surgeons can often achieve operative reduction of distal radius fractures with a combination of manual reduction and provisional pin fixation. Traction, volar translation, and pronation frequently restore alignment in the typical pattern of dorsal angulation and translation [1], and reduction with buttress plate and fixation works well for volar shear fractures. When fractures are impacted or scarred, dorsal periosteal elevation and brachioradialis tenotomy facilitate mobilization. When these reduction techniques are unsuccessful, however, accurate reduction requires direct fragment manipulation techniques. Direct fragment reduction can be achieved with a variety of elevators, pins, and forceps. Kapandji intrafocal pinning can improve position and provide provisional fixation [3, 4], but the distal radius metaphysis is predominantly cancellous, frequently comminuted, and thin cortically, so there may not be sufficient purchase to achieve alignment. Another option is to use volar locking plates to fix distally first, and then lever the distal fragment into alignment (Fig. 1 A-B), but this requires familiarity with the positioning of the specific plate in relation to distal bony landmarks and accurate approximation of tilt correction [5]. Malalignment on the distal fragment(s) can result in improper position on the diaphysis, or inadequate reduction.Fig. 1 A-B: (A) An example of a dorsally impacted distal radius fracture with distal screw insertion is shown. There is a locking screw placed in the shaft of the plate for stabilization during distal screw insertion. (B) The plate is levered toward the diaphysis in order to restore volar tilt. Screw fixation is then completed proximally. (Published with permission from Stephen A. Kennedy MD, FRCSC).A simple and reproducible technique that I use for restoring alignment alone or with an untrained assistant is subchondral pin assisted reduction (SPAR). The most reliable bone for stable fixation is the dense subchondral bone. Multiple subchondral pins are used to lever the radius fragment(s) into alignment, with a volar plate fixed proximally before fixing distally. To counterbalance the pull of forearm musculature, longitudinal finger trap traction can be applied with five to 10 pounds of weight (Fig. 2), but this is optional. I use an open volar approach, and through that volar incision, the pronator quadratus and dorsal periosteum are elevated, and the brachioradialis is released as needed to mobilize the fracture fragments. Then three or four 0.054-inch (1.4 mm) pins are placed in the subchondral bone from the dorsal side (Fig. 3 A-B).Fig. 2: A typical traction setup is shown with sterilized pulley clamped to the end of the hand table, and 10 pounds traction applied through finger traps. (Published with permission from Stephen A. Kennedy MD, FRCSC).Fig. 3 A-B: (A) A dorsally angulated and impacted extra-articular distal radius fracture is shown. (B) Three subchondral pins are inserted percutaneously under fluoroscopic guidance dorsally. (Published with permission from Stephen A. Kennedy MD, FRCSC).The pins are aligned with one another during insertion following the inclination and tilt of the radius (Fig. 4 A). To allow forearm supination without penetration of the drapes, the pins are cut short and the forearm is placed on towels at the forearm and hand, creating an effective cut-away platform for the wrist (Fig. 4 B). This setup allows for forearm rotation for both plate positioning and fluoroscopic imaging. More towels distally facilitates true lateral radiographs with 15° inclined to visualize the lunate facet [6].Fig. 4 A-B: (A) Three subchondral pins are inserted dorsally, spaced apart, and in line with the radial inclination and tilt. (B) Towels should be placed under the hand and the forearm to allow for supinated positioning of the forearm during plate positioning and confirmation of reduction. (Published with permission from Stephen A. Kennedy MD, FRCSC).Once SPAR pins are inserted, an efficient lever is achieved for restoring volar tilt, with distribution of force through the pins, little effort, and little or no migration through the bone. The primary surgeon can maintain the volar tilted position either by having an assistant hold the wires, or by using the index finger of the nondrill hand (Fig 5 A-B).Fig. 5 A-B: (A) Pin positioning from an overhead view is shown. Pins are cut short to avoid penetration in drapes. (B) The pins are levered together distally with an index finger. An assistant can also provide this leverage as needed. (Published with permission from Stephen A. Kennedy MD, FRCSC).The plate can then be provisionally positioned and clamped/pinned to the diaphysis, and the final position can be adjusted after performing a reduction maneuver (Fig 6 A-C). The volar plate is then fixed in the shaft proximally, without trying to maintain volar tilt during the process. Once fixed in the shaft of the plate, the surgeon restores the volar tilt with leverage of the SPAR pins while locking screws are drilled and inserted into the distal subchondral bone (Fig. 7 A-C). Each screw can be drilled using fluoroscopic guidance. Once adequate fixation is achieved in the distal fragment, the reduction pins can be removed (Fig. 8 A-B).Fig. 6 A-C: (A) SPAR of the distal radius is shown. (B) This image depicts the position of the index finger. (C) Placement of the volar plate fixation and temporary pinning is shown.Fig. 7 A-C: (A) The volar plate is fixed proximally with three screws after confirming mediolateral and proximal-distal position. (B) A posteroanterior view confirming mediolateral position is shown. (C) This image shows the fluoroscopically guided drill insertion for the variable angle locking plate. (Published with permission from Stephen A. Kennedy MD, FRCSC).Fig. 8 A-B: (A) Final posteroanterior view after reduction and fixation is shown. (B) Final true lateral view after reduction and fixation. (Published with permission from Stephen A. Kennedy MD, FRCSC).For patients with multiple articular fragments, subchondral pins can be placed through the open volar incision into volar fragments and percutaneously into dorsal fragments, and then passed between each other to restore alignment of the distal articular block prior to applying the same principles for reducing the articular block to the shaft (Fig. 9 A-F). Alternatively, each fragment can be reduced using this technique and fixed using fragment specific fixation techniques. Bone graft or substitute can be used to fill areas of localized bone loss as needed.Fig. 9 A-F: Multifragmentary example with (A) volar rim and dorsal rim fragments, (B) insertion of subchondral pins in both fragments, (C) longitudinal traction and volar translation of the carpus, (D) alignment of the volar rim fragment, (E) alignment of the dorsal rim fragment, and (F) passage of the volar pins through the dorsal fragments to move the dorsal block of fragments as a unit. (Published with permission from Stephen A. Kennedy MD, FRCSC).Routine placement of pin fixation in the radial styloid is not needed with this technique because manual pressure on the SPAR pins tends to maintain more accurate reduction than a radial styloid pin can often maintain, and pins in the styloid can block full reduction at the time of final fixation. Reduction is necessary at the time of plate positioning on the diaphysis to ensure accurate placement, but is not necessary to hold it while screws are drilled and inserted in the shaft. During distal locking screw fixation, the alignment is held at its most anatomic position. Percutaneous radial styloid pins also risk injury to the superficial radial sensory nerve and the radial artery [2]. Small incisions can be made around SPAR pins to protect local structures, but the dorsal central wrist tends to be a watershed area between the dorsal ulnar cutaneous branch and the superficial radial nerve, so nerve injury is unlikely with percutaneous pins. I find the SPAR technique a powerful method for restoring alignment and a reproducible method for treating challenging distal radius fractures." @default.
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• W2810961570 date "2018-07-17" @default.
• W2810961570 modified "2023-09-26" @default.
• W2810961570 title "Pearls: How to Use Subchondral Pin Assisted Reduction to Restore Alignment of Distal Radius Fractures" @default.
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