distal radius fixation through a mini-invasive approach of 15 ......lower limb orthopedic surgery:...
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ORIGINAL ARTICLE
Distal radius fixation through a mini-invasive approachof 15 mm. PART 1: a series of 144 cases
Frederic Lebailly • Ahmed Zemirline •
Sybille Facca • Stephanie Gouzou • Philippe Liverneaux
Received: 21 October 2013 / Accepted: 3 November 2013
� Springer-Verlag France 2013
Abstract The volar Henry approach is becoming the gold
standard for distal radius fracture fixation. It decreases the
incidence of nonunion, limits complications especially
complex regional pain syndrome (CRPS) type I, and allows
early mobilization of the wrist. Nonetheless, it has some
disadvantages such as the size of the incision, which is not
esthetically pleasing, and the loss of ligamentotaxis. This is
why some authors have developed a mini-invasive approach.
The aim of this work was to evaluate the feasibility of the
anterior mini-invasive approach of 15 mm in a clinical series
of 144 cases of distal radius fracture. All patients were
operated under regional anesthesia using the same tech-
niques by five surgeons of the same team. According to the
AO classification, there were 83 type A fractures, 2 type B,
and 59 type C. A volar plate (Step One�, Newclip Tech-
nicsTM, Haute-Goulaine, France) was used in all cases. The 2
proximal metaphyseal screws and the 2 distal central
epiphyseal screws were monoaxial locking. The 2 distal
ulnar and radial epiphyseal screws were placed in polyaxial
locking at 20� angulation maximum. Skin closure without
drainage was performed. No postoperative immobilization
was prescribed, and patients were encouraged to use their
upper limb immediately postoperative. No postoperative
physiotherapy was prescribed. The mean follow-up was
4.1 months. The final size of the incision was on average
16.1 mm. Mean pain score was 1.8. The Quick DASH score
was average 25. Average range of motion was more than
85 %, and global force of the hand was 67 % compared with
contralateral side. On X-ray, the mean radial slope was 22�,
the mean radial tilt was 8.3�, and the mean radioulnar vari-
ance/index was -0.4 mm. There were nine cases of CRPS
type I, which all resolved. Specific complications included
two secondary displacements and nine tenosynovitis cases.
No tendon rupture was noted. Two intra-articular distal ra-
dioulnar joint screws had to be removed at 3 months. One
epiphyseal screw required removal 1 month postoperative
due to loosening. There were no intra-articular radiocarpal
screws. Distal radius fracture fixation using a mini-invasive
approach is a reliable and reproducible procedure with few
complications. It allows anatomical reduction in the distal
radius fractures including intra-articular ones. It can be
associated with arthroscopy, scaphoid screw fixation or even
percutaneous pinning. Thus, most traumatic lesions of the
wrist bony or soft tissue can be treated through this mini-
invasive approach.
Keywords Minimally invasive surgical procedure �Fracture fixation � Bone plates � Wrist � Distal radius
Introduction
Mini-invasive surgery has been gradually established in
lower limb orthopedic surgery: percutaneous surgery of the
foot, knee arthroscopy, hip and knee prostheses and fixation
of trochanteric fractures [1]. It is essential to define precise
anatomical landmarks for this surgical approach, appropri-
ate placement of material and equipment, and description of
fracture reduction and implant placement techniques.
