orthopaedic i n s i g h t s - Cleveland Clinic

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Volar Plating of Distal Radius Fractures
By Jeffrey N. Lawton, M.D., and Peter J. Evans, M.D., Ph.D., FRCSC
Numerous surgical options for addressing
displaced distal radius fractures exist,
including internal and external fixation.
While volar plating for certain types of
distal radius fractures has been used in the
past, dorsally placed plates and external
fixators have dominated. Recently, newer
constructs that provide a locked volar
plate have expanded the indications for
plating distal radius fractures.
Today, volar locked plates are being used
in a majority of distal radius fracture
types. Although many of these fractures
exhibit dorsal displacement and dorsal
comminution, which are better biomechanically
addressed with a dorsal plate
in buttress mode, enthusiasm for routine
dorsal plating of distal radius fractures
has been limited by complications associated
with extensor tendons. Extensor
tendon adhesions, tendonitis and
tendon ruptures are thought to occur
because of the limited soft tissue interposed
between the dorsally applied
plates and the extensor tendons.
With the ability to lock the screws at various
angles, a blade plate-type rigid construct
is created. Therefore, despite being
placed on the volar side of a dorsally displaced
fracture, the articular surface and
subchondral bone can be maintained in
a reduced position during healing. Depending
on the system, the angle that the
distal fixed screws/pegs make with the
plate allows various fracture fragments
to be addressed individually.
Perceived concerns with the volar approach
include injury to the radial artery
and/or median nerve. A modified Henry
approach with incision of the flexor
carpi radialis (FCR) sheath allows a re-
Simple wounds in the diabetic foot can
rapidly progress from minor problems
to limb-threatening ulcers due to the
presence of diabetic vascular disorders
and neuropathy. The Cleveland Clinic
Diabetic Foot Care Program, established
in 2003, applies the latest treatments,
technology and computer approaches to
prevent and manage wounds and ulcers
in the diabetic foot.
People with diabetes have a lifetime risk of
15 percent of developing a foot ulcer, and
a non-healing ulcer is the most common
antecedent to lower-limb amputation.
Our aggressive team approach includes
ulcer prevention and treatment, regular
foot examinations, patient education,
and therapeutic intervention to reduce
the risk of ulcers and lower-extremity
amputations.
Patients with emergent problems are
scheduled for immediate consultation
in our Diabetic Foot Care Clinic within
the Department of Orthopaedic Surgery
so that appropriate treatment and intervention
can be initiated rapidly. Other
patients receive a comprehensive evalua-
producible exposure with protection
of the neurovascular structures. The surgeon
makes a longitudinal incision overlying
the FCR tendon. The FCR tendon
is then retracted radially, and the surgeon
incises the floor of the FCR sheath. Blunt
dissection allows identification of the
pronator quadratus, which is then incised
off the radial aspect of the radius,
leaving a cuff of tissue for later repair.
This approach exposes both the fracture
site and the area for the volarly placed
plate. To allow for further mobilization,
or in the subacute setting, the brachioradialis
can be subperiosteally elevated and
released, thus eliminating its deforming
force upon the distal fragment.
The fracture is then reduced and
provisionally stabilized with a styloid
K-wire or, alternatively, with the aid
of the plate and the provisional K-wire
holes provided in some systems.
In Step with Diabetic Foot Care
By Peter Cavanagh, Ph.D., D.Sc., and Georgeanne Botek, D.P.M
tion that includes foot pressure mapping
together with vascular and neurologic
workups to identify risk factors and
to define the cause of ulcers and other
problems.
Physicians apply the PEDIS (perfusion,
extent/size, depth/tissue loss, infection
and sensation) classification system
to assess ulcers and evaluate progress
toward healing so that staging and
description of ulcers is consistent. To
complement this standardization, our
electronic medical records system has
been enhanced to capture photographs
of wounds as part of the patient’s
medical record. This innovation allows
clinicians to track wound healing more
effectively and consistently.
Relief of weight bearing is critical in the
healing of diabetic foot ulcers and is well
documented in the literature. Yet it is frequently
overlooked or undertreated by
many clinicians and, therefore, remains
the single most significant reason that
ulcers in the diabetic foot fail to heal.
Our clinicians often use a total contact
cast, which encloses the foot, as an
Following final plate placement, bone
grafting through a small incision dorsally
can be made to fill the void left by
the implanted cancellous bone.
Based upon stability, a typical postoperative
course involves seven to 10 days in a
postoperative splint, followed by a thermal
plastic splint. An early supervised
protocol of wrist and forearm range of
motion as well as maintained digital and
shoulder motion and edema control also
are recommended. At approximately
eight to 10 weeks, based upon clinical and
radiographic progress, one may begin
progressive strengthening.
Dr. Jeffrey Lawton, a member of the Section
of Hand and Upper Extremity Surgery,
can be reached at 216/445-6915.
Dr. Peter Evans, is head of Hand and
Upper Extremity Surgery and a member
of the Lerner Research Institute. He can
be reached at 216/444-7973.
integral part of the treatment plan.
This device effectively relieves pressure
to allow the ulcer to heal.
With a total contact cast, changed
regularly and closely followed by the
physician, ulcers heal in an average of
42 days, compared with healing times
as long as a year with treatments that
do not address the weight relief issue.
We have achieved similar rapid healing
times in ulcers that have remained open
for as long as two years.
After an ulcer is healed, managing
the foot’s mechanical interaction with
the world is critical to preventing ulcer
recurrence, which, in various studies,
has been shown to occur in 50 percent
to 100 percent of patients within three
years. Proper footwear can reduce this
risk significantly. Our research team uses
computer modeling based on MRI images
to digitally reconstruct feet in three
dimensions (see accompanying article
on p. 12). This will eventually enable
individualized footwear recommendations
to be made for each patient.
Reduced distal radius fracture
with volar locked plate
A map of pressure underneath the foot during
walking is collected as part of the patient evaluation
in the Diabetic Foot Care Program.
An IRB registry is maintained, and,
through this database, we have been able
to pursue a number of clinical research
projects during the past two years.
Current projects include a study of
methicillin-resistant bacteria in foot
ulcers; footwear management in patients
with Charcot fractures, and studies
of new approaches to ulcer healing.
Patients can enroll in clinical trials of
these new approaches to wound care.
Dr. Peter Cavanagh is Chairman of the
Department of Biomedical Engineering
and Academic Director of Diabetic Foot
Care. His specialty interests include foot
disorders in diabetic foot disease and bone
loss in long-duration spaceflight. He can
be reached at 216/445-6980 or via e-mail
at cavanap@ccf.org.
Dr. Georgeanne Botek is Medical Director
of the Diabetic Foot Care Program and
has a strong interest in diabetic foot care.
She can be reached at 216/445-8152 or via
e-mail at botekg@ccf.org.