Tangential views of the articular surface of the distal radius—aid to open reduction and internal fixation of fractures☆
Introduction
Internal fixation with plate and screws has become a favoured option for treating distal radial fractures after failed conservative management, in the presence of significant dorsal cortical comminution, or for displaced intra-articular fractures. This is mainly because external fixation of such fractures alone has failed to show consistently satisfactory functional results. Bridging external fixation has a high incidence of joint stiffness and reflex sympathetic dystrophy [1], [2]. Lately, plating has gained popularity and various types of plates are being used to treat distal radius fractures [3], [4], [5], [6], [7], [8].
It is not uncommon that screws need to be placed close to the radio-carpal joint either because of the fracture configuration or because of the surgeon's desire to obtain a good hold in the sub-chondral bone which is felt to be denser than the rest of the distal radius. Use of an image intensifier is helpful, but in routine antero-posterior and lateral views it is difficult to assess the position of the screws because of the obliquity of the distal radius in both planes. As a result the plate may be positioned more proximally than desired.
We describe two new radiographic views of the wrist joint, which, to our knowledge, have not been described before in the literature [9], [10], [11], [12], [13], [14], [15], [16], [17]. They show the tangential views of the articular surface of the distal radius in the antero-posterior and the medio-lateral directions and intra-operatively help to place the screws in the sub-chondral bone without giving a false impression of the joint penetration.
Section snippets
Technique
For the tangential antero-posterior view, the wrist is placed in full pronation on the operating table and is elevated above the table so that the forearm makes an angle of 10–15° to the operating table. For the tangential lateral view, the wrist is placed in mid-prone position on the operating table and is elevated above the table so that the forearm makes an angle of 20–25° to the operating table. Following the positioning of the forearm the X-ray beam is then directed perpendicular to the
Results
Screws appeared penetrating into the joint in the standard lateral views of all the ten patients and in the standard antero-posterior views of the eight patients taken intra-operatively (Fig. 2, Fig. 3). The tangential views showed the correct relation of the screws with the articular surface of the distal radius and no screw was seen penetrating the joint in these views (Fig. 2, Fig. 3). This was confirmed arthroscopically in one patient. It was hence possible to place the plate more distally
Discussion
Several radiographic views of the wrist have been described in the literature. Most of these views are described to visualise carpal fractures and instability [9], [10], [11], [12], [13], [14], [15], [16], [17]. These views do not show the true profile of the articular surface of the distal radius without an overlap. The distal radius articular surface has an average ulnar inclination of 22° and an average volar tilt of 14° [17]. Lifting the wrist above the operating table in the manner
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This article should be attributed to the Department of Trauma and Orthopaedics, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QH, UK.