At the wrist, only the posterior approach for placement of
a centromedullary nail can be considered mini-invasive [2,
3]. But this technique is only valid for extra articular distal
radius fractures and is used by only a few authors [4]. It is the
anterior Henry approach that is becoming the gold standard,
F. Lebailly � A. Zemirline � S. Facca � S. Gouzou �P. Liverneaux (&)
Hand Surgery Department, Strasbourg University Hospitals,
10 Avenue Baumann, 67403 Illkirch Cedex, France
e-mail: [email protected]
123
Eur J Orthop Surg Traumatol
DOI 10.1007/s00590-013-1363-2
Table 1 Casuistics of type A and B fractures
No. Age (years) Sex F/M Dominant side Affected side Classification AO Lesions associated Treatment of associated lesion
1 86 F R R A3.2
2 89 F L L A2.2
3 74 F R L A3.2
4 24 M R L A3.2
5 87 F R R A2.2
6 68 F R L A3.2
7 86 F R L A2.2
8 43 F R L A2.2
9 41 F R R A3.2
10 58 F R R A2.2
11 86 F L L A2.2
12 64 F R L A3.2
13 57 M R R A2.2 Scapholunate rupture Arthroscopic debridement and
pinning
14 52 F R L A2.2
15 31 F R L A2.2
16 79 F R R A3.2
17 84 F R L A2.2
18 80 M R L A3.2
19 84 F R L A2.2
20 53 M R R A3.2
21 23 M R L A2.1
22 43 F R R A2.2
23 65 F R L A2.2
24 59 F R R A2.2
25 72 F R R A3.2
26 69 F R L A3.2
27 74 F R L A3.2
28 61 F R R A2.2
29 65 F R L A2.2
30 81 F R L A2.2
31 53 F R R A2.2
32 29 F R L A2.2
33 41 F L L A2.2
34 103 F R R A3.2
35 26 M R R A3.2
36 59 F R R A3.2
37 43 M R L A2.2
38 57 F R L A2.2
39 33 F R R A2.2
40 63 F R L A2.2
41 16 M L R A3.2
42 45 M R L A2.2
43 57 F R L A2.2
44 73 F R R B3.3
45 78 F R R A2.2
46 82 F R R A3.2 Ulnar neck fracture
47 68 F R R A2.2
48 79 F R R A3.3
Eur J Orthop Surg Traumatol
123
thanks to the wide use of anterior locking plates for distal
radius fracture fixation. It decreases the incidence of non-
union, limits complications especially complex regional
pain syndrome (CRPS) type I, and allows early mobilization
of the wrist [5]. Nonetheless, it has some disadvantages such
as the size of the incision, which is not esthetically pleasing,
the loss of ligamentotaxis associated with the detachment of
the articular bony fragments from their ligament, capsule and
muscle attachments. This is why some authors have devel-
oped a mini-invasive approach [6].
The aim of this work was to evaluate the feasibility of
the anterior mini-invasive approach of 15 mm in a clinical
series of 144 cases of distal radius fracture.
Materials and methods
Between February and July 2012, 188 patients were
operated in our unit for distal radius fractures. Among
these, 144 were operated using a mini-invasive approach
Table 1 continued
No. Age (years) Sex F/M Dominant side Affected side Classification AO Lesions associated Treatment of associated lesion
49 65 F R R A2.2
50 63 F R L A2.2 EPL rupture Transfer of EIP and splinting
3 weeks
51 68 F R L A3.2
52 82 F R R A3.2
53 47 M R L A2.2
54 76 F R R A3.2 Ulnar neck fracture
55 79 F R L A3.2
56 72 F R R A2.3
57 86 F R L A2.3
58 69 F R R A2.3
59 91 F R R A3.2
60 99 F R R A3.2
61 17 F R R A2.2
62 87 F R R A2.2
63 55 F R R A2.2
64 51 F R L A3.2
65 39 M R L A2.2
66 69 F R L A2.2
67 35 F R R A2.2
68 16 M R L A2.3
69 94 F R L A3.1
70 70 F R L A3.2
71 74 F R L A3.3
72 26 F R R A2.2 Ulnar nerve contusion
73 35 M R R A2.2
74 88 F R L A3.2
75 72 F R L A3.2
76 31 F R R A2.2
77 25 M R L A3.2
78 86 F R L A3.2
79 56 M R L B3.2 Kienbock stage IV
