Yeah, so I'll say in opening, in preparing for this, I looked up mine for the last few years and I'm still plating about 80% volar and 20% dorsal. So I think this talk will really hinge on when should you choose a dorsal plate versus a volar plate if you're going to do internal fixation. One other piece of housekeeping. It says in the syllabus, I don't have any disclosures. I do. And here they are. None of them are particularly relevant for this talk, even though some include plates. This talk is going to be more about principles and not a specific company's plate. So again, when should we choose dorsal plates? I think the contraindications when you should not choose them include volar shear fractures, so volar Barton's fractures. And just like Fraser pointed out, those volar lip fractures, particularly that volar ulnar corner that we call the critical corner. And I think these plates are less ideal for Smith fractures or flexion fractures of the distal radius. I think that's better served typically with a volar plate. Otherwise, I think the literature, as we'll see during this talk, supports using it essentially any time you want to that you need to fix a distal radius fracture that it meets operative indications. I think it's better than a volar plate for dorsal shear fractures, fractures in which direct articular visualization and particular direct reduction is desired, and then die punch fractures where you've got the depressed articular fragments. I think dorsal plates are superior in that, in my hands at least. Another time I'll use them a lot is cases where you think there's a chance you're going to need a bridge plate, because then you're already going to be dorsal to place that. So I think fractures that you look at and think, fix versus bridge plate in my hands, I prefer to go dorsal initially and make that decision then. On the fractures that you can't get a good read on the articular surfaces, I do think CT is very helpful in preoperative planning, and Matt mentioned that as well. There's a nice study by David Ring showing us that that not only helps surgeons identify the fragments and where they need to be, but often influences the decision of which approach to use as well. So any case that I'm on the fence, I think a CT is very helpful in making that call. Additional indications where I think dorsal plates are advantageous include associated proximal pulse scaphoid fractures, or cases in which carpal ligament injuries are suspected like an SL injury. Open fractures dorsally are good indications, poor volar skin, and then I don't hesitate to combine it with volar approaches when needed. And for me, just like the case Kevin just described, that can be two things. That can be one, I tell our residents all the time what I call just a dorsal check. So if you fix it volar, you're unsure about that dorsal ulnar corner, do you really have it, do you not? I don't hesitate to make a small dorsal opening in arthrotomy. You can check for screws in the joint, and you can make that decision, do I need to add another plate, do I need to add pins? So any time combined fixation may be needed. So surgical technique is fairly straightforward, a midline dorsal approach that we're all familiar with, just ulnar to lister's tubercle. Beware of not only the superficial branch of the radial nerve, but also the dorsal cutaneous branch of the ulnar nerve. The EPL can be transposed out of the third compartment radially, and left in that transposed position. And I think one of the most important steps is elevating the second and fourth compartments. You really want to get this subperiosteal, because these can be raised so that the floor of those compartments is in contact with the plate at the completion of the procedure rather than the tendons of those compartments. As you come around radially and come beneath the second compartment, you can come beneath the first. From the dorsal approach, you can still release brachioradialis. If you need to mobilize the radial column better. And then for your arthrotomy, there's two ways. I usually just do a straightforward longitudinal arthrotomy. You can do a ligament-preserving arthrotomy, where you parallel the dorsal radiocarpal and dorsal intercarpal ligaments. I think that's useful if you suspect an SL injury, because then you can augment your repair with a portion of the dorsal radiocarpal or dorsal intercarpal ligaments if needed. And then I liberally use K-wires, and I'll show some examples of that coming up, to gain the reduction with K-wires and that direct articular reduction, and then add your plate at the end. So here's an example of that, a dorsal approach. There tends to always be a dorsal central fragment that can be opened up like a book. You see that in the pickups there. And I typically just book that fragment open, and now you've got great visualization of the articular surface. Usually with these die-punch fragments, like the central fragment that you can see right here, these fragments are real hard to catch with