Anatoma del radio distal y sus implicaciones

para el tratamiento de las fracturas

Christian Dumontier, MD, PhD
Guadeloupe
Presentation is available at
www.diuchirurgiemain.org

Has anatomy changed recently ?

Hippocrate

Claude
Pouteau

Abraham
Colles

Guillaume
Dupuytren

Hippocrate un-recognized the fracture: the joint dislocates

either medially or laterally

Jean-Louis Petit (1705) suggests they could be fractures

1st description by Pouteau (1725-1775) then Colles
(1814): ...The injury...has not...been described...: indeed the form of the
carpal extremity of the radius would rather incline us to question its being liable
to a fracture. The absence of crepitus and other common symptoms of
fracture together with the swelling, which instantly arises in this, as in other
injuries of the wrist, render the difficulty of ascertaining the real nature of the
case very considerable....

Joseph
Franois
Malgaigne

No, what have changed are:

The epidemic of osteoporosis:
USA: 14% males & 40% females > 50 yrs
will have a porotic Fx.
Late healing with a poor mechanical quality
of the callus
Less stability of the callus (hardware
failure)
risk of secondary displacement

The increased frequency of DRF

Frequency of DRF increases faster than the
population aging (20 to 50% according to
series)
Multiplied by 100 for females older than 40
years old. Up to 15% of white females over
50 will have a DRF

No, what have changed are:

The (close) relation between restitution of a normal
anatomy and the clinical outcomes
Experimental studies have shown:
Increase pressure and surface contact area
with radius shortening
Translation of surface contact area with dorsal
angulation
Sliding of instant center of rotation with
shortening and dorsal angulation
Clinically: Dorsal angulation with carpal
malalignement seems to be the most predictive
factor of the functional results
Use of locking plates

Why anatomy of distal radius so important if we use locking plates ?

Henrys approach has not changed

The way you manage the pronator
quadratus muscle has no clinical
consequences
Problem is with the bony anatomy

Nho JH et al. Examination of the pronator quadratus muscle during hardware removal procedures after volar plating for distal radius fractures. Clin
Orthop Surg. 2014 Sep;6(3):267-72.

Tosti R, Ilyas AM. Prospective evaluation of pronator quadratus repair following volar plate fixation of distal radius fractures. J Hand Surg Am. 2013
Sep;38(9):1678-84.

Swigart CR et al. Assessment of pronator quadratus repair integrity following volar plate fixation for distal radius fractures: a prospective clinical cohort
study. J Hand Surg Am. 2012 Sep;37(9):1868-73.

Locking plates have biomechanical

advantadges
Internal fixator (Chhabra) no
need to be stuck to bone

Conventional

Unique rigid system - Each screw

adds stability to the whole system
Experimental works suggest than
epiphyseal screws are not rigid
enough to sustain the loads in a
portico radius epiphysis
Experiments suggest the superiority
of locked plates (to conventional) in
porotic bones
Locking

However: The use of locking plates does not allow

us to forget the principles of osteosynthesis
Bone fragments must be in
contact to obtain healing
and reduced before fixation
Screws must go through
both cortices (or at least
75%)
To hold a fracture, distal
screws or pegs must be
placed within 4 mm of the
articular surface
1. Cornell, C. N.: Fixation considerations in osteoporotic bone fractures. Curr Opin Orthop, 2005; 16: 376-381.

2. Drobetz H et al. Volar fixed-angle plating of distal radius extension fractures : influence of plate position on secondary loss
of reduction : a biomechanic study in a cadaveric model. J Hand Surg Am 2006; 31 : 615-22.

3. Wall LB et al. The eects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar
locking plates. J Hand Surg Am. 2012;37(3):446e453.

Frequency of complications after

DRF ?: 21-27% - 1,5 to 2,6%
are related to the device, with
0-12 % of tendinous ruptures
Of 230 screws controlled with
sonography, the tip of 59 was
0,5 mm or over the dorsal cortex
(tenosynovitis 18 cases, ruptures
2 cases)
Intra-articular screws were
reported in 12 to 45% of cases
controlled with arthroscopy

1. Sgn TS et al. Screw prominences related to palmar locking plating of distal radius. J Hand Surg Eur Vol 2011 36:
320-324.