80 65 F R R A3.2
81 83 F R R A2.2 Median nerve contusion
82 89 F R L A2.2 Ulnar neck fracture
83 73 F R R A3.2
84 33 M R L A3.2 Median nerve contusion
85 54 F R R A3.2
Eur J Orthop Surg Traumatol
123
Table 2 Casuistics of type C fractures
No. Age
(years)
Sex
F/H
Dominant
side
Affected
side
Classification
AO
Lesions associated Treatment of associated lesion
86 61 F R L C1.3
87 82 F R L C3.1
88 60 F R R C3.1
89 75 F L L C2.2
90 53 H R R C3.2
91 60 F R R C2.1
92 51 F R R C2.1
93 49 F R R C1.2
94 76 F R L C2.3
95 46 F R R C2.1
96 66 H L R C1.1
97 61 F R R C2.3
98 83 H R L C3.1
99 56 F L L C2.3
100 52 F R R C1.2
101 75 F R R C3.1
102 68 F R L C2.3
103 71 F R L C3.1 Degenerative scapholunate
rupture
104 55 F R L C1.3
105 62 F R L C3.1
106 61 F R R C3.1
107 22 F R L C2.1
108 87 F R L C2.2
109 81 H R R C2.2
110 89 F R R C2.2
111 57 F R L C1.1
112 48 H R L C1.2
113 88 F R L C2.2
114 78 F R L C1.2 Degenerative scapholunate
rupture
115 54 H R L C3.1
116 88 F R R C3.1
117 53 F R L C3.1 Fracture proximal humerus Orthopedic treatment
118 65 F R R C1.3
119 78 F R R C1.3
120 29 F L R C1.2 Rupture scapholunate Arthroscopic debridement and
pinning
121 29 F R L C1.1 Rupture scapholunate Arthroscopic debridement and
pinning
122 33 F R R C1.2 TFCC peripheral detachment Arthroscopic re-insertion
123 42 F L R C2.2 Fracture ulnar neck
124 79 F R R C3.3
125 50 F R L C2.3
126 57 H R R C2.3 Scaphoid Fracture Percutaneous screw fixation
127 65 F L L C1.2
128 42 H R L C3.2 Rupture scapholunate Arthroscopic debridement and
pinning
129 67 F L L C1.2
Eur J Orthop Surg Traumatol
123
(Tables 1, 2). The mean age was 63 with extremes of 16
and 103 years. The sex ratio was 4.8. The dominant side
was affected in 50 % of cases. According to the AO
classification, there were 83 type A fractures, 2 type B,
and 59 type C. Associated lesions included 6 scapholu-
nate ligament ruptures, 4 of which were recent, 1 TFCC
tear type 1B Palmer, 1 scaphoid fracture, 4 ulnar neck
fractures, 3 nerve contusions: 2 median and 1 ulnar.
All patients were operated under regional anesthesia
using the same techniques by five surgeons of the same
team. Most patients were seen in emergency and
rescheduled to day surgery. An anterior plate (Step
One�, Newclip TechnicsTM, Haute-Goulaine, France)
was used in all cases. The 2 proximal metaphyseal
screws and the 2 distal central epiphyseal screws were
monoaxial locking. The 2 distal ulnar and radial epiph-
yseal screws were placed in polyaxial locking at 20�angulation. The reduction fixation technique is described
step-by-step in Figs. 1, 2, 3, 4, 5, 6, 7 and 8. Skin
closure without drainage was performed. No postopera-
tive immobilization was prescribed, and patients were
encouraged to use their upper limb immediately post-
operative. No postoperative physiotherapy was
prescribed.
In case of intra-carpal lesions, a mini-invasive technique
was used in the same procedure. The scaphoid fracture was
fixed using retrograde percutaneous screws with 6 weeks
postoperative splinting. The 4 scapholunate ruptures were
treated arthroscopically by pinning and splinting for 6 weeks.
Results were evaluated using perioperative, clinical and
radiological data.
The size of the incision was measured in millimeters;
the tourniquet time was noted in minutes, and the dosim-
etry was measured in milli Grays at the end of surgery.