screws, and it tends to be that lunate facet as well. So I will liberally use threaded K-wires and put it into that fragment, get it reduced, and then just cut that off flush. And then when you roll that bookend piece back down, you can apply your plate to cover everything else. But it's hard to catch some of those smaller die-punch fragments, and so threaded K-wires can be very helpful there. So some other pearls about dorsal approach in general. Again, I think that meticulous elevation of the second and fourth is really important, so that the plate's sitting beneath the compartment itself and not the tendons. Traction and traction is really helpful in these to help see that articular surface. So I usually make a big bump, and either finger traps and weights or have a resident pulling a longitudinal traction and flexion really helps assess that articular reduction well. Lister's tubercle, frequently it's fractured off and it's a non-issue. But if it's not, then oftentimes it'll block your plate from sitting just where you want it. It kind of pushes it to one side or the other. I don't hesitate just to ronger that off and just use it as bone graft if I need to to allow the plate to sit more flush. Don't let it be an impetus to putting your plate where you want it to go. Few other ones. I don't bone graft just to radius fractures very often, but for some of those die punch fragments, once you elevate it, you've got a big void beneath it. So in those cases, I do think cancellous bone graft is very helpful. I just use allograft chips to place under those pieces to help keep them elevated so that they don't want to depress around a screw fragment. And then the screws on dorsal plates, dorsal plates tend to sit more distal. So traditional views, and we've heard a lot about tilt views that can be helpful for our assessing the screw placement. For the dorsal approach, the beauty is you don't have to worry about your views. You just have to look straight at the joint surface and make sure they're not in the joint. So direct articular visualization of your screw placement is very easy. And at the completion of these, just as at the completion of any distal radius fracture, I always tell our guys, you want to assess distal radial ulnar joint stability, a Watson shift test, and then I just do an axial grind test. Just put axial load on the carpus and flex and extend the wrist to make sure there's no crepitation for concerns of interarticular hardware. The dorsal approach, two of those are already eliminated because you've directly visualized the SL ligament and you've directly visualized your articular reduction as well as your screw placement. So a nice technique, this is a good paper that Kevin did along with the guys out of WashU. This is a good just surgical technique paper from JHS last year, kind of highlighting a lot of the principles I just spoke about. In their paper, they were using two, four small locking plates. I'm not sure if that's still the ones they're using. These require manual contouring. They do have plates now that are pre-contoured that has that advantage, but they got very good results with these in a different article written on outcomes that they had. But this is a good paper just to have if you're considering dorsal plate and just want a review of the technique. So what about the biomechanics comparing vulvar plates and dorsal plates? There's been two studies that were in JOT comparing this and in essence found that there was no difference with respect to ultimate load to failure and no difference with respect to the rate of displacement. This was the first one in 2008. And then the second study in 2011 compared locking versus non-locking plates and the same held true. So whether you use a vulvar locking, vulvar non-locking, dorsal locking, or dorsal non-locking biomechanically they all seem to be fairly similar. Dorsal plates in this study had the advantage of less fracture gap motion, however in the presence of vulvar comminution as you would expect they were less stable than a vulvar locking plate. So complications of dorsal plating. If you look at the literature pre-mid 2000s there's a ton of papers with complications and these are primarily related to the types of dorsal plates that were being implanted in the 90s and early 2000s when it became popular. The pie plate in particular got a bad rap for good reasons. If you look on the left at the plate that was originally placed back then these plates had a lot of prominence. They had a lot of sharp edges, they stuck off the bone a lot, screws didn't sit as flush and you see a lot of places for extensor tendons to rub and irritate themselves. Versus the newer generation plates have a lot of advantages. Now the dorsal plates are polished, they're highly polished, they have very tapered edges, they're much lower profile, they have locking screws that sit flush with the plate, and they're pre-contoured. So just looking at these two comparisons I think any time you look at complications in the