Okay, welcome everyone. This is the ASPS Global Partners webinar series. Thank you guys all for joining today. We have a double feature for you. So go ahead and get out your popcorn or make your cocktails and get ready for two wonderful back-to-back webinars, the first of which will be on distal radius fractures, contemporary concepts and management. If we want to go ahead and advance the next slide. So this, throughout these talks, we do want you guys who are here to submit your questions through the Q&A function at the bottom. And we will kind of tabulate those questions and go through them at the end. The panelists will be able to answer those and we'll have some good discussion at that time. Please also make a note that this webinar is recorded and will be posted on the ASPS EdNet probably as soon as tomorrow, if you miss anything or need to review. So without, this is just an overview of the webinar. We'll again, start with the distal radius fractures, contemporary concepts and management, and then move on in the second hour to Hot Pockets, Tips and Tricks, and Plane Conversion for Breast Surgery. So without further ado, we'll get started with Dr. Rachel Hooper, who is a clinical assistant professor at the University of Michigan. She is general surgery, plastic surgery, and hand surgery trained, fully board certified and a hand surgeon extraordinaire in many things, not the least of which is distal radius fractures. She's going to be talking to us about an important topic for anyone who fixes distal radius fractures, dorsal bridge plating, Plan A, B, or C. So go ahead, Rachel. Thanks, Dr. Schmucker, and thanks ASPS and Global Partners for the opportunity to speak. I have no disclosures, though the objectives for me are to kind of introduce the history of dorsal bridge plating. We'll talk about the indications and progression of plate technology, the surgical indications, excuse me, the surgical technique, some case examples, and then some outcomes and complications. In terms of the history, this technique was introduced in 1998, and it has evolved because of difficulties in maintenance of reduction with an external fixator, as well as some of the difficulties associated with pins extending outside of the skin, including infections and stiffness. In terms of the indications for dorsal bridge plating, this is often used in high-energy unstable injuries, intra-articular fractures with a lot of comminution that you want to get distraction on, radiocarpal dislocations, salvage fixation following an amputation as seen in the image on the right. This is a patient who had an amputation at the wrist, and we used dorsal bridge plating as part of our fixation with the replantation. It's also used in polytrauma patients, particularly those that are dependent on their upper extremity for mobility. Some of the benefits of dorsal bridge plating, including being a, quote-unquote, internal external fixator, it allows for spanning ligamentotaxis and distraction of some of those comminuted fractures. This type of fixation uses dense diathesal bone of the metacarpal and the shaft of the radius. It avoids the cumbersome construct of an X-fix, as well as those pin site infections that I mentioned earlier, allows unrestricted use of the hand, and can afford individuals kind of immediate partial weight-bearing with assistive devices. Contradications to dorsal bridge plating include infection, gross contamination, poor soft tissue coverage, metacarpal injuries, and I put questionable non-trustworthy patient. The reason for this is these patients require a second operation for removal, so you want to make sure that they're trustworthy in the sense that they'll come back for their second operation. So this is kind of the landmark paper that described the use of this internal distraction plate by Burke and Singer, and their approach was through a large midline incision spanning the middle finger metacarpal to the radius. And here, they identify kind of one of the sort of challenges with this approach, and that is potential injury to the extensor pollicis longus, so you have to be sure that the plate is passing deep to this. Their case example in this landmark article included a 63-year-old orthopedic surgeon, which is kind of ironic, with this terrible-looking fracture. It is severely comminuted, loss of height, dorsal dislocation, and so they kind of describe and show their intercarpal fixation, radial fixation, with pinning as well as using this sort of spanning distraction plate. This is another example of kind of an earlier paper that sort of popularized the use of this technique. Again, a terrible-looking fracture, significant metaphyseal comminution and displacement, in which they use this spanning plate. And for this particular paper, you see a little evolution in terms of the approach. The authors here used two incisions, one over the radius and one over the metacarpal, and you can see this sort of high-profile, excuse me, plate with screw holes kind of throughout the plate. And I'll show you as the technology progresses, we realize that we don't need as many screw holes. In any event, they show kind of their case example where they got a nice reduction and were able to hold it out to length with this dorsal spanning plate. In terms of the progression of the plate technology, I show you this plate that was kind