Clinical criteria at final follow-up included pain mea-
sured on VAS from 0 (no pain) to 10 (maximum pain
imaginable). The global hand function was evaluated using
the quick D.A.S.H. score from 0 (normal upper limb
function) to 100 (no upper limb function). Wrist mobility
was measured in flexion, extension, pronation and supi-
nation. The results were expressed in percentage of
Table 2 continued
No. Age
(years)
Sex
F/H
Dominant
side
Affected
side
Classification
AO
Lesions associated Treatment of associated lesion
130 70 F R R C3.1
131 87 F R L C1.2
132 88 F R L C3.1
133 69 F R R C3.1
134 69 F R R C3.1
135 90 F R L C1.2
136 81 F R L C2.3
137 65 F R R C3.1
138 61 F R R C3.2
139 57 F R R C2.3
140 83 F R R C3.1
141 84 F R R C2.3
142 61 F R R C3.1
143 23 H R L C1.1
144 58 F R L C3.1
Fig. 1 Design of the incision. The most distal point is situated
20 mm from the radial styloid. The incision is extended 15 mm from
this point proximal along the Henry approach between the flexor carpi
radialis and radial artery
Eur J Orthop Surg Traumatol
123
contralateral limb function. Force was measured using the
Jamar dynamometer placed in position 2 (Sammsons
Preston RyolanTM, Bolingbrook, IL, USA). The results
were expressed in percentage of the contralateral side.
Radiological criteria included radial slope and radial
tilt in degrees, and the distal radioulnar index or variance
in millimeters was measured on standard PA and lateral
X-rays after consolidation at final follow-up.
Results
The mean follow-up was 4.1 months with extremes of 0.3
and 9.8. The results analysis is presented in Tables 3 and 4.
Clinically, the initial incision was 15 mm in all cases, and
the final size was on average 16.1 mm (15–40). Average
Fig. 2 The plate is introduced. The distal border of pronator
quadratus is incised transversely, then dissected subperiosteally
longitudinally off the radial metaphysis proximally. The plate with
2 drill guides fitted in the distal epiphyseal holes is introduced,
proximal part first, beneath the released pronator muscle
Fig. 3 Positioning of the pivot point of the plate. A 2-mm K-wire is
introduced into the ulnar-most guide and drilled while mobilizing the
plate to find the most ulnar and distal point of the anterior radius.
Position is checked using the fluoroscope especially on lateral view
where the pin must be applied onto the subchondral bone. If the
position is unsatisfactory, the pin is withdrawn, the plate moved and
the pin re-drilled until a satisfactory position is obtained. At this stage,
only the position of the K-wire at the ulnar pivot point of the plate is
controlled. The plate is not applied on the proximal fragment of the
radius
Fig. 4 Orientation of the plate on the distal radial diaphysis. A 2-mm
K-wire is introduced in the radial-most drill guide, drilled while
mobilizing the plate to find the most radial and distal point of the
anterior radius. Position is checked using the fluoroscope especially
on lateral view where the pin must be applied onto the subchondral
bone. If the position is unsatisfactory, the pin is withdrawn, the plate
moved and the pin re-drilled until a satisfactory position is obtained.
At this stage, only the position of the plate in relation to the radial
styloid is controlled. The plate is not applied on the proximal
fragment of the radius
Fig. 5 Plate fixation on the distal epiphysis of the radius. The 2
central fixed-angle epiphyseal screws are fixed. If the plate is not
firmly applied to the radius, an additional non-locking lag screw is
used to compress the plate to the radius. The 2 radial and ulnar fixed-
angle epiphyseal screws are placed. The orientation of these 2 screws
depends on the fracture line, and the displacement of the radial styloid
and the posteromedial fragments
Eur J Orthop Surg Traumatol
123
tourniquet time was 48 min (17–136). Mean operative
dosimetry was 2.6 mG (0.6–8.6). The mean tourniquet time
was 43 min for type A fractures, 55.3 for type C fractures,
and 105 min when an associated procedure was performed (5
arthroscopies and 1 scaphoid screw). In 10 cases, plate
removal was performed through a 12.9-mm starting incision
reaching 13.1 mm at the end of the operation.
Mean Pain score was 1.8 (0–6). The Quick D.A.S.H.
score was average 25 (0–82). Average range of motion in
flexion was 86 %, extension 86 %, pronation 96.4 % and
supination 91.2 %. Global force of the hand was 67 %
(0–167). Twenty-eight patients (19.4 %) had physiotherapy
after radiological consolidation.