literature of distal radius plating dorsally you really have to look at what types of plates is this older generation or newer generation. And the newer studies are showing now that there's not complications that we used to see in the past compared to the vulvar plates which we'll go into. That said, complications can still occur. Dorsal plating, the two main things that the literature bears out is from an outcome standpoint stiffness is still a problem, which obviously is not unique to dorsal plating but to any fixation. And an extensor tendon irritation and rupture can still occur even with the lower profile plates. However, I would suggest that that's also seen with vulvar plates. Here's a patient from last year that I took back and you can see multiple extensor tendon ruptures and this was from a vulvar plate. And you see the two screws that are just barely through the dorsal cortex and not even that prominent but enough to cause three extensor tendon ruptures. So tendonitis after plating in general, one thing, this patient came to me a year and a half out from this injury with symptoms perfect for intersection syndrome. Inject them three weeks later, he said he felt a lot better but now symptoms are back. And one thing, any time you have plating in place, no matter how good the x-rays look, be aware that I think to me this is hardware induced until proven otherwise. And here's a look at the intersection of the first and second compartments and it's removed and here's the prominent screw. And interestingly, that was the most distal screw, the one that you see there, that radiographically you would think there's no way that would be causing this extensor tendon problem but indeed it is. So I think any time you have any tendon related problems, it's hardware related until proven otherwise. So looking now at complications of dorsal plates with newer generation plates, the study from JHS in 2011 looked at 104 fractures, three and a half year follow up comparing vulvar plates to dorsal plates and found no difference in tendon related complications. And if you look at their list of complications there, in fact, the only statistically significant difference was with median nerve problems from vulvar plates, four instances versus none in dorsal. Another study out of Germany comparing the outcomes of vulvar and dorsal plates, a retrospective study, showed no difference in patient related outcome measurements and that dorsal plating showed statistically improved vulvar tilt and DRUJ angle relative to vulvar plates. Another one comparing vulvar and dorsal 2-4 locking plates for C3 fractures, 41 fractures, three year follow up, no x-ray difference, no objective functional difference between vulvar or dorsal plates and, in fact, there was earlier motion gains in the dorsal plates relative to the vulvar group. In terms of complications, again, a higher instance of median nerve related complications that were transient in the vulvar group compared to the dorsal group. And lastly, out of Wash U, they had a comparison looking at 60 fractures with dorsal plates, not a comparison, just a straight view of 60 dorsal plates with two year follow ups, no extensor tendon complications, one case of hardware removal, and you can see excellent DASH scores and Gartland-Worley scores, 80% range of motion and 90% grip. So dorsal plating clearly is having good outcomes with lower complication rates than the historical literature would suggest. And then the AOS guidelines, which have been mentioned already, when they looked at dorsal versus vulvar approach, the guidelines recommended neither for or against one specific approach. So I think it's whichever you personally feel more comfortable with. So now I chose kind of four cases that I think kind of highlight good examples, at least in my hands, of when I think dorsal plating is a better choice. This is a 54-year-old softball coach who ran into a wall with their glove hand, and this is the fracture we see on the right on x-ray and the CT scan. So large, depressed, die-punch fracture, for me personally, this is better handled with a dorsal plate. I don't know how many people would try to tackle that vulvarly. Any of the panelists try to tackle that vulvarly? So no. So I think I agree. So there's die-punch fractures, the articular fractures, and so dorsal approach is what I used. I did get on the resident for stapling this one up in closure. But one thing I think it shows, this is what I was talking about using K-wire. So those little articular pieces that are fairly large articular fragments but have very little bone support, you can see a lot of little threaded K-wires that I'll put in and just cut flush. And then that dorsal central fragment will rotate over those K-wires, and they're just embedded in there. And I think those can be really helpful. I think this one you could argue to add a radial column plate. I just added radial column K-wires for this. And here she is at 10 weeks with a fairly acceptable outcome. And she went back