of used earlier. Nowadays, the plates are a bit lower profile and allow for locking screw technology as well. And there's no longer the radiocarpal screw holes because you don't need to use those. In terms of where to fix the plate distally, in the earlier papers that I showed you previously, the authors placed the distal fixation on the middle finger. And this paper used a cadaveric study to kind of look at kind of the risks and benefits of fixating the plate on the index versus the middle finger. And so, the image on the right shows cadaveric fixation of the plate on the index finger metacarpal showing kind of nice placement deep to the EPL tendon as indicated by the black arrow. In the image on the right, the authors show the plate being fixed to the middle finger metacarpal. And this is sort of fraught with high risk of injury to the extensor retinaculum as well as entrapping the EPL and first compartment tendons. And so, they did six cadavers for each type of fixation. And they found that when they fixed the plate to the second metacarpal, there were zero entrapped first and third dorsal compartment tendons as well as no injury to the extensor retinaculum. However, when they fixed it to the third metacarpal, there was variable injuries to these intervening structures. So, it's kind of convincing that, you know, the index finger is sort of preferable for distal fixation and it also helps improve radial inclination as well. In terms of immediate weight bearing, as I mentioned, this is important for polytrauma patients that have lower extremity injuries that may need walkers to get around. That's true for elderly patients with assistive devices. However, it depends on the fracture patterns, you know, if you're going to allow patients to start weight bearing immediately after surgery. In this particular paper, the authors, again, used a cadaveric study. They created two and five millimeter osteotomies to sort of simulate intra and extra articular fractures. And they surmised that to use a walker or crutches, this requires about 22 to 50% of your weight bearing capacity respectively. And what they found was that the low-tip failure was greater than these requirements to weight bear when there was a five millimeter osteotomy. However, for the two millimeter osteotomies, the low-tip failure was lower. And so, their recommendation based on this is that it's okay for patients to kind of bear enough weight to use a walker, so that's the 22%. However, they recommend avoiding full weight bearing, and that's required for crutches. Now, I'll move on and kind of talk about the technique in terms of placement. The schematic sort of shows the incisions, though, as I mentioned previously, preferentially, it's placed distally over the index finger and proximally between the first and second compartments. Typically, you do a subperiosteal dissection distally, create a pocket, and kind of plaster the plate from distal to proximal. Several companies have sort of different modifications and different handles that you can use to sort of facilitate this part of the procedure, and then you fixate the plate with two to three screws. So, now I'll just show a couple of cases in my own practice where the dorsal bridge plate was kind of used as plan A, B, or C. So, this particular patient is a 66-year-old nurse, right-hand dominant, who fell on out of her chain. She went to the emergency room and had a reduction and was referred for outpatient follow-up by demonstrating the dorsal comminution and sort of relative carpal subluxation and impaction of her fracture. You can see she's quite ulnar positive on this AP, and this was her reduction. And so, in our discussion, you know, I discussed with her both volar and dorsal approaches as sometimes you think you can fix this with one approach, and you need to use a combination of approaches. And so, that speaks to kind of having all the available plates in the operating room in case you need to adjust kind of your plan. And so, I started volar. You can see the freer kind of on the fracture site. I'm trying to get a reduction. And as I was attempting to place my volar plate, the fracture was so distal, I wasn't able to accomplish that as the fracture remained quite kind of impacted. And so, I added a dorsal bridge plate, and for this particular procedure, I did do three incisions kind of highlighted by the red and black boxes. And here, after placing the dorsal bridge plate and getting some distraction, I'm just showing kind of the provisional fixation, so proximal screw and the distal screw here. The green line is showing kind of the metacarpal neck, which is the most distal extent that you want to place your plate to avoid kind of fractures of the metacarpal. And here, you see this screw fixation on the index finger. And so, after getting a bit more distraction, I was able to place my volar plate. And this sharing of real estate when you have plates both volar and dorsal on the metacarpal, you have to sort of be creative in terms of how long your screws are, and that's where the locking technology comes in, and you're able to not necessarily have bicortical fixation but have something that's rigid enough to push your goals. So here, I'm showing I'm able to get the distal screws without being in the joint. And again, sharing the real estate where that second screw that's more