AO钢板

Original Instruments and Implants of the Association for the Study of Internal Fixation — AO ASIF 2.4 mm LCP® Distal Radius Plates Technique Guide Titanium Volar Distal Radius Plate Titanium Dorsal Distal Radius Plates The 2.4 mm LCP® Distal Radius Plates Indications For fixation of complex intra- and extra-articular fractures and osteotomies of the distal radius and other small bones. Features • Smaller plates and screws address fracture fragments individually, with less overall implant bulk • Different dorsal and volar plates allow implant placement to match the individual fracture pattern • Low plate-and-screw profile minimizes potential for tendon and soft tissue irritation • Highly polished surface and rounded edges also minimize potential for tendon adhesion • Volar and straight plates are precontoured for anatomical fit • Locking Compression Plate (LCP®) holes allow locking screw fixation with angular stability in the threaded section, or compression with cortex screws in the Dynamic Compression Unit (DCU) section of the hole • Locking screws offer a fixed-angle construct to support the articular surface, reduce the need for bone graft, and obtain fixation in osteoporotic bone • Choice of two lengths of each type of plate precludes the need to cut plates which can result in tendon irritation 1 Three-Column Theory of Dorsal Distal Radius Fracture Fixation ■ Radial column Lateral side of radius including the radial styloid and scaphoid fossa ■ Intermediate column Ulnar side of radius, including the lunate fossa and sigmoid notch ■ Ulnar column Ulnar head, including the triangular fibrocartilage complex (TFCC) and the ulnar part of distal radioulnar joint (DRUJ) The two-plate technique of dorsal fixation of fractures of the distal radius offers increased stabilization. This is due to the 70°– 90° angle between the two plates. One plate buttresses the radial column (the dorsoradial plate), and the other plate supports the intermediate column (the dorsoulnar plate). Volar Fixation of Fractures of the Distal Radius A volar approach is usually used for volarly displaced fractures, and may be preferable for some dorsally displaced fractures. Columns of the distal radius 2 Dorsal Distal Radius Plate Features • Right-angle L-plates, oblique L-plates and straight plates are used in the dorsal two-plate technique. This offers a strong construct for complex distal radius fractures, avoids removal of Lister’s tubercle and decreases tendon and soft tissue irritation. Straight Distal Radius Plate, end detail The 2.4 mm LCP® Distal Radius Plates (continued) • Straight plates, contoured to fit the radial column, have a notched tip that allows these plates to fit on the radial styloid adjacent to a temporary K-wire fixation. 442.500 –90° 442.501 442.506 442.507 442.504 442.505 442.479 442.479 Profile442.490 442.502 442.503 442.508 442.509442.512442.511 –90° +90° +90° +20°–20° 3 Volar Distal Radius Plate Features • Complex AP bend fits volar surface of the distal radius • 18° angulation of distal plate head provides anatomic fit for radial inclination • 5° angulation of threaded holes allows more distal placement of the plate • Available in left and right designs 5° 5° angulation 442.491 442.493 442.494442.492 Left Right 4 2.4 mm Titanium Locking Screw, self-tapping with StarDrive recess • Threaded, conical head locks securely into the threaded holes in the plate to provide angular stability • Locked screws allow unicortical screw fixation and load transfer to the near cortex • 6 mm to 30 mm lengths (2 mm increments) • StarDrive recess mates with self-retaining screwdriver • StarDrive recess improves torque transmission Note: For information on fixation principles using conventional and locked plating techniques, please refer to the Small Fragment Locking Compression Plate (LCP®) Technique Guide. 2.4 mm Titanium Cortex Screws, self-tapping with StarDrive recess • For use in round or LCP holes • Low-profile head in the plate holes • Used to provide compression or neutral fixation • 6 mm to 30 mm lengths (2 mm increments) Note: The StarDrive T8 recess in the screw head offers improved torque transfer, high strength, and self-retention of screws, when compared to cruciform and hexagonal drives. Please note the StarDrive recess in the surgical report. This will remind the surgeon to have a StarDrive screwdriver available for removing these screws. 