On X-ray, the mean radial slope was 22� (7–45); the
mean radial tilt was 8.3 (-7 to ?20); and the mean ra-
dioulnar variance/index was -0.4 (-5 to ?5).
There was no infection, but general complications
included 9 cases of CRPS type I, (6.3 %), which all
Fig. 6 Preparation of the proximal plate. Two drill guides are
screwed on the holes of the proximal fixed-angle screws
Fig. 7 Reduction in the fracture onto the plate. The plate is applied
and orientated on the anterior cortex of the metaphysis by pressure. A
drill bit of 2 mm is introduced into the most proximal drill guide and
driven through the 2 cortices of the metaphysis. It is left in place to
stabilize the plate, and a second drill bit is driven into the most distal
guide through both cortices and withdrawn. The distal screw is
inserted. If the plate is not firmly applied to the radius, a lag screw is
driven into the oblong slot for further compression of the plate to the
bone. Then the proximal screw is placed
Eur J Orthop Surg Traumatol
123
resolved. Specific complications included 2 secondary
displacements, of which one was re-operated with a good
final outcome. There were 9 tenosynovitis cases, 3 of
which involved the long fingers, 3 the Flexor Pollicis
Longus and 3 the tendons of the first extensor compart-
ment. All resolved after plate removal. No tendon rupture
was noted.
Two intra-articular distal radioulnar joint screws had to
be removed precociously at 3 months. One epiphyseal
screw required removal 1 month postoperative due to
loosening.
There were no intra-articular radiocarpal screws.
Discussion
Mini-invasive surgery is the current trend in all specialties,
not only for obvious esthetic considerations, but also for
technical and physiological reasons. A limited approach
has been shown to spare the ligament and muscle attach-
ments of the distal radius and carpus, thus facilitating
fracture reduction by ligamentotaxis [7–9]. This concept is
completely contradictory to that developed/proposed by
Orbay et al. [10] who advocate an almost total denudation
of the radius for fixation of complex fractures with anterior
plates. A limited approach avoids ischemia and necrosis of
the small articular fracture fragments and nonunion noted
in cases of extensive approach with periosteal stripping in
patients with comorbidities [11]. Finally, a limited
approach preserves the fracture hematoma promoting
consolidation [12].
All mini-invasive techniques entail a learning curve
[13], and prior cadaveric training is recommended to avoid
tendon and joint complications with this approach.
Tenosynovitis is a possible but rare complication in our
series (9 cases). No tendon ruptures were noted such as
those encountered in other series using the same anterior
plates [14, 15]; this is probably due to meticulously
avoiding any contact with the flexor tendons. The quality
of the reduction and restoration of the natural radial slope
as well as the low profile of the anterior plates help keep
the anterior radius away from the flexor tendons. However,
A theoretical risk of flexor tendon entrapment by the plate
does exist. It is thus essential to verify free excursion of
thumb and digit flexor tendons at the start and end of the
operation, possibly by placing them on a silicon sling.
In two cases, a screw protruding into the distal radio-
ulnar joint necessitated early removal. Theoretically, if the
joystick K-wire in the ulna is well positioned (Fig. 3), this
complication should not happen. However, when this
K-wire is replaced with a screw using a variable angle hole,
this screw can take a different direction while tightening,
especially to fix a displaced posterior ulnar fragment. It is
very important to always verify complete passive mobility
after all the screws are fixed on the plate at the end of the
operation. This is equally important in the mini-invasive
technique, and our distal radioulnar intra-articular screws
were due to negligence to check pronosupination and
X-rays of the distal radioulnar joint. This is a fault of the
operator and not of the technique itself.
In one case, the epiphyseal screw loosened secondarily
and was removed 1 month postoperative with a good final
result. This was due to a faulty screw initially, and not to
the mini-invasive technique itself. We recommend the
habitual use of a dynamometric screw to avoid this
complication.
We noted 2 secondary displacements. In one case, it was
due to a technical fault using an epiphyseal screw that was
too short. The posterior displacement was less than 30� in
an 83-year-old patient with limited functional demand, and
she was not re-operated. In the second case, the posterior
displacement was due to a second fall and the patient was
re-operated with good results.