distal is not quite bicortical, but it's locking and staying in place. And this is kind of what it looks like on the table, both dorsal and volar plates and skin closure. And I follow these patients monthly with serial x-rays, and typically, I do my removal with three or four months, as long as the x-ray is showing evidence of healing. In terms of the removal, you really only need to open the distal and proximal incisions, remove the screws, dislodge the plate, and slide it out. And this is what it looks like when the plate is removed in the fluoro. And then this is her two-week post-op x-ray, reasonable radial inclination, still a little bit ulnar positive, but better than she was preoperatively. In her lateral, she has neutral allotment for incisions. These incisions heal fairly well, and here you can see those. And then from a functional standpoint, she has reasonable wrist extension, as well as flexion. So not a bad outcome in a 66-year-old with a really bad fracture. This case was a bit more complicated, a 53-year-old gentleman, right-hand dominant, who fell while he was rollerblading. And here you can see kind of the obvious wrist deformity. And this was his preoperative x-ray, so kind of this comminuted impacted fracture, and some dorsal comminution and tilt. And so for this fracture, I approached it with fragment-specific, you can see the intermediate and radial columns. And intraoperatively, I flexed this patient and didn't see really any movement of this dorsal fragment. And against my better judgment, I didn't put anything dorsally at this juncture and followed him for four weeks. And unfortunately, that fragment did displace. And so I always refer to this quote whenever I have a complication, Dr. Cameron, good judgment comes from experience, and experience comes from bad judgment. So I went against my original plan and didn't put any dorsal fixation, and this patient necessitated an additional operation. Again, I used a three-incision approach for this case, removed the plate, pried up the articular surface. You can see kind of that bone gap. We packed some bone graft from a dorsal approach, again, using the dorsal bridge plate to get some distraction on this fracture, and then place a dorsal buttress plate over that main dorsal fragment. And here is kind of the in situ sort of photos showing the plate in place and the fixation. And these are his intraoperative fluoroscopy pictures and closure. And similar to the previous patient, follow these patients with, you know, serial x-rays at two weeks, one month. Here's some clinical photos, still working on finger range of motion, you know, and scar massage, trying to maximize the use of his hand. This is his two-month post-operative x-rays showing kind of incorporation of the bone graft and healing. And then I removed the plate, I removed the dorsal bridge plate at three months and left the dorsal buttress plate in place. And I allow these patients to move three days after removal of the plate as much as they can. His sort of functional outcome wasn't as great as the previous case, given the pattern of fracture and the other surrounding circumstances. So here he has, you know, a little bit of extension and very little flexion, but a stable pain-free wrist for his injury. And then the final case I'll just share is kind of along the same lines, different, you know, fracture pattern, multiple fragments, intra-articular fracture with dorsal combination. And again, to just show how helpful the dorsal bridge plate can be with kind of holding that distraction. So I reduced the fracture of volarly in this patient as well, and then used the dorsal bridge plate to hold things out to length, fixated the plate, and then did use a volar plate to support that distal fragment from displacing on intraoperative fluoroscopy. There was some movement. However, the plate was placed so distal. I couldn't put screws in the distal aspect of the volar plate seen here, so we just placed some proximal screws and just kind of used that to hold that distal fragment in place. And again, following these patients monthly, and this, I just recently removed her, both of her plates, and you can see she's in a neutral alignment, has a fairly good height and inclination, and is on to recovery. Several systematic reviews have been done examining the use of the dorsal bridge plate. As I have described, these plates are typically moved somewhere between three and four months. Around 8% of patients in this study required extensor tenolysis when they were removed. Mean range of motion is somewhere between 45 degrees of flexion and 50 degrees of extension. Patients have really good pronal supination, 75 and 73 degrees respectively, and you're able to get at least neutral tilt, if not a little bit of volar tilt, and their mean dash scores are about 26. In this sort of single-institution study of 18 patients with one-year follow-up, the authors found kind of similar findings, you know, wrist flexion in the mid-40s, grip strength was about 86% of the contralateral risk, and they noted, you know, complications including chronic pain, tendon irritation, and infection, and they kind of broke down kind of the relative percentages, so hardware failures, kind of breakage of the plate occurred in 3% of the patients, symptomatic nonunion, nonunion also occurred in 3%, persistent pain 