Great. Thanks, Kevin and Jeff, and thank you for being here this morning. My charge to you this morning is to talk about VOLR plating for distal radius fractures. And I do have relative conflicts, and I've been involved in some design of plates, but it shouldn't interfere with this talk in the sense that this is not about a comparison of different fixation in terms of VOLR plates, but I wanted to point that out. So many of you in the audience take care of distal radius fractures. So if this was your wrist, if you look at the x-rays, relatively critical, hands up those who would consider x-fix and percutaneous pinning. Hands up those who would have a VOLR plate. So I don't have to give my talk now. We're ahead of schedule now, we've never stopped. But I think the question really comes when Kevin Chung's doing a great study on the wrist study that looks at x-fix and VOLR plating and operative management, and so if your patients are astute, they're going to ask you, so why, doctor, would you put a VOLR plate on me? Why would you do that? What's the evidence that would show us why a VOLR plate would be beneficial or better than other treatments? And we know Hans Krieger's work and Doug Hanel, they've gone through and multiple studies, as was pointed out in the last talk, really haven't shown necessarily the benefit in good, well-designed, prospective, randomized studies. You can see here, no difference in range of motion, functional outcome scores. Other study, Ken Eagle, pointed out higher re-operation rate in ORIF group. Other studies, Abramo, has pointed out in the randomized prospective study that, again, no significant differences in DASH scores are ultimate outcomes for our patients. So how do we show them the evidence? The meta-analyses, similar findings. And again, as was pointed out in the last talk, Dave Lichtman's work with the Academy group in terms of looking at all the data, and there were really no strong recommendations for these fractures. But I think we all know that we have to individualize treatment, as was the real strong conclusion for the last. So I think we could probably agree, since we all probably have put a VOLR plate on, that there are some advantages for putting on a VOLR plate. It's a closed system. In other words, we don't have pins and bars that our patients can't get gloves on. We recognize it's a rigid, fixed-angle device that supports the subchondral surface. And it's, I think, becoming more of a simple approach, although there are nuances that we can sometimes run into trouble with. But there are drawbacks, and obviously there are complications that we have to recognize. In terms of the FCR approach, and George Orbe and others have really helped us to better understand the extensile approach and really give us good advantage to approaching our fracture, even sneaking around the radial side. But really, the FCR approach and the VOLR approach to the risk gives us a reasonable and reproducible surgical approach. The anatomic reduction, we're based on the thicker VOLR cortex. It's a nice hinge if you can manipulate and reduce your fracture. There's less comminution VOLR-ly than dorsally in terms of fixation. And again, the subchondral support is what we're using for our fixed-angle device. We're putting the fixation on the tension side of the fracture, of the injury. And that, relatively speaking, our rigid fixation in the select patient, we can potentially get them moving a little easier than if they've got pins or external fixators and other devices that may limit soft tissue gliding around the region of the wrist joint. In terms of the articular fractures, remember that the VOLR plate doesn't give us a great visualization of the articular surface, so we have to be careful if we need to look at the joint specifically. And obviously, with many of these fractures, we don't often need to add adjunctive bone grafts, so we sometimes can sneak around the radial side again or make a separate incision dorsally. And probably for many of us, it avoids the complications of the middle-of-the-night phone call about concerns about pin sites, irritation within a cast, and so forth. And that's maybe, perhaps, why many of us select this. Anatomy-wise, I think it's important to realize, obviously, that there's a greater soft tissue buffer between your hardware and your gliding tendons on the VOLR side of the wrist compared to the dorsal aspect of the wrist. In terms of dorsal plating, that can be an issue in terms of complications, even though I think, saying that, we have to be careful that dorsal hardware is possible with VOLR plating, as we all know, with the dorsal penetration of our screws. So our typical approach, this is, I typically make a small brunner based on the VOLR and the more proximal VOLR wrist crease, making a longitudinal limb overlying the FCR. So here's your FCR that you can find relatively easily within the distal forearm. Sometimes you can be led astray somewhat, thinking if somebody's got a palmaris, you might be a little bit more ulnar than you'd like. And then you can see here the sheath of the floor of the FCR is a nice guideline here for opening up your exposure to the VOLR aspect of the distal radius. What do you have to watch for? You have to be aware of the palmar cutaneous branch of the median nerve. As soon as you open up that fascia, as you all know, the fascia rolls up and it looks like a little nerve running down towards the distal wrist. And so here's your interval. Typically your median nerve is between your FCR and your superficialis muscle bellies. Here's your palmar cutaneous