CRPS type I were rare in our series (9 cases), as in with
anterior plate series, whereas this complication is fairly
common with K-wires [16]. This is due to early mobili-
zation thanks to a stable fixation with plates. With 15 mm
incisions, patients are reassured and keen to move their
wrists early.
The use of arthroscopy recommended by many authors
is the treatment of distal radius fractures when intra-artic-
ular reduction is difficult or when an associated carpal
ligament lesion is suspected [17–19]. We agree with this
Fig. 8 Closure. The flexor tendon excursion is verified. The quality
of the fracture reduction and the position of the plate and screws are
verified radiologically before skin closure
Eur J Orthop Surg Traumatol
123
Ta
ble
3R
esu
lts
of
typ
eA
etB
frac
ture
s
No
.In
cisi
on
(mm
)
To
urn
iqu
et
tim
e(m
in)
Do
sim
etry
(mG
y)
Fo
llo
w-u
p
(mo
nth
s)
VA
S(/
10
)
Qu
ick
DA
SH
(/1
00
)
Fle
x.
(%)
Ex
t.
(%)
Pro
.
(%)
Su
p.
(%)
Fo
rce
(%)
Vo
lar
tilt
(�)
Rad
ial
tilt
(�)
Ind
exR
UD
(mm
)
Co
mp
lica
tio
ns
13
03
31
.61
.43
27
10
01
00
10
01
00
10
07
18
0
21
55
19
.81
99
31
08
10
01
00
64
-6
19
1
31
56
92
.9L
ost
02
40
41
53
81
.4L
ost
10
19
-2
51
53
31
.8L
ost
12
30
61
53
11
.06
.62
59
49
21
00
10
07
31
12
0-
1F
PL
ten
din
itis
71
53
11
.05
.85
43
10
06
71
00
11
46
32
17
0F
PL
ten
din
itis
81
86
25
.28
.02
91
07
13
01
00
71
71
20
22
0
91
55
02
.09
.31
11
10
89
21
00
10
03
31
42
30
De
qu
erv
ain
ten
din
itis
10
15
37
1.2
8.0
52
79
49
21
00
10
06
04
26
0C
arp
altu
nn
el
syn
dro
me
11
15
64
4.1
2.7
02
78
71
10
08
94
05
30
3
12
15
50
7.2
8.0
19
60
73
10
67
58
21
12
82
SD
RC
de
typ
eI
13
15
89
8.6
5.2
66
87
77
81
00
10
06
07
20
-1
14
15
43
1.6
7.9
22
01
00
11
19
41
06
94
02
00
15
15
36
2.2
8.6
00
10
01
00
10
01
00
10
00
24
0
16
15
48
3.1
3.5
00
80
10
01
00
10
01
67
16
19
0
17
20
63
5.1
Lo
st6
23
-1
De
qu
erv
ain
ten
din
itis
18
15
35
2.8
5.9
05
10
98
31
00
10
01
23
41
61
Car
pal
tun
nel
Sy
nd
rom
e
19
20
45
2.6
Lo
st5
24
0
20
15
83
5.1
8.3
21
11
25
80
10
09
41
33
13
25
-1
21
15
27
2.5
Lo
st1
82
00
22
15
31
1.5
4.4
67
78
01
00
10
09
43
81
72
60
De
qu
erv
ain
ten
din
itis
23
15
59
3.7
4.5
02
59
64
94
82
62
-2
18
0
24
15
34
1.4
5.8
39
10
01
10
10
01
00
10
01
32
40
Car
pal
tun
nel
syn
dro
me
25
15
28
1.6
7.0
00
10
81
00
10
01
00
90
13
27
-1
26
15
47
1.5
5.9
23
11
00
10
01
00
10
09
08
18
0
27
15
40
1.0
5.5
12
86
10
91
00
10
07
41
21
81
28
15
23
0.7
6.7
00
10
71
20
10
01
00
10
91
22
1-
3
29
15
41
1.0
6.6
01
11
16
13
01
00
10
01
00
41
9-
1
30
15
30
1.8
1.7
33
6.3
69
08
21
00
10
06
70
25
-5
Eur J Orthop Surg Traumatol
123
Ta
ble
3co
nti
nu
ed
No
.In
cisi
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(mm
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To
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iqu
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tim
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mp
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31
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26
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10
01
08
10
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00
11
41
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60
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15
48
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23
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01
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10
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22
0
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25
34
1.4
1.6
35
97
39
01
00
88
67
10
13
0
35
15
80
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35
77
96
71
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10
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31
72
3-
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36
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21
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54
31
00
92
10
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42
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22
-1
37
15
64
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02
86
10
01
00
10
09
49
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0
38
15
30
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00
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49
49
61
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24
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32
09
41
00
10
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72
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41
15
52
1.6
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76
10
01
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10
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56
26
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42
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49
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41
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10
01
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70
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43
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50
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41
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10
01
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86
72
21
44
15
35
1.3
3.1
24
36
78
61
00
10
06
31
22
30
45
15
72
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2.8
02
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58
76
41
00
10
08
81
42
01
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pal
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nel
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nd
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46
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57
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81
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72
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69
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1.5
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tra-
arti
cula
r
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w
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66
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st9
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Eur J Orthop Surg Traumatol
123
Ta
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63
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64
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67
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31
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1
69
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60
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79
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71
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74
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FD
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78
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25
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75
10
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54