2%, superficial infections 1%, and deep infections 2%. So in summary, the dorsal bridge plate is a really versatile form of fixation. It's really helpful for those unstable, common rooted, intra-articular, metaphyseal, distal radius fractures. It's really helpful for those polytrauma patients and elderly patients that do require assistive device for getting around. I think the index finger is preferable in most cases to avoid injury to those structures that we discussed. And then, you know, when you're proposing these to patients, it's important that you establish a good rapport and reliability, because this does require a second operation for removal. Thank you. Excellent. Great talk, Dr. Hooper. Next, we'll hold questions till the very end and we can go through those for both panelists. So next speaking is Dr. Mathani with a talk titled, Snakes in the Grass, Pitfalls and Complications of Distal Radius Fixation. Dr. Mathani is an associate professor at Duke University in plastic and reconstructive surgery and orthopedic surgery. He's a hand and upper extremity surgeon there and currently the interim chief of the division of plastic surgery. So go ahead and we're looking forward to your talk. Thank you so much. Pleasure to be with you all this evening. And so I wanted to talk about the things that come out to bite you when you're least expecting them. And we live in North Carolina where there are copperheads hiding around every corner. And one of my senior partners is fond of talking about the snakes in the grass that are always out there and particularly the ones that are associated with distal radius fractures and fixation. And so I was going to go through some problematic fracture patterns. My relevant disclosures, I'm a consultant for Restored, which does do some 3D printed solutions for individual fracture patterns. So my plan today is to go over some problematic fracture patterns, particularly focusing on volar shear and radiocarpal dislocations, and then talk about some of the other sneaking up on your complications related to malunion as well as hardware. So let's start with the problematic fracture patterns. The common themes related to these problematic fracture patterns are ligamentous attachments or lack thereof, and the result of instability from this resulting in radiocarpal translation. And really the two things that you see are an escaped volar lunate facet and a volar shear injury, which tears the volar ligaments, resulting in significant displacement that needs to be addressed. A very, very, very brief anatomy review and really the two ligaments or the three ligaments that we're going to kind of focus on relative to these fracture patterns are the radioscapheal capitate, which goes from the radial styloid across the waist of the scaphoid and inserts on the capitate, and the long and short radial lunate, which basically bind the lunate to the distal radius. And these are key to ligamentous stability of the wrist joint. So the two fracture patterns that are, I think, the snakes in the grass to talk about are radiocarpal fracture dislocations and volar shear injuries. They're on the same spectrum, even though they can dramatically look different from one another. They have radiocarpal instability due to ligamentous injury. And the pattern of instability is either due to a retained radioscapheal capitate ligament attached to a relatively large radial styloid fragment for which the fracture follows the displacement of the radial styloid fragment. And you can see that here in the x-rays that I'm showing here with a dorsally displaced radial styloid fragment and carpal subluxation dorsally following that radial styloid. The other pattern of instability can be due to injury to the radial lunate ligaments. And again, this is potentially part of this fracture pattern that I'm showing you here as well, in that the dorsal displacement will be resisted by the radial lunate ligaments, but is not because of injury to them. So these patterns are highly unstable. They're better handled sooner than later. And the thing that kind of keys you in that there may be something more going on than just a fracture is that they have a dramatic degree of displacement relative to the radiographic extent of the fracture. And this is a perfect example. You have a little tiny radial styloid fragment, and the whole carpus is shifted relative to that fragment. So the radial carpal fracture dislocation itself is a relatively uncommon fracture pattern. It was originally categorized by DuMontier. And basically, these injuries involve the radial styloid and the radioscapheal capitate. So basically, they divided these into type 1 and type 2. The type 1s were really tiny, small fragments of the radial styloid, and there was a radioscapheal capitate injury causing sag and subluxation of the carpus. The type 2 injuries that they identified were those that involved radial styloid fractures that included greater than a third of the scaphoid fossa, and essentially, the carpus followed the displacement of the radial styloid fragment because the RSC was still attached to the styloid. Randy Bindra attempted to further classify this into four types for the radiocarpal fracture dislocations to include some type of understanding of the potential injuries to the ligamentous structures beyond the radial styloid, and these are the four