Volar Plating for Distal Radius Fractures

Chuck and Chris discuss volar plating for distal radius fractures.  What are the alternatives, what are some technical pearls,  and more.

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Transcript

Christopher and Charles discussed their upcoming podcast recording plans, with Christopher mentioning he would lecture residents about grant writing. They briefly talked about the recent fellowship interview day, where 31 candidates were interviewed for 3 available spots, with Christopher noting it was an impressive group of applicants. Charles mentioned missing the fellowship interviews for the first time in 24 years due to a scheduling conflict.

AI's Impact on Medical Information

Charles discussed his experience using ChatGPT to search for medical treatment information, specifically regarding radial deficiency with a deviated wrist. He expressed concern about the AI's prioritization of certain treatment options that might not be generally acceptable to surgeons. Charles noted that AI searches work differently from traditional Google searches using retrieval augmented generation (RAG), which affects how medical information is found online. He plans to update his blog to better address these changes in how patients search for medical information.  Christopher and Charles discussed SEO optimization and its relevance to medical practices, noting how some doctors use direct-to-consumer advertising to gain visibility. 

Volar Plating for distal radius fractures

The conversation then shifted to volar plating for distal radius fractures, where they explored scenarios where alternative approaches might be more appropriate. Charles mentioned that closed reduction and pinning could be suitable for simple Colles fractures in thin patients, while Christopher expressed concerns about the stability and confidence of early motion protocols with two K-wires compared to volar plates in adult populations.

Charles noted that pinning procedures are uncommon in his practice, with only 1-2 cases per year, and expressed uncertainty about performing them in the procedure room due to anesthesia requirements. They also touched on the use of local anesthesia for procedures like dorsal wrist ganglion surgery, with Charles sharing his recent experience performing such a case under local anesthesia. The discussion concluded with Charles mentioning that he sometimes uses dorsal plating for certain complex cases, particularly when there is joint involvement or multi-fragmentary intra-articular fractures.

Wrist Fracture Treatment Approaches

Christopher and Charles discussed treatment approaches for specific wrist fractures, particularly focusing on volar plates and the management of lunate facet pieces. Charles emphasized the importance of proper recognition of these fractures and noted that standard volar plates are often not appropriate, requiring modifications or fragment-specific approaches. The discussion concluded with a brief mention of upcoming educational webinars, including one on spasticity by Peter Ree and Kitty Wu, and a WashU Nerve course scheduled for May 29-30.

Technical Considerations

Charles and Christopher discussed surgical approaches for exposing the pronator quadratus, with both describing similar techniques involving the FCR approach and careful nerve management. Charles shared his preference for repairing the pronator when possible, though he expressed some uncertainty about its effectiveness. Charles also emphasized the importance of avoiding over-retraction on the median nerve, particularly when using Homan's approach on both sides, and mentioned concerns about potential CRPS from excessive retraction.

Median Nerve Protection in Surgery

Charles and Christopher discussed techniques for minimizing risks to the median nerve during hand surgery procedures. They highlighted the importance of being aware of the nerve's location, particularly when dealing with long fractures and when using scissors or scalpel near the FCR sheath. Christopher shared his approach of not repairing the pronator muscle and suggested splitting the BR longitudinally to facilitate easier repair. Charles mentioned his method of dividing the pronator longitudinally and using a rasply for exposure, while also discussing a technique using a laminar spreader to adjust the position of the proximal fragment during reduction.

Volar Plating Techniques for Fractures

Charles and Christopher discussed techniques for volar plating of distal radius fractures. They covered key points including reduction methods, plate placement relative to the watershed line, and screw placement strategies. They agreed on using unicortical locking screws to minimize risk to extensor tendons, with Christopher noting he typically stabilizes the intermediate column first before placing radial-sided screws. The discussion concluded with a recognition that while volar plates work well for straightforward fractures, complex cases require additional troubleshooting and expertise.