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45
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n
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85
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25
0
Eur J Orthop Surg Traumatol
123
Ta
ble
4R
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lts
of
typ
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frac
ture
s
No
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(mm
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To
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86
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70
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06
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92
94
10
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69
62
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52
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3.2
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82
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91
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80
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92
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46
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26
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93
15
33
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50
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12
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16
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94
38
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96
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97
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73
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76
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11
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32
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54
92
10
01
00
10
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92
20
CR
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typ
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10
11
53
72
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10
86
83
10
01
00
67
11
20
0
10
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80
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94
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21
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11
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00
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58
89
69
75
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51
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pla
cem
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11
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59
64
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10
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11
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34
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55
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75
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10
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91
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09
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08
31
92
50
Eur J Orthop Surg Traumatol
123
Ta
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4co
nti
nu
ed
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cisi
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(mm
)
To
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tim
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lar
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Rad
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Ind
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)
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mp
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12
01
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18
78
68
28
98
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11
51
08
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08
68
84
42
61
53
02
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51
20
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01
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48
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12
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50
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71
55
42
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20
63
67
10
08
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52
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12
81
51
36
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77
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53
44
72
93
12
91
55
63
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97
18
31
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01
00
42
30
13
01
56
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13
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36
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67
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13
51
52
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79
67
10
08
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61
52
74
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71
54
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07
11
02
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08
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77
10
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0
13
91
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54
59
56
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50
10
09
45
01
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14
11
58
26
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02
96
61
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10
09
04
01
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42
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on
dar
y
dis
pla
cem
ent
14
21
55
66
.51
.92
22
64
50
88
94
47
82
40
14
31
54
62
Lo
st0
15
24
-1
14
41
52
.41
.45
70
69
86
10
08
82
91
52
51
Uln
ar
acro
par
esth
esia
Eur J Orthop Surg Traumatol
123
view and used arthroscopy in 5 cases in our series where
there were associated intra-carpal ligament lesions. Nev-
ertheless, it seems paradoxical to combine a mini-invasive
technique such as arthroscopy with the classic open ante-
rior approach to distal radius fractures. It seems more
appropriate to couple arthroscopic intra-carpal ligament
repair with a mini-invasive approach of the fracture.
In conclusion, based on our series of 144 cases, distal
radius fracture fixation using the mini-invasive approach is
a reliable and reproducible procedure with few complica-
tions. It allows anatomical reduction in the distal radius
fractures including intra-articular ones. It can be associated
with arthroscopy, scaphoid screw fixation or even percu-
taneous pinning. Thus, most traumatic lesions of the wrist
bony or soft tissue can be treated through this mini-inva-
sive approach.