patterns that he kind of showed in that paper, and describing them as such that he also tried to describe them as well as posit treatment options that were more ideal for management of these kinds of things. And so, particularly when you look at the injury patterns, it's not just that the radial styloid dorsal fragment is large or small, but it's the injury that goes to the volar lunate facet and the size of that injury keying you in as to whether or not the carpus is moving with the bones, with ligaments attached to them, or that the smaller fragments are loose and essentially there's ligamentous injuries causing the carpus to subsequently dislocate, and that drives the decision making in terms of whether fixation alone is worthwhile or is necessary versus some type of ligamentous repair. This other study from the Journal of Wrist Surgery took the what I would call the bender type 2 patients, those with the flipped volar lip, and basically classified those folks and said that, gosh, if you have fixed these types of injuries and there's still some instability as you stress in the operating room, and Dr. Hooper alluded to this in her talk, that really, you know, you do your fixation and you feel like your joint aligns well, then the next thing to do before you complete your operation is to stress this under fluoroscopic visualization on both the PA and lateral views. And in this particular paper, these patients had persistent instability despite adequate fixation, and they were subsequently stabilized by doing a ligament repair with suture anchors. To note, these fracture patterns tend to be high energy fracture patterns, so they tend to have concomitant other injuries associated with that as a little bit of an aside. This is the patient that I initially described in the title slide, and this was one that we addressed by repairing the radial styloid, and I think that you have options as it relates to managing the ligamentous instability, so you can either directly repair the ligaments or you can do some type of dorsal distraction plating to essentially neutralize the wrist and during the healing time to essentially allow those ligaments to heal prior to bridge plate removal. And in a lot of situations, I will elect to do a bridge plate in addition to my fixation. This is a slightly different pattern here with this, the dorsal subluxation, and you can see here that volar lunate facet, which is relatively small and hard to capture. And so, when we reduce this one, we actually are able to reduce that volar lunate facet, which can't be fixated with some suture anchors, then repair that radial styloid with a cannulated headless compression screw, and then many times in a belt and suspenders kind of fashion because I'm a little bit nervous about letting people move alone with just basically two tiny suture anchors holding their carpus in place. I usually put a dorsal distraction plate on and then after removal looks pretty reasonable. So, what I'd say is kind of the summary that I'd have for the radiocarpal fracture dislocation or these sheer injuries. If the fracture seems innocuous relative to displacement, there's likely a ligament injury. And so, be super attentive to persistent instability after fixation and consider ligament repair or dorsal distraction plating or the combination thereof to address this. The other snake in the grass that will come up to bite you is the malunion. And the biggest driver of the malunion that causes problems, at least for those patients that have been operated on, are those that have an unreduced volar lunate facet. This can be oftentimes challenging to capture and you have to be hypercritical of your images and x-rays when you do this corner, the volar lunate facet. It's termed the critical corner because many times those ligamentous attachments drive carpal translation. This is one where a plate was placed relatively adequately and an attempt was made for an extra plate screw to kind of hold the lunate facet and that proved to be inadequate. And what you can see when you look at this, and it's not a perfect PA view, but radial placement of the plate prohibits the ability of the plate to buttress the volar lunate facet. Even sometimes if you can't fix it, you can at least use the plate as a buttress to hold it in place. In this case, it didn't. And you can see that lunate facet continues to be dislocated and then the carpus continues to be translated as a result of that. And the patient in this situation has a limited extension and supination as the result of it. And the CT scan more clearly delineates on the coronal, sorry, the parasagittal views, that's volar translation of the carpus relative to the distal radius. This was described previously and established the critical importance of the critical corner and really highlighting the fact that you really need to capture that volar lunate facet. And many times, interarticular distal radius fractures, the ability to capture that volar lunate facet impacts out pumps significantly. And you need to be considering something like fragment specific fixation or dorsal distraction plating, but really have to be super critical about your position. And they gave an example that you can see here where the plate, again, is placed too radially causing some issues related to this. And then what happens with an unreduced volar lunate