2. Varitimidis SE et al. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?
J Bone Joint Surg 2008;90B:778 785.

Anatomy of the anterior surface of the radius

The anterior surface is

flat up to 1 cm above
the joint line
i.e. up to the distal level
of the pronator
quadratus (11 mm above the
lunatum fossa, 13 mm above
the scaphoid fossa)

Anatomy of the anterior surface of the radius

Then concave anteriorly up to
the most anterior part called
the watershed line (the
most prominent part)
Is a plate projects distally to the
watershed line, flexor tendons
are in danger of abutment and
it increases the risk of intraarticular screw placement
FDPi & FPL are 2.2 mm
anterior to radius, 3 mm
above the watershed line
Agnew SP et al. Danger Zones for Flexor Tendons in Volar Plating of Distal Radius Fractures. J Hand Surg 2015 (in press)

However, the location of the watershed line is

highly variable

Fig. 1. Radius distal sec de face en lgre supination, de face en lgre pronation et de profil. La stylode nest pas dans le plan de lpiphyse. La prem
(double trait) du carr pronateur, termine la face plane du radius. La seconde ligne (en pointill) du partage des eaux ou watershed line , est le point le plus
du radius distal. Les implants ne doivent pas dpasser cette limite antrieure, au risque dentraner un conflit avec les tendons flchisseurs des doigts.

lpiphyse radiale cause des deux colonnes complique la mise

au point dune plaque anatomique .
2.2. Biomcanique
Les forces qui sappliquent au niveau du radius distal sont
extrmement variables : les mouvements du poignet lors
dactivit de la vie quotidienne gnrent des sollicitations qui
approchent 100 Newtons (N) (10 N = 1 kg), alors que la flexion
des doigts entrane des sollicitations moyennes de 250 N [17].
Putnam et al. ont montr que lors dune prise de poigne de 10 N,
on pouvait mesurer au niveau de la mtaphyse du radius distal
une force axiale de 26,3 N. En fait pour chaque dizaine de N
applique lors dune prise, ce sont 26 52 N qui sappliquent
sur le radius distal selon la position de la main et la longueur du
radius [18]. Mais si cette force de poigne atteint 450 N (force de
poigne moyenne chez lhomme), 2410 N sappliquent alors sur
la mtaphyse radiale. Ainsi dans certaines positions et dans
certaines prises de poigne, il peut sappliquer plus de 3000 N au
niveau du radius distal [19]. Il faut, en revanche, des
sollicitations de 2500 N pour fracturer un radius distal [20].
Lors de la rducation, les exercices de force de serrage ne
devraient pas dpasser 169 N et les exercices de mobilisation, la
moiti de la force entranant la faillite de limplant, ce qui nest

pas forcment une notion extrapolable lchelle du

Les forces entranant la faillite des systmes de fixati
troitement lies au type dostosynthse et leurs
intrinsques, et varient de 55 825 N [19].
3. Du mcanisme de la fracture son analyse
3.1. Les mcanismes de la fracture

Il ny a pas de fracture du radius distal typique

spectre lsionnel, consquence dune hyper-extension v
Pechlaner et al. [21] ont rapport les rsultats dun
cadavrique dans laquelle 63 avant-bras avaient t soll
hyper-extension sur machine. Selon la position de la
proximale du carpe lors de limpact, les pressions app
sur la surface articulaire du radius vont gnrer des f
plutt dorsales, centrales ou palmaires. Dans chacune d
localisations, les lsions ont une gravit croissante a
lsions mtaphysaire pures, puis mtaphyso-pip
(refend articulaire) et enfin avec luxation. La forme
frquente tait la forme articulaire et mtaphysai
dplacement dorsal [21]. Dans deux tiers des cas, il exi
ailleurs des lsions associes au niveau du co
triangulaire (avec ou sans avulsion de la stylode uln

[(Fig._ 2)TD$FIG]

Between individuals
Between the radial and
ulnar side of the epiphysis

Fig. 2. Aspect de trois radius secs montrant la grande variabilit du promontoire.

