Minimally invasive plate osteosynthesis for distal radius fractures using a 3-point positioning technique

Abstract

Background: The volar approach with plate fixation is the gold standard for treating distal radius fractures, often requiring incision of the pronator quadratus (PQ) muscle. Preserving the PQ during surgery may facilitate early postoperative recovery. However, conventional minimally invasive plate osteosynthesis (MIPO) techniques frequently necessitate multiple (3-4) intraoperative fluoroscopic adjustments to achieve optimal plate positioning, which can inadvertently damage the PQ muscle. Based on our clinical observations, we developed a novel 3-point positioning technique to minimize PQ injury while ensuring accurate plate placement. Preliminary results demonstrate promising early clinical outcomes.

Aim: To retrospectively analyze distal radius fractures treated using the 3-point positioning-assisted MIPO technique with preservation of the PQ.

Methods: The 3-point positioning technique was applied: The Kirschner wire was inserted after fluoroscopy and was correctly adjusted the position of the plate above the PQ. With the aid of Kirschner wires positioning the PQ stripping was performed only once, and the plate then placed in a correct and satisfactory position. Operation time, incision length, wrist pain score, upper extremity function disabilities of the arm, shoulder and hand (DASH) score, wrist Gartland-Werley score, wrist grip strength, and range of motion were among the quantitative variables recorded. Qualitative variables including AO fracture classification, intraoperative and postoperative complications were evaluated.

Results: At a mean follow-up of 6.9 ± 0.8 months, the mean scar length was 25.4 ± 1.5 mm, the pain score was 0.7 ± 0.6, the DASH score for the upper limb was 4.7 ± 1.3, and the Gartland-Werley score for wrist function was 4.1 ± 1.1 at the last follow-up. Mean flexion was 97.3%, extension was 97.0%, pronation was 98.9%, supination was 98.9%, and grip strength was 86.6% compared to contralateral values. No unfavorable intraoperative or postoperative complications occurred.

Conclusion: The 3-point positioning technique may reduce the damage to the PQ muscle and is a safe and effective method for MIPO for distal radius fractures.

Keywords: 3-point positioning technology; Distal radius fractures; Minimally invasive plate osteosynthesis; Pronator quadratus sparing technique.

Figure 1

A patient with a C1 distal radius fracture underwent manual reduction and temporary Kirschner wire fixation after being anesthetized. A and B: 3D reconstruction computed tomography of the fracture; C: Closed manipulation reduction; D: A 15 mm diameter Kirschner wire was inserted from the styloid process of the radius to the ulnar side of the proximal fracture; E and F: Anteroposterior and lateral wrist joint X-rays were taken after manual reduction and temporary Kirschner wire fixation.

Figure 2

Schematic diagram of injury to the pronator quadratus during minimally invasive plate osteosynthesis with a small incision. A: The surgical incision; B: The distal margin of the pronator quadratus (PQ) was exposed; C: The PQ was incised; D: The plate was inserted beneath the PQ; E and F: Due to blind penetration, the plate may be placed on the radial or ulnar side during the operation; G and H: The PQ muscle was incised at both its origin and insertion points along the volar surface of the distal third of the radius.

Figure 3

Schematic diagram of the three-point positioning technique. A: The plate was placed above the unseparated pronator quadratus (PQ) muscle; B and C: Two 1.5 mm Kirschner wires were inserted through the radial and ulnar distal screw holes of the plate, penetrating both cortices. An additional 1.5 mm Kirschner wire was placed adjacent to the ulnar border of the plate's central portion to verify proper radial axis alignment; D: Following trimming of all three Kirschner wires to approximately 0.5 cm in length and leaving them in situ, the plate was removed and subperiosteal dissection of the PQ muscle was performed; E and F: The locking hole of the plate's distal radial and ulnar sides were "guided onto" into the two shorted Kirschner wire posts at the distal end after the plate was inserted into the tunnel from the radial edge of the proximal Kirschner wire.

Figure 4

Follow-up data of a 61-year-old woman with C1 fracture. A and B: Preoperative anteroposterior and lateral X-rays; C and D: Anteroposterior and lateral X-ray immediately after surgery; E-H: Wrist range of motion at final follow-up; I: Incision length and scar appearance.