to coaching at about the three-month mark. Here's another one now, stepping it up with the articular comminution. So this is a 65-year-old, probably the worst comminution I've seen from a simple ground-level fall and has a distal ulna fracture associated with it. So I think this one, the decision tree gets a little trickier. I think this is one that I like dorsal because I had thought that this would either be a bridge plate in my hands or a dorsal plate. I don't know many people that would try to tackle that. Anybody want to try that one vulvar? Fraser, can you get that one vulvar? I can't see the letter from here, sorry, but I would probably end up putting a bridge plate on and maybe a vulvar plate that punches the vulvar cortex. But either a vulvar plate or no plate. Jeff wants the no plate, the X-Fix and pins. Kevin, how would you go after that one? I'd probably be thinking about a dorsal spanning plate. So spanning plate or X-Fix seems to be the most popular. Anybody want something different? Do you have a CT scan? I didn't get a CT scan of that one, actually. Or if I did, I didn't have it available to me when I was putting this talk together. So I went through the same thought, figured we'll go dorsal, we'll see what happens. We'll either bridge plate or dorsal plate. And surprisingly, the articular surfaces came together fairly well. There was a ton of metaphyseal comminution. So like I said, I don't routinely bone graft distal radius fractures. Be interested to see who does if they do. I use it to buttress up articular fragments, but in this case I did use it for that. And the distal ulna, I chose not to fix it. How many guys in the panel would fix the distal ulna on that one? One, two, three, four, everybody. I'm an odd man out on that one. But here's how she did. So she's three months out, and here's what we got, final result. So a little bit of supination loss and a little bit of loss of flexion, but overall a pretty good result considering the difficulty of that fracture at a three-month follow-up. And we did close that one with suture too, which made me feel better. So how about this one? This is a 26-year-old motorcycle wreck, median nerve-related symptoms, and we've got this volar fracture dislocation. This is one that in the very beginning, as I said, I don't like for volar shear fractures, volar lip fractures, or fracture dislocations. I don't think simple dorsal plating is the best. This is one to me that a bridge plate is going to be a better choice, which many people have mentioned. Anybody want anything other than a bridge plate or X-Fix? I'd go both sides on this one. Front-back approach, and I think especially with the median nerve symptoms, you have to go volar anyway to do the carpal tunnel, and just like Jeff suggested, that was my approach as well. Go volar first, carpal tunnel release, fix those little volar lip fragments. Those were actually just a combination of K-wires and suture for me on this one and anchors. I don't fix owner-style hood fractures very often, but I think in these fracture dislocations when you open them up, everything's stripped and everything's gone. So for stability, I think these are the cases that it's best to do it with. This guy actually ended up with CRPS, incredibly stiff and did terrible, but his X-rays looked really good, so I was proud of that, so I thought I'd put him up. And kind of a fourth case here. This is a 32-year-old who falls off his RV during a NASCAR race, presents with an incredibly gifted tattoo of his six-pack abs, and has this common interarticular distal radius fracture, scaphoid fracture, and tricuitral fracture. So what about the panel up top? How does everybody want that one? Volar, dorsal, X-fix? What do you do, Jeff? Before I made a decision, I'd want to see what this looks like with traction applied. I'll probably make my decision after I see. But if you need to get to the articular surface of this, then dorsal. And you go dorsal for that scaphoid as well. Anybody different? Similar feelings. Yeah, so this one had about five different articular fragments plus the scaphoid, which to me is simple to address from the dorsal side as well. So same thought as Jeff. Go dorsal. Again, it's harder to see here, but there's some little threaded K-wires that I've cut off inside trying to get the articular surface reduced, and then a dorsal plate and can address the scaphoid at the same time. Tricuitral was rather pulverized and not very amenable to any fixation, so it was just left. So in summary, I still plate about three-fourths of mine volarly, but I think dorsal plating has several advantages, particularly the ability to see that articular reduction, get direct articular reduction, assess the SL ligament, and the ability to convert it to a bridge plate if you need to. And the literature would suggest the outcomes and the complications of newer dorsal plates parallel those of volar plates. Thanks.

dorsal plate

volar plate

internal fixation

distal radius fractures

contraindications