Imatani et al. An anatomical study of the watershed line on the volar distal aspect of the radius. J Hand Surg 2012; 37(8):1550-4

Watershed line is different from pronator

quadratus insertion

Very close to the distal PQ

laterally (red dotted line),
More distally medially
(blue dotted line)

lpiphyse radiale cause des deux colonnes complique la mise

au point dune plaque anatomique .

pas forcment une notion extrapolable lchelle du

Les forces entranant la faillite des systmes de fixati
troitement lies au type dostosynthse et leurs
intrinsques, et varient de 55 825 N [19].

Important variations of the shape of the distal

radius
2.2. Biomcanique

Les forces qui sappliquent au niveau du radius distal sont

extrmement variables : les mouvements du poignet lors
dactivit de la vie quotidienne gnrent des sollicitations qui
approchent 100 Newtons (N) (10 N = 1 kg), alors que la flexion
des doigts entrane des sollicitations moyennes de 250 N [17].
Putnam et al. ont montr que lors dune prise de poigne de 10 N,
on pouvait mesurer au niveau de la mtaphyse du radius distal
une force axiale de 26,3 N. En fait pour chaque dizaine de N
applique lors dune prise, ce sont 26 52 N qui sappliquent
sur le radius distal selon la position de la main et la longueur du
radius [18]. Mais si cette force de poigne atteint 450 N (force de
poigne moyenne chez lhomme), 2410 N sappliquent alors sur
la mtaphyse radiale. Ainsi dans certaines positions et dans
certaines prises de poigne, il peut sappliquer plus de 3000 N au
niveau du radius distal [19]. Il faut, en revanche, des
sollicitations de 2500 N pour fracturer un radius distal [20].
Lors de la rducation, les exercices de force de serrage ne
devraient pas dpasser 169 N et les exercices de mobilisation, la
moiti de la force entranant la faillite de limplant, ce qui nest

The ulnar side varies in

size and shape

3. Du mcanisme de la fracture son analyse

3.1. Les mcanismes de la fracture

Il ny a pas de fracture du radius distal typique

spectre lsionnel, consquence dune hyper-extension v
Pechlaner et al. [21] ont rapport les rsultats dun
cadavrique dans laquelle 63 avant-bras avaient t soll
hyper-extension sur machine. Selon la position de la
proximale du carpe lors de limpact, les pressions app
sur la surface articulaire du radius vont gnrer des f
plutt dorsales, centrales ou palmaires. Dans chacune d
localisations, les lsions ont une gravit croissante a
lsions mtaphysaire pures, puis mtaphyso-pip
(refend articulaire) et enfin avec luxation. La forme
frquente tait la forme articulaire et mtaphysai
dplacement dorsal [21]. Dans deux tiers des cas, il exi
ailleurs des lsions associes au niveau du co
triangulaire (avec ou sans avulsion de la stylode uln

[(Fig._ 2)TD$FIG]

Inclination is 145 at
the lunate fossa, vs
155 over the scaphoid
fossa (average 150)
[(Fig._ 3)TD$FIG]
290

Fig. 2. Aspect de trois radius secs montrant la grande variabilit du promontoire.

5)TD$FIG] 31 (2012) 287297

L. Obert et al. / Chirurgie de la[(Fig._ main

All plates are designed

with a 155 angle
Fig. 5. Mesure diffrentielle de la pente des deux colonnes, radiale gauche,
ulnaire droite.

Aucune des classifications ne remplit les trois conditions

On the radial side

There is a palpable vertical ridge
A too lateral plate will be pronated
and palpable through the skin

The radial styloid

Is not in the same plane
as to the anterior surface
of the radius
Plates should include a
special orientation for the
screws in the radial styloid

As a consequence

Most of the designed

locking plates do not fit
with the anatomy
(Between 3 to 6% of
contact zones)

Buzzell JE, Weikert DR, Watson JT, Lee DH. Precontoured fixed-angle volar distal radius plates: a
comparison of anatomic fit. J Hand Surg Am 2008;33:114452.