2.7 mm Titanium Cortex Screws, self-tapping • For use in LCP holes of the 2.4 mm LCP® locking volar distal radius plates • Used to provide compression or neutral fixation • 10 mm to 30 mm lengths (2 mm increments) • 2.5 mm hexagonal recess 2.4 mm Titanium Cortex Screw, self-tapping, with StarDrive recess 2.7 mm Titanium Cortex Screw, self-tapping Screws 401.756 – 401.780 2.4 mm Titanium Locking Screw, self-tapping, with StarDrive recess 412.806 – 412.830 402.810 – 402.830 5 Featured Instruments For the 2.4 mm LCP® Distal Radius Plates Handle, with quick coupling [311.43] Used with [314.467] StarDrive Screwdriver Shaft Holding Sleeve [314.468] Used with [314.467] StarDrive Screwdriver Shaft to hold locking screws during insertion, if desired. The conical head of the holding sleeve allows the plate to be pulled to the surface of the bone before the locking screw is locked into the plate. 1.8 mm Drill Bit with depth mark, quick coupling [310.509] Used to drill the hole for the 2.4 mm self-tapping locking screws. The mark on the drill bit gives a direct measurement of screw length, when used with the Threaded LCP Drill Guide [323.029] 314.467 311.43 314.468 Threaded LCP® Drill Guide [323.029] Centers the 1.8 mm drill bit to ensure engagement of the locking screw in the threaded hole in the plate. The threaded drill guide provides direct measurement of the screw length with drill bit [310.509] 323.029 StarDrive Screwdriver Shaft, T8 [314.467] Used for insertion and removal of 2.4 mm Locking and Cortex Screws with StarDrive recess 310.509 6 Surgical Technique General Notes on Technique Plate contouring Contour plates as needed using Bending Pliers [329.12] 329.12 Screw insertion • Determine where locking screws will be used. Use 2.4 mm locking screws in the distal arms and 2.4 mm locking or 2.4 mm cortex screws in the shaft of dorsal and volar plates. • 2.7 mm cortex screws can be used only in the LCP holes in the shaft of the volar plates. • If a combination of locking and cortex screws is planned, a cortex screw should be used first to pull the plate to the bone. • If a locking screw is used first, care should be taken to ensure that the plate is held securely to the bone to avoid spinning of the plate as the screw is locked into the plate. Contour the plate carefully for position as distal as possible. If necessary, fine bending may be achieved using Threaded LCP Drill Guides [323.029]. Be careful to avoid overbending and damage to plate threads. Note: The plate holes have been designed to accept some degree of deformation. Undercuts help protect the threaded holes from distortion. Significant distortion of the locking holes reduces locking effectivness. 7 Insertion of cortex screws • Use the 2.4 mm Universal Drill Guide [323.202] or the 2.7 mm Universal Drill Guide [323.26] for an eccentric (compression) or neutral (buttress) insertion of cortex screws. • For the 2.4 mm cortex screw, use the 1.8 mm drill bit for the threaded hole and the 2.4 mm drill bit for the gliding hole. For 2.7 mm cortex screws, use the 2.0 mm drill bit for the threaded hole and the 2.7 mm drill bit for the gliding hole. Insertion of locking screws • Screw the Threaded LCP Drill Guide [323.029] into a hole until it is fully seated. • Use the 1.8 mm Drill Bit with depth mark [310.509] to drill to the desired depth. Determine the screw length directly from the mark on the drill bit and scale on the threaded drill guide. This may also be checked using a Depth Gauge [319.006]. • Insert the locking screw manually with the self-retaining StarDrive Screwdriver Shaft [314.467] and Handle [311.43]. Carefully tighten the locking screw. Excessive force is not necessary to lock the screw to the plate. Determine desired screw length using mark on drill bit. Lock the screw into the plate. 8 General Notes on Technique (continued) Alternate Method: Locking screw insertion with holding sleeve An alternate method may be used for insertion of locking screws, using the locking screw to pull the plate to the bone. Place the Holding Sleeve [314.468] onto the StarDrive Screwdriver Shaft [314.467]. Pick up the locking screw with the holding sleeve, and insert the screw into the screw hole (A). With the locking screw still held by the holding sleeve, tighten the screw until the plate is drawn to the bone (B, C). Pull up on the holding sleeve to release the screw head, and tighten the locking screw into the plate (D). Postoperative treatment Postoperative treatment with locking compression plates does not differ from conventional internal fixation procedures. Implant removal To remove locking screws, unlock all screws from the plate and then begin to remove the screws completely from the bone. This avoids rotation of the plate when removing the last locking screw. A B C D Surgical Technique (continued) Extensor retinaculum Compartment 3 Extensor pollicis longus Extensor retinaculum Extensor retinaculum Compartment 3 Incision Compartment 4 Compartment 5 Compartment 2 Compartment 1 9 Dorsal Surgical Technique Patient position Place the patient in the supine position with the hand and arm on a hand table, preferably radiolucent for fluoroscopic imaging. Approach Make a straight incision 5 cm to 9 cm in length, approximately 2 cm proximally from the base of the second