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Minimally Invasive Plate Osteosynthesis of Distal Radius Fractures
Key Points
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The minimally invasive approach of the flexor carpi radialis can be used for volar plate fixation of distal radius fractures.
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The upsides of this technique are the preservation of the ligamentotaxis to facilitate the reduction of the fracture and the small size of the incision to improve the cosmetic results of the procedure.
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The incision can always be extended in case of difficulties of reduction.
Acknowledgment
Pr François Severac, Marie Mielcarek, Public Health Department and Statistics, Strasbourg University Hospitals, France.
Conflicts of Interest
Philippe Liverneaux has conflicts of interest with Argomedical, Newclip Technics. None of the other authors have conflicts of interest.
Panel 1: Case Scenario
A 49-year-old, left-handed female director of a cosmetic enterprise sustained a dorsally displaced extraarticular distal radius fracture when walking her dog. Radiographs show 25 degrees of dorsal angulation and dorsal metaphyseal comminution. In your office she immediately states that she refuses surgery as she does not accept any large scar on her wrist. You esteem that casting nor K-wire fixation will yield sufficient stability in her mild osteoporotic bone and comminutive fracture, for which you recommend plate fixation. What are the advantages and drawbacks for minimal invasive plate fixation?
Importance of the Problem
Since the year 2000, the fixation of distal radius fractures by volar locking plate has become the gold standard. Three surgical approaches have been described: conventional, extended, and minimally invasive.
The conventional approach of the flexor carpi radialis (FCR) ( Fig. 1 A ) has been developed to treat volar tilt fractures. It corresponds to the distal part of the Henry Approach and is less aggressive for the extensor tendons than dorsal approaches. It also enables the fixation of dorsal tilt fractures where the reduction is facilitated by ligamentotaxis.
The extended approach of the FCR ( Fig. 1 B) is used for dorsal tilt fractures. The incision is 8–10 cm long. The distal edge of the pronator quadratus (PQ) forms a transverse line on the surface of the radius called the watershed line beyond which the plate should not be positioned to avoid conflicts with the flexor tendons. The PQ is elevated to expose the fracture site without risk of necrosis for some authors, and with a risk of necrosis for others. MIPO enables the mobilization of the proximal end of the radius in pronation through the fracture site giving a large exposure. Ligamentotaxis is limited with this technique.
Minimally invasive plate osteosynthesis (MIPO) techniques were developed for hip, knee, ankle, shoulder, and elbow surgeries. They aim at preserving bone vascularization, improve bone healing, reduce the rate of infections, ease the reduction of the fracture using ligamentotaxis, and meet the cosmetic expectations of the patients.
For the wrist, the concept is raised in 2000. It has been reported to improve bone healing because of the preservation of the periosteum and PQ at the fracture site unlike in the traditional approach. The cosmetic benefit is notable.
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