Conflict of interest Philippe Liverneaux is a consultant for Newclip
Technics, Small Bone Innovation, Integra, and Argomedical. Dr.
Lebailly, Dr. Zemirline, Dr. Facca, Dr. Gouzou have no conflict of
interest to declare.
References
1. Scuderi GR, Tria AJ (2010) Minimally invasive surgery in
orthopedics. Springer, Berlin
2. Konstantinidis L, Helwig P, Seifert J, Hirschmuller A, Liodakis
E, Sudkamp NP, Oberst M (2011) Internal fixation of dorsally
comminuted fractures of the distal part of the radius: a biome-
chanical analysis of volar plate and intramedullary nail fracture
stability. Arch Orthop Trauma Surg 131:1529–1537
3. Orbay J (2005) Volar plate fixation of distal radius fractures.
Hand Clin 21:347–354
4. Burkhart KJ, Nowak TE, Gradl G, Klitscher D, Mehling I, Mehler
D, Mueller LP, Rommens PM (2010) Intramedullary nailing vs.
palmar locked plating for unstable dorsally comminuted distal
radius fractures: a biomechanical study. Clin Biomech (Bristol,
Avon) 25:771–775
5. Lattmann T, Dietrich M, Meier C, Kilgus M, Platz A (2008)
Comparison of 2 surgical approaches for volar locking plate
osteosynthesis of the distal radius. J Hand Surg Am 33:1135–1143
6. Zenke Y, Sakai A, Oshige T, Moritani S, Fuse Y, Maehara T,
Nakamura T (2011) Clinical results of volar locking plate for
distal radius fractures: conventional versus minimally invasive
plate osteosynthesis. J Orthop Trauma 25:425–431
7. Bindra RR (2005) Biomechanics and biology of external fixation
of distal radius fractures. Hand Clin 21:363–373
8. Geissler WB, Fernandes D (2000) Percutaneous and limited open
reduction of intra-articular distal radial fractures. Hand Surg
5:85–92
9. Kapandji A (1987) Intra-focal pinning of fractures of the distal
end of the radius 10 years later. Ann Chir Main 6:57–63
10. Orbay JL, Touhami A, Orbay C (2005) Fixed angle fixation of
distal radius fractures through a minimally invasive approach.
Tech Hand Up Extrem Surg 9:142–148
11. Segalman KA, Clark GL (1998) Un-united fractures of the distal
radius: a report of 12 cases. J Hand Surg Am 23:914–919
12. Kolar P, Schmidt-Bleek K, Schell H, Gaber T, Toben D,
Schmidmaier G, Perka C, Buttgereit F, Duda GN (2010) The
early fracture hematoma and its potential role in fracture healing.
Tissue Eng Part B Rev 16:427–434
13. Thornhill TS (2004) The mini-incision hip: proceed with caution.
Orthopedics 27:193–194
14. Cognet JM, Dujardin C, Popescu A, Gouzou S, Simon P (2005)
Rupture of the flexor tendons on an anterior plate for distal radial
fracture: four cases and a review of the literature. Rev Chir
Orthop Reparatrice Appar Mot 91:476–481
15. White BD, Nydick JA, Karsky D, Williams BD, Hess AV, Stone
JD (2012) Incidence and clinical outcomes of tendon rupture
following distal radius fracture. J Hand Surg Am 37:2035–2040
16. Birklein F, Kunzel W, Sieweke N (2001) Despite clinical simi-
larities there are significant differences between acute limb trauma
and complex regional pain syndrome I (CRPS I). Pain 93:165–171
17. Cognet JM, Martinache X, Mathoulin C (2008) Arthroscopic
management of intra-articular fractures of the distal radius. Chir
Main 27:171–179
18. Del Pinal F (2011) Technical tips for (dry) arthroscopic reduction
and internal fixation of distal radius fractures. J Hand Surg Am
36:1694–1705
19. Herzberg G (2010) Intra-articular fracture of the distal radius:
arthroscopic-assisted reduction. J Hand Surg Am 35:1517–1519
Eur J Orthop Surg Traumatol
123