facet? You can lose extension and supination. And here you can see that this type of a variant of a volar Barton's type of fracture causing volar translation and subluxation. So not only is the carpus translated and subluxed, but the DRUJ is incongruous. And so you lose forearm rotation as well. And this is a situation in which with a large enough lunate facet fragment that's unrecognized, you can go back and do an osteotomy and you can repair it with a plate that is a little bit more distal and dorsal. Many times we will do this repair and fixation in conjunction with either an external fixator or a bridge plate as well to kind of support that. As you can imagine, trying to do an osteotomy of these kinds of things can be really problematic. So the other type of malunion that you'll run across, which I think is more common in the setting of somebody that's been managed non-operatively, is the extra articular malunion and less frequently with inadequate ORIF. And we see that less and less frequently as most people use volar plates, but oftentimes you'll get folks that are either just in an external fixator or with pins that are performed and those patients have a tendency towards less ideal reductions. So when you have an extra articular malunion, you've kind of got two options. You oftentimes have a radial height discrepancy. And so the radius is short. So you can oftentimes match it with an ulnar shortening osteotomy to kind of reduce that incongruence in the ulnar positivity. Sometimes there's an issue with tilt and inclination as well as length and a corrective osteotomy can be indicated. And sometimes you need to do a little bit of both, particularly in the setting of a established malunion. Isolated ulnar shortening osteotomy was first described in the mid-90s and it was kind of not felt to be a great option because of the complications associated with it, but there have been substantial advances in the intervening several decades with regard to technique and implants. So it is a reliable type of procedure. We looked at this, my co-fellow looked at this when we were in training and posited that for patients with extra articular malunions with loss with up to 20 degrees of volar dorsal tilt, that they can be successfully treated with isolated ulnar shortening osteotomy and showed that in the patients that we treated, that there was a significant improvement in the flexion extension arc as well as forearm rotation with adjusting the ulnar variance alone. So basically if you have extra articular distal radius malunion with less than 20 degrees of tilt derangement and isolated ulnar shortening osteotomy is a sufficient solo treatment for improving their functionality. In some situations though, you'll have to do a corrective osteotomy and I think that it takes significant preoperative planning technique and some adjunctive tools may be necessary for doing it. For the most part, you think about with an extra articular malunion, the reality is you probably don't need to have a CT scan to be able to give you a sense of what's wrong with the fracture for malunion correction. This study showed that basically the measurements one takes from plain films relative to what the measurements are from CT scans were relatively similar, but the CT scan may be indicated if there's a concern for rotational malalignment, that's to say something that affects the DRUJ causing forearm rotational issues. Then when you go to correct the malunion, do you do a dorsal or volar approach? A couple of studies basically showing essentially equivalent results with the exception of slightly better flexion via volar approach. Because we tend to use volar plates much more so these days for their complication profile, most of my osteotomies for malunions tend to be volarly anyway. This is a malunion case that we saw. You could see a little bit of shortening, but really mostly about tilt. This is kind of more of a nascent malunion, somebody that was managed non-operatively. And this is one where you kind of expose and the volar and dorsal lips are flipped because it's extended. And so you can kind of open that up to do an osteotomy. I tend to do the correction by kind of doing a volar wedge, and then we'll try to really free the fracture so that I can kind of mobilize the fragments. And then I'll put the plate on the distal fragment, try to get it lined up once I have it kind of reduced the way that I want. And then subsequently do the attachments on the, or do the screws onto the shaft. So then I regain my tilt. So first establishing the distal fixation and the distal fragment, and then bringing it down to the forearm fragments that kind of allows for, I think, better correction of tilt. And as well as, this is particularly helpful if you don't have a lot of loss of radial height and inclination in this setting. Sometimes 3D planning is necessary for things that are complex, like intraarticular, multiplanar, longstanding, or very distal malunions. And these things can be quite complex. So this is a patient, as I alluded to, that was treated with a closed reduction percutaneous pin fixation. You can see the lack of reduction of the distal radius here, and this is how it went on to heal in that setting. So a lot of loss of tilt, loss of height, loss of inclination, all of the above are there. And so this is one where we, because