The radial septum is made by the

1st compartment and the distal
tendon of the brachioradialis
It limits the surgical extension
laterally
In DRFx, the distal epiphysis is
pulled in supination and proximally
by the brachioradialis tendon
When using anterior plates, the
BR tendon must be either cut or
lengthen to correctly reduce and
fix the epiphysis and the radial
septum must be divided (which
has no clinical consequences on
the strength in supination)

On the lateral side

Vascular anatomy
Vascularization of the distal epiphysis is
made by branches of the anterior and
posterior interosseous arteries
Avoid injuries to the medial part of the
radius

Dorsal side
Highly contoured shape of the
dorsal side
Extensor tendons are located
into gutters
The height of Listers tubercle
varies from 3,3 to 6,6 mm,
and the depth of the gutter of
the EPL may be as deep as
3,2 mm !

Variations in the depth of the radius from

medial to lateral
The width of the radius at the level of
Listers tubercle is 22 +/- 2 mm (do not
use screw longer than 20 mm at that level)

Ljungquist KL et al.Predicting a Safe Screw Length for Volar Plate Fixation of Distal Radius Fractures:
Lunate Depth as a Marker for Distal Radius Depth. J Hand Surg Am. 2015;40(5):940e944.

Surgical consequences
A screw must be 6,5 mm
longer than the cortical bone
in the radial side, and 3 mm
in the ulnar side to be seen
on the lateral view !
If you do lateral view with
pronation and supination, a
screw should be at least 2-3
mm longer than the cortical
bone to be seen
1. Maschke SD et al. Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius:
a cadaveric study. Hand 2007;2:144 150.

Surgical consequences
Use special fluoroscopic incidences
Skyline view (2010).
Sensibility, specificity and diagnostic
precision was 83% for screw longer
than 1 mm (compared to 77% for
pronation views and 51% for the
lateral view)

1. Riddick AP et al. Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius
fixation. J. Hand Surg. (Eur. Vol.) 2012; 37E(5) 407411.

Example: cadaveric study with the skyline view

The dorsal horizon view

Using this incidence, Joseph and

Harvey had to changed 26% of their
screws

1. Joseph SJ, Harvey JN. The Dorsal Horizon View: Detecting Screw Protrusion at the Distal Radius. J Hand Surg
2011;36A:16911693

Medial side: the DRUJ

Trochod joint
Allows a normal rotation of 140-150

The DRUJ is highly unstable

It presents bony
reinforcements to resists
subluxating forces

The DRUJ is part of the injury

Radius and ulna form a
frame
A displaced DRF implies
that there are lesions on the
ulna and/or ligaments
Up to now, management of
ulnar styloid fractures is not
correlated with outcomes
Souer JS et al. Eect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw
fixation of a distal radial fracture. J Bone Joint Surg Am. 2009 Apr;91(4):830-8

The articular surface

Frontal inclination is
about 22
Sagittal inclination is
7-10
In the frontal plane,
the scaphoid fossa is
more concave than
the lunate fossa

?
Anatomy explains why 12-30% of distal screws
are intra-articular !
To avoid mis-placement of distal screws:
Start with the most medial screws
Fluoroscopic control with variation on the
angulation: AP with 10 of beam inclination;
lateral with 10 (medial side) and 20 of
inclination (lateral side)

10 angulation
helps to study
the articular
surface in the
frontal plane

20 angulation
helps to study
the articular
surface in the
sagittal plane

And for the restitution of articular

surfaces ?
There is no anatomical
landmarks you may use
Only visualization either with
a fluoroscope (accuracy 1,5
mm) or with an arthroscope
Restauration of articular
surface under arthroscopic
control improves outcomes
Doi K et al. Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduction
compared with open reduction and internal fixation. J Bone Joint Surg Am. 1999 Aug;81(8):1093-110

Conclusions
Anatomy has not changed
But it is our search for improving functional outcomes that
prompt us to design new implants
The use of these new implants has changed our knowledge
of the anatomy which is obviously more complex than
previously thought