title: Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius: a cadaveric study.
abstract: BACKGROUND
  Extensor tendon irritation and attritional tendon ruptures are potentially serious complications after open reduction and internal fixation of distal radius fractures. These complications are well recognized after dorsal plating of distal radii; and these are now being reported after errant screw placement during volar fixed-angle plating. Intraoperative detection of improper screw placement is critical, as corrective action can be taken before completion of the operative procedure. The purpose of this study was to define the extensor tendon compartments at risk secondary to dorsal screw penetration and to compare pronation and supination fluoroscopic images with standard lateral images in demonstrating dorsal screw prominence during volar locked plating.
  
  
  METHODS
  Eight fresh-frozen human cadaveric upper extremities underwent fixation with a volar, fixed-angle distal radius locked plate (Wright Medical Technology, Arlington, TN). Three fluoroscopic views (lateral, supinated, and pronated) followed by dorsal wrist dissections were compared to determine accuracy in detecting dorsal screw prominence and extensor tendon compartment violation. Subsequently, screws measuring 2, 4, 6, 8, and 10(mm longer than the measured depths were sequentially inserted into each distal locking screw, with each image deemed either "in" (completely inside the bone) or "out" (prominent screw tip dorsally-would typically be exchanged for a shorter screw intraoperatively).
  
  
  RESULTS
  The radial most distal locking screw (position 1) violated either the first (25%) or second (75%) extensor tendon compartments. The average screw prominence required for radiographic detection was: 6.5(mm for lateral views and 2(mm for supinated views. Pronated views did not identify prominent screws. Screws occupying plate position 2 consistently entered Lister's tubercle, with 5/8 exiting the apex and 3/8 exiting the radial base. The average screw prominences for radiographic detection were: 2.75(mm-lateral views and 3.0(mm-supinated views. Although the screws entered the second dorsal compartment, they did not encroach upon either of the tendons. Screws occupying plate position 3 violated the third extensor tendon compartment in 7/8 specimens with 1/8 exiting the Ulan base of Lister's tubercle. The average screw prominences for radiographic detection were: 3.5(mm-lateral views and 2.5(mm-pronated views. Supinated views did not identify prominent hardware. Screws occupying plate position 4 all violated the IV dorsal extensor compartment-2/8 screws were noted to tent the posterior interosseous nerve. The average screw prominences required for radiographic detection were: 4.0(mm-lateral views and 2.5(mm-pronated views. The supinated views did not identify prominent screws.
  
  
  CONCLUSIONS
  Volar fixed-angle plating has shown great promise in the advancement of distal radius fracture management. We have seen in our referral practices and in the literature an increase in the number of extensor tendon complications arising from unrecognized dorsally prominent screws, pegs, or tines. Standard PA and lateral radiographs cannot adequately visualize screw position and length secondary to the complex geometry of the dorsal cortex. We believe this study supports the routine application of intraoperative, oblique pronosupination fluoroscopic imaging for enhanced confirmation of distal locking screw position and length.
authors.affiliation: Department of Orthopedic Surgery, Cleveland Clinic, 9500 Euclid Avenue A41, Cleveland, OH, 44195, USA. maschks@ccf.org
authors.forename: Steven D
authors.initials: SD
authors.lastname: Maschke
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Evans
authors.forename: David
authors.initials: D
authors.lastname: Schub
authors.forename: Richard
authors.initials: R
authors.lastname: Drake
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Lawton
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