of the multiple planes of correction needed for this osteotomy, we use bilateral 3D CT scans to kind of do some virtual surgical planning and generate some implants to be able to use both cut guides, as well as kind of with the plating construct in mind. This setting was when we had planned both a radial osteotomy as well as an ulnar shortening to facilitate that, and it went on to heal relatively uneventfully. So malunions, in summary, the neglected fracture may come back to bite you. Radial shortening must be corrected. If it's the only parameter with minimal loss of tilt, consider an ulnar shortening osteotomy. If you need to do a radial osteotomy, volar and dorsal approaches are both successful, but if it's complex, multi-planar, inter-articular 3D planning is a reasonable consideration for management of malunions. The final thing I'll talk about is hardware complications. I think this is the ultimate snake in the grass because we see our patients for a certain period of time, and then afterwards they're gone. And so I've generally, you know, followed my patients out for a year at the bare minimum, if not longer, but it's hard to get patients back that are doing well for much longer than that. In general, hardware complications of the distal radius are related to plate placements either too distal, too proud, or too radial. This can result in flexor tendon irritation and rupture. This is a patient who is 10 years post-open reduction internal fixation, and not really terrible plate placement, but came with an FPL rupture that you can kind of see here from the rubbing and irritation on the plate. And you can kind of see that distal FPL and how torn it is. And we ended up repairing it with graft. We, our group kind of looked at the complications we had in volar plates of distal radius. We found that we had about a 6.6% hard removal rate and a 1.1% tendon rupture rate, of which two-thirds of those were extensor tendon ruptures, which is more a function of the fracture, I think, than it is of the fixation. But we as a group are extremely aggressive with hardware removal at one year. So basically, if somebody comes in at the one-year mark and I can detect any type of crepitants, I'm taking their hardware out at that point. And I think that so far, knock on wood, I have not had any flexor tendon ruptures with that kind of process in place. So I think you really do need to be critical of your plate placement. And I would kind of urge everybody that if there's crepitants at one year to go ahead and take the hardware out. Thank you all very much for your time and attention. Awesome. Those were both excellent talks. We don't currently have any questions in the chat, but just want to remind our attendees that any questions you have for the panelists can go in that Q&A box on the bottom of the screen. While we see if there's any questions rolling in, I have a couple for each of you. I was going to ask Dr. Hooper, you know, so you showed a couple three incision insertions of a dorsal spanning plate. Do you ever use two only? And if you do, do you have any tips or tricks for keeping the EPL out from under the plate and placing it? And Dr. Mythani, you're welcome to answer on how you do it as well. Yeah, thanks for that. I like the two incision if I don't have to do any work kind of in the distal part of the radius. I typically start distally and do a subperiosteal dissection and then kind of use kind of either a Big Kelly to kind of spread and try to create kind of that retrograde path. And then I'll do my proximal dissection. And then in terms of connecting them, I kind of load the plate on that handle. And if it's kind of, if it goes subperiosteal and it kind of goes smooth and it's, you know, not too difficult, then I'll pass it without making that second sort of intervening incision. If there's any resistance or anything like that, I don't hesitate to make a central incision. But if I don't have to do something like pec bone graft or do something from a fixation standpoint to the radius there, I typically do two incisions. I do tend to use three and I do go to the long finger. I've kind of gone back and forth about going to the index versus the long finger. And the thing that I kind of, at least in my hands, what I've found is that I can get radial height and inclination better if I go to the index finger. But many times we're faced with this really smashed fracture that's kind of interarticular and the cup of the distal radius is disrupted both volarly and dorsally. And I find that if I go to the long finger, I'm able to kind of buttress that dorsal lunate facet as well as kind of use ligamentotaxis to kind of get the volar shear part to kind of come up a little bit. And I do make the third incision kind of adjacent to the lister's tubercle, lift the fourth compartment subperiosteally, almost always transpose the EPL. So it's time intensive. I mean, I much prefer to go to the index finger because it's a third of the time that it takes to go to the long finger, but some of it's just dictated by the character of the fracture pattern. Yeah, I agree. I think one size doesn't fit all with these. And if I go to the third, I do make a separate central incision because of that risk of entrapping the third and fourth compartments. And I think if you're going to the second, it's really easy for those who