branch, palmaris longus, and your FCR retract out of the way. So if you're putting your retractors in on the VOLR radius approach, you have to be careful that as you move your FCR out of the way or your palmaris out of the way, you're distorting the relative relationships of your anatomic structure. So you can be fooled as to perhaps where the palmar cutaneous branch of the median nerve is or even the radial artery, including the deep and the superficial branches. Remember the superficial branch of the radial artery crosses the FCR sheath at the level of the VOLR wrist crease. So that's a nice way of remembering where to find that. We typically will expose the pronator quadratus. Sometimes it's nice and intact as on the bottom right-hand corner of your screen there. Sometimes it's very indistinguishable from the fracture site, so you have to be careful as you elevate your pronator. And then the key is to find your VOLR distal radius from radial all the way over to your ulnar critical ulnar corner, and if you're not exposing that width, you may not be adequately able to restore your distal articular surface and your distal VOLR articular fragments. So again, if we consider those relatively simple steps, we might say, well, boy, I should just put a plate on everything. But I think you have to be careful that with the VOLR plate, that pendulum swings so far over that we're starting to put a VOLR plate on everything, and it may not be the ideal choice for some fractures. So how do we decide what we put a VOLR plate on? Well, I think as Dave Roush has pointed out nicely and has let me borrow his slides here, the fracture you have to think of in terms of the characteristics of your fracture. We all have a personality. And I think if you can appreciate the various components of your fracture, whether it's via radiographs, as you can see here, or even with a CT scan, as was pointed out in terms of advanced imaging that can be helpful for preoperative planning, I think here you can start to see how you're going to bring these individual pieces back together again. And maybe a VOLR plate that fits one size doesn't fit all, remember? So sometimes your VOLR plate can actually help to bring these fracture fragments back together again, but sometimes it may not. So multiple personality disorders of your fracture, we want to restore our palmar tilt. You have to remember that some patients have such osteopenic bone that that subchondral support may not be adequate, and you have to consider, uh-oh, let's see here, we may need some AV support here. So remember your palmar lunate facet, your VOLR lip fragment, and obviously restoring and being aware of your DRUJ, which is sometimes not considered in our fracture reduction but certainly is considered later on when a patient may lose pronosupination. So we show this fracture. How do we get that palmar tilt restored? Well, you feel like you're pulling and tugging in the emergency room, even in the operating room. I point out to our trainees that you really, once you've exposed through the VOLR approach, you really don't need a lot of force to restore your fracture fragment. You can use a small freer and just hinge over the palmar cortex. But as you're doing this in a closed way and you're trying to decide if you can actually get there by putting a VOLR plate on, we saw this anatomy earlier with Matt Monnier's talk. Remember that the dorsal ligaments will have a greater elongation than the VOLR ligaments. So usually you can pull that reduction dorsally and get that dorsal palmar effect, but that those palmar ligaments don't really pull all that far and so your palmar lunate facet may not follow suit. In other words, it doesn't help get that distal direction of your tension on your fracture. So key is to restore your palmar cortices in terms of levering this forward. If this was done as a percutaneous technique, you may use a K-wire or a Steinmann pin, but very similarly in the operating room, you want to hinge that palmar cortex to restore your initial reduction if you're going to put a palmar plate on. You don't want to typically try to let that be an indirect reduction as best you can help it. So restoring this palmar tilt, obviously, the goal of this is to then restore your subchondral support to prevent that loss of palmar tilt in a backwards direction, as was pointed out. Another component of your fracture is the palmar lunate facet, and as you can see on a lateral view, you get that typical widening from top to bottom, as Andy Comins pointed out, and this width here is important to look at critically. Why do you have to look at this? Well, typically the palmar lunate facet, which you can see on the bottom here, we don't have a pointer, but this is what's attached, your radiolunate, your radiocarpal ligaments, and this palmar lunate facet is not well reduced if you're simply looking at traction through the level of the wrist. And this is important because, as Dave Rusch and others have pointed out, poor reduction of your palmar lunate facet will lead to persisting pain and loss of range of motion, particularly with supination of the forearm. And what happens is, as you can see here, the carpus here will follow the palmar lunate facet. So here's the longitudinal axis of your carpus, here's your palmar lunate facet, and you can see this volar translation of your carpus relative to your radial shaft and your longitudinal alignment of your forearm. And this can limit, obviously, your overall range of motion and outcomes. You have to be careful, also, of the volar lip fragment, that piece that's very, very subtly small. You can't put a screw into it, perhaps, and there may be important means of not just assuming that you're buttressing that with your volar plate, because if you don't capture it or if you don't prevent dorsal translation of your carpus and the remainder of your fracture, you may end up with something like this, where you've lost your effective buttress in a dorsal direction. So sometimes augmenting a volar plate, if you choose a volar plate with an external fixator, with a dorsal bridge plate that spans the carpus, temporarily may be helpful in something like this. So here's another example of a patient that underwent ORIF, and what was felt to be an appropriate reduction here. You can see what happened here. Everything translated dorsally, with the carpus much more dorsal than the longitudinal axis of your forearm. So DRUJ congruity, we talked about in the last talk, pointed out that translation of your distal radius. And if you have that subtle fracture that enters into the distal radial ulnar joint, if you don't reduce that, and sometimes just simply a reduction tenaculum can be very helpful. You obviously have to be careful of that with somebody with significant osteopenic changes. So sometimes removing that direct pull of the brachioradialis can be helpful with a tenotomy. And that will help you to restore that typical radial translation of your distal articular segment. And so here's another example here of the opposite direction. In other words, you can have your carpus and your fracture fragment translate ulnarward, and this is with a radial styloid fracture, which has, remember, the origin of your extrinsic radiocarpal ligaments, your radioscapulocapitate, your long radiolunate ligaments. And if that's not reduced, you can end up having this radial or this sort of ulnar translation of your carpus. Combined treatment, as I pointed out, may be appropriate, and you have to be aware of that. Again, it's not looking at everything like a hammer and a nail, and you have to be prepared to augment your fixation as needed, including radial styloid pins. So volar block plating, what are our assumptions? Early exposure and application, you have reality, you have to be relatively aware of sometimes the limitations of your exposure. In other words, you can't get dorsally, you can't look at the articular surface very well. Fracture reduction is simplified. That's true in many cases, but the fracture often will reduce to the plate, not the opposite way around. And so sometimes if you're using a plate-specific system, you may be counting on the fracture to reduce to the plate, which may not always be in the best interest of your fracture reduction. And then it provides a buttress of the volar lip fragment. That's not always the case, and so you have to be careful of that small volar lip fragment. And then precontoured plates are helpful, and screws are always perfect. That's not a reality, as we all know. You have to be very particular in recognizing that some patients may have a malunion to start before their distal radius fracture, or some fractures you can't adequately reduce. You have to be careful that those fixed angles aren't guiding you for screw placement into the distal radial ulnar joint, or missing and going dorsally. So here's why you have to be careful. The distal radius, remember, on a lateral view, it's hiding the fact that the tendons on the dorsal aspect of the distal radius, at the level of the distal radius, are very, very closely approximated to the dorsal cortex, and it's very easy for a screw to be not appreciated in terms of its protrudence or its prominence dorsally, and we all probably have seen one or two extensor tendon irritations or ruptures, which are very difficult to explain away at the end of the day. So there's your lateral view, and you have to be aware, again, of your DRUJ in terms of that very ulnar screw placement, particularly when you don't want to run into problems with extensor tendon injuries. The other issue of volar lock plating, remember that one size doesn't always fit all, and so you have to be aware of Soong's article in JHS in showing and pointing out the importance of the watershed line and trying to avoid distal plate placement, but also plate placement where you've got a significant prominence of your hardware at the distal aspects. You have to be really aware of those patients that come back in with volar wrist pain and pain with gripping and grasping and resisted flexor tendon activity, particularly with the FPL and the index finger being a little bit more susceptible to this. So the take-home message, this is a spectrum of injury, remember, of our distal radius fracture. It involves soft tissue and bone, and so you really have to individualize treatment. You want to restore articular anatomy as being pointed out with stable fixation. Our volar plates will typically do this for us. It allows us to get early range of motion, but at the same time, we want to protect soft tissues with our hardware placement. You want to allow for early controlled motion, and you want to minimize complications for this. So again, at the end of the day, you want to ask yourself, what would you do for this fracture? The same with answering your patient, why would you put your volar plate on as opposed to other treatments? I think that's something we have to ask ourselves with each case, not just the end of the day we're putting a volar plate on everything. So thank you very much for your time. Thank you.

volar plating

distal radius fractures

evidence

individualizing treatment

anatomy of the wrist