Tangential views of the articular surface of the distal radius—aid to open reduction and internal fixation of fractures

doi:10.1016/S0020-1383(01)00155-3

Injury

Volume 32, Issue 10, December 2001, Pages 783-786

https://doi.org/10.1016/S0020-1383(01)00155-3 Get rights and content

Abstract

Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius. Imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint. We describe two new radiographic views of the wrist joint, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them.

However, no screw was seen penetrating the joint in these new views. It was hence possible to place the plate distal enough to enable the screws to engage the sub-chondral bone. We recommend the use of these views in the open reduction and internal fixation of distal radius 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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Cited by (20)

Anatomical tilt lateral wrist X-ray – Not always 22°
2023, Radiography
Open Reduction and Internal Fixation (ORIF) with volar locking plates are commonly used to manage distal radial fractures. The anatomical tilt lateral (ATL) wrist X-ray is often required for evaluation of intra-articular screw penetration due to the screw position. This study aims to evaluate the correlation between the tube angulation given by performing radiographers for the ATL projection and the post-examination measurement of radial inclination (RI) on the Posterior Anterior (PA) wrist image.
A retrospective review was performed for 36 patients. A standardised method developed by Kreder et al. (1996) was used to measure the RI on the PA wrist image. All ATL images sent into Picture Archiving and Communications System (PACS) have the tube angulation applied annotated on the image. Pearson's correlation was used to analyse the co-relationship between the RI and the tube angle applied for ATL projection.
The average angle of RI measured by the four observers was 19. Normality of 0.385 was established. A positive correlation (p = 0.792) between the RI and the tube angle applied for ATL was found.
Our study found a strong positive correlation between the tube angulation applied by performing radiographers for the ATL projection and the post-examination RI measured on the PA wrist image by the independent reviewers. This suggests that radiographers can use the measured RI to apply the tube angulation when performing the ATL wrist X-ray, instead of estimating the tube angulation to be applied.
Using the measured RI to apply the tube angulation when performing the ATL wrist X-ray will ensure a more reliable and reproducible way that could reduce the number of repeated images and, thus, unnecessary radiation dose to patients.
Toward an Improved Wrist View: Qualitative and Quantitative Investigation of the 20° Axial Lateral Wrist X-Ray
2020, Journal of Medical Imaging and Radiation Sciences
Citation Excerpt :
We could find no previous study comprehensively assessing patients having wrist radiographs for any indication. With the exception of the original 1946 study, in which the X-Ray tube was angled to produce the angled lateral view, most others have angled the wrist using a wedge-shaped sponge [3,5,13]. Kumar et al performed an intraoperative study assessing whether the radiocarpal joint was free of hardware under fluoroscopy when the wrist joint was in the lateral position and elevated 20°–25° to the operating table [3].
In standard lateral wrist radiographs, the radiocarpal joint is often obscured because of the angulation of the radial styloid process. A modified lateral projection at a 20° angle has been shown to demonstrate the distal radius in profile in postoperative patients without superimposing of the orthopedic hardware used in open reduction and internal fixation procedures over the wrist joint. We assessed whether this 20° axial-lateral view is advantageous in a wider patient group.
Consenting adults receiving wrist radiographs in a tertiary hospital radiology department for any indication underwent posteroanterior, posteroanterior-oblique, 0° lateral, and 20° lateral views. A musculoskeletal radiologist and a radiology technologist, blinded to clinical data and to which view was 0°/20°, both evaluated 0°/20° images in random order for whether the radiocarpal joint was obscured by radial styloid, radiocarpal articular margins, or ulnar styloid process, and which view was preferred.
In 124 cases, the radiocarpal joint was shown clearly on more 20° than 0° views (75/124 vs. 23/124, P < .001). Orthopedic hardware obscured joint lines in fewer 20° than 0° views (12/124 vs. 28/124, P < .001). There was a trend to the ulnar styloid process obscuring part of the radiocarpal joint less in 0° view (28/124 vs. 78/124 in 20°; P = .088), primarily in 20° laterals of wrists with positive ulnar variance. The 20° view was preferred by the radiologist in 76% (95/124) and preferred by the technologist in 83% (104/124).
The 20° lateral view was superior to the current 0° lateral view in a wide range of patients, with the radiocarpal joint obscured significantly less by hardware or adjacent anatomy, and preferred by both the blinded radiologist and technologist.
Dans les radiographies latérales standard du poignet, l'articulation radiocarpienne est souvent obscurcie en raison de l'angulation de l'apophyse styloïde radiale. Il a été démontré qu'une projection latérale modifiée à un angle de 20° permettait de démontrer le radius distal de profil chez les patients postopératoires sans surimposition du matériel orthopédique utilisé pour une procédure de fixation interne par réduction chirurgicale sur l'articulation du poignet. Nous avons évalué si cette vue axiale latérale à 20° pouvait être avantageuse pour un groupe plus large de patients.
Des adultes consentants recevant une radiographie du poignet dans le service de radiologie d'un hôpital tertiaire ont reçu des vues postéro-antérieure, postéro-antéro-oblique, latérale à 0° et latérale à 20°. Un radiologiste musculosquelettique et une technologue en radiologie, aveugles aux données cliniques et à quelles étaient les vues 0°/20°, ont tous deux évalué les images 0°/20° en ordre aléatoire pour déterminer si l'articulation était cachée par l'apophyse styloïde radiale, les marges de l'articulation radiocarpienne ou l'apophyse styloïde cubitale, et quelle était la vue préférée.
Dans 124 cas, l'articulation radiocarpienne apparaissait clairement sur un plus grand nombre d'images à 20° que d'images à 0° (75/124 contre 23/124, P < ,001). Les appareils orthopédiques obscurcissaient les lignes de l'articulation dans moins d'images à 20° que d'images à 0° (12/124 contre 28/124, P < ,001). L'apophyse styloïde cubitale avait tendance à moins cacher une partie de l'articulation radiocarpienne dans les images à 0° (28/124 contre 78/124 dans les images à 20°; P = ,088), principalement dans les images latérales à 20° de poignets présentant une variance cubitale positive. La vue à 20° était préférée par le radiologiste dans 76% des cas (95/124) et dans 83% des cas (104/124) par la technologue.
La vue latérale à 20° était supérieure à la vue latérale à 0° actuelle chez un large éventail de patients, l'articulation étant significativement moins obscurcie par le matériel orthopédique ou l'anatomie adjacente, et préférée en aveugle autant par le radiologiste que par la technologue.
Radiological results of surgical management of fracture of the distal radius treated with volar locking plates
2020, Injury
Citation Excerpt :
Our reported incidence of intra-articular screws was of 5,9%, higher than those described by other authors (0,5–1,3%) [23,44,52] which we can't relate to the experience of the surgeons performing the surgeries as mentioned before. In 2001 Kumar et all published how to perform intraoperative tangential radioscopic views to avoid intra-articular penetration [53]. We found a non-significant higher complication rate in complex intraarticular fractures (AO-2R3C).
Distal radius fracture (DRF) is the most common upper extremity fracture. The incidence of complications after surgical treatment still remains high.
The objective of our study was to assess functional and radiological results of DRF treated with volar locking plate.
We conducted a retrospective study including DRF treated by open reduction and internal fixation with a volar locking plate during a period of 8 years (2010–2018). Data were collected from clinical records and included patient demographics, fracture characteristics, radiological parameters (radial inclination, palmar tilt, ulnar variance, articular step-off), range of motion (ROM), complications and reinterventions.
A total of 170 patients (63.5% female) met the inclusion criteria with a mean age of 55.9 years [24.1–83.7; 13.76]. High energy injuries were more frequent in younger patients (25.56% vs 3.95%; p < 0.0001). AO classification was: 2R3A: 23.5%, 2R3B: 24.1% and 2R3C: 52.4%. Time until surgery was 8.5 days, longer in extraarticular fractures (AO-2R3A: 12.22 days, AO-2R3B: 7.97 days, AO-2R3C: 7.04 days, p = 0.018). Younger patients had better radial inclination (excellent in 85.1% vs 59.21%, p = 0.001) and radial shortening (excellent in 100% vs 88.15%, p = 0.001).
ROM was: flexion 63° [0–90°; 19.73], extension 57.67° [5–90°; 21.61], pronation 78.94° [40–90°] and supination 81.76° [38–90°; 8.87]. We found a weak correlation between ROM in flexion-extension and radial shortening (r = 0.218; p = 0.001) and articular step-off (r = −0.269; p = 0.002). We had 39 complications (21.18% of patients). 10.6% of patients needed a re-operation, being the most frequent hardware removal (6.5%) and tendinous disruptions repairs (2.4%). Reintervention rate was higher in younger patients (14.9% vs 5.3%; p = 0.042), complete articular fractures (AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and high energy injuries (8.4% vs 22.2%; p = 0.044). Patients undergoing reintervention had a decreased flexion-extension (94.44° vs 123.83°, p = 0.007).
Radial shortening and articular step-off seem the most important predictors for postoperative range of motion. Worse radiological outcomes are observed in complete articular fractures and those affecting elder population.
Although radiological and functional results are good or excellent in most of cases, the incidence of complications and need for reintervention still remains noticeable. Re-operations were more frequent in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes.
Anatomic Variation in Volar Tilt of the Scaphoid and Lunate Facet of the Distal Radius
2016, Journal of Hand Surgery
The aim of distal radial fracture treatment is to achieve optimal function through the restoration of normal anatomy, including volar tilt. The accuracy of assessing volar tilt on standard lateral radiographs compared with anatomic tilt lateral (ATL) radiographs is uncertain. This study aimed to investigate the anatomy of the articular surface of the distal radius, in particular measuring the angle between the dorsal and volar rims at several points from radial to ulnar, to ascertain whether volar tilt is uniform between the scaphoid and lunate facet and to explore consistency between standard lateral and ATL views.
We studied 38 dry cadaveric specimens of radii. The distal articular surface of each specimen was marked at 5 intervals and placed in a customized jig. A 1.5-mm stylus was placed at each marker to represent the articular surface angle, and was photographed in standard lateral and ATL projections. An on-screen protractor was used to measure each angle from the digital photographs.
The volar tilt measurements at the lunate facet demonstrated a significantly shallower angle than those at the scaphoid facet. The measurements between the standard lateral and ATL were found to have no significant difference.
Adjusting the projection angle between a simulated standard lateral and ATL view did not significantly change the volar tilt measurements in this anatomic study. The lunate facet was found to have a significantly shallower volar tilt than the scaphoid facet. Variance in radiographic volar tilt may relate to different anatomic sagittal planes, reflecting the anatomic variation between the scaphoid and lunate facets.
A detailed understanding of distal radius anatomy is required by the surgeon for accurate radiologic interpretation and anatomic fracture reduction and fixation.
Avoiding and Treating Perioperative Complications of Distal Radius Fractures
2012, Hand Clinics
Intraoperative imaging of the distal radioulnar joint using a modified skyline view
2012, Journal of Hand Surgery
Citation Excerpt :
Because intraoperative CT scans or 3-dimensional image intensifiers are not commonly available, various simple radiological views have been described to improve visualization of different regions of surgical interest that consider the natural anatomical tilt of the distal radius. Most views address dorsal screw penetration in volar locking plating or subchondral screw positioning at the distal radius.7–16 Lundy et al9 performed a cadaveric study evaluating tilted radiographs for the assessment of fractures of the lunate facet.
Nonanatomic reduction of the sigmoid notch in distal radius fractures may lead to limited motion, instability, or pain with pronation and supination. Standard radiological projections only poorly capture the sigmoid notch contours in the axial plane. The purpose of this study was to find an intraoperatively feasible radiological projection that will facilitate an axial view of the distal radioulnar joint.
We modified a previously described radiographic projection termed the skyline view for evaluating the distal radius axially. We created intra-articular steps at the sigmoid notch in solid foam forearm models to identify the best of 12 projections using an image intensifier. Four observers scored each projection based on the clarity of the sigmoid notch contour and indicated the presence and location of an intra-articular stepoff.
The sigmoid notch was best visualized in the modified skyline view with the wrist in extension and 10° to 15° of dorsal forearm angulation relative to the x-ray path. All observers correctly recognized the presence and location of intra-articular steps at the sigmoid notch with this view. The same forearm angulation with the wrist in flexion did not reach equally good visibility of the sigmoid notch. Arm position (wrist flexion, forearm rotation, or forearm angulation) and intra-articular stepoff (none, palmar, or dorsal) were dependent determinates. Elimination of the variable forearm rotation had minimal effect, indicating that forearm rotation is not important for visualization of the sigmoid notch.
The modified skyline view for visualization of the distal radioulnar joint in an axial plane allows good visibility of the sigmoid notch and reliable identification of stepoffs. Further cadaver and in vivo studies are required to verify the validity of this method.
Diagnostic IV.

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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.

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Tangential views of the articular surface of the distal radius—aid to open reduction and internal fixation of fractures☆

Abstract

Introduction

Section snippets

Technique

Results

Discussion

J. Hand Surg.

J. Hand Surg. [Br]

J. Hand Surg.

J. Hand Surg. [Am]

J. Hand Surg. [Am]

Hand Clin.

Radiol. Clin. North Am.

J. Hand Surg.