haven't done it to kind of slide into the subcutaneous tissue and very superficial. And so you really have to, as you're going proximal, keep that plate subperiosteal and then range your EPL intraoperatively after you've got the first two screws down to make sure you don't have it. If you're not going to make that second incision. This is for both of the panelists. We talked a lot about the importance of stressing the fracture under fluoro after you apply your initial fixation. And I tell our fellows that all the time. So what are you guys looking for? Are you looking for subluxation of the carpus? Are you looking for displacement of the fragments? Just for our participants, what are you looking at? What kind of parameters do you look at under live fluoro when you're adding stress and how do you stress the risk? I would say like all of the above. I, you know, I do the usual sort of, you know, lateral AP, oblique, dorsal tangential. I've tried to remind myself to do that one as well because I've been fooled a couple of times that, oh, the screw is not, you know, piercing the dorsal cortex. And then you can see a little something on that view. And then it just kind of depends on what the pattern of the fracture is. But yes, I'm looking for all of the above mobility of those fragments. I'm looking at the carpus. I'm also seeing like the patient is never going to flex as much as I would do them passively. So I'm also sort of getting a sense of like, you know, is this someone that I want to start moving at like a week or two? Or is this someone that I want to give a little bit more time? Kind of they can transition to an orthoplast, but not move too much, you know, so all of the above. On the same, I try to be, it's like emotionally taxing, go through a hard case and then like put a ton of stress through it on the views. But I think you have to do it because the patients are going to do that. And I have found like, as time has gone on, I immobilize these folks for shorter and shorter periods of time. At this point, most people get a removable wrist brace coming out of the operating room that they can take on and off within the first couple of days. And so just, you know, you try to protect your x-rays when you're first starting out, and then you start to see patients coming back and you wish you hadn't immobilized them for too long. And then you kind of start changing your practice and trying to figure out how you can avoid complications by being too aggressive. Yeah. Yeah. It helps you sleep at night and you would much rather see them displaced in the operating room when you can do something about it than on your two-week x-ray that your PA texts you later and you get that terrible feeling. So I was going to ask, so how do you guys prefer if you have a very small lunate facet fragment, do you prefer fragment specific? Do you use a hook plate or a hook onto a bowler plate? What's your preferred method for fixing those small lunate facet fragments? Hook plate for me, like I've not had good success trying to use like hand plates for those kinds of things. So the fragment specific design plates that several companies have, if the fragment is big enough, it works. I will say that I'm a little bit of a chicken. So a lot of times I will back that up with a bridge plate if I have any concern at all. So when I kind of get in there and I put the drill holes in for the hook and then I put it down, I'm like, okay, that reduced. I don't know how it reduced. Then I'm like, all right, let me put a bridge plate on this because I can't trust that. And then there are other ones that you're like, oh, there's lunate facet fracture fragments that extend down along the ulnar border of the distal radius. And those ones you're like, okay, I got a really good bite on this thing and I'm feeling pretty good about this and I'll kind of let it roll. Also, sometimes my adjunctive fixation is dictated to some degree by the amount of displacement that happens, right? So if the carpus is vulnerably dislocated, I don't really think that a three hole hook plate is going to hold that thing back in. And so once I put the hook plate on, I've kind of precluded myself from doing a suture anchor type of thing. And so then I'm back to the bridge plate situation. I think same. I prefer the fragment specific. You know, the thing that I've learned as I showed in one of my complications obviously is that it's not necessarily rigid, right? The distal hooks are kind of, you're impacting them into the bone. It's not bicortical. And so, you know, you have to think about backing it up with something, whether it's a dorsal bridge plate or if there's a radius something else that is getting you some rigid fixation, some support to help augment that. Yeah, I think that was a great case to show because your volar reduction, those hook plates are awesome. But if sometimes you need a volar plate to kind of hold that up or around the world, dorsal and volar plates. And so that was a great one to show for sure. Do we have any other questions from the audience? Not seeing any, and if that's the case, I think we will go ahead and transition to Dr. Meyer for the breast portion of the webinar.

distal radius fractures

breast surgery

dorsal bridge plating

ligamentous injuries

carpal alignment

volar lunate facet

high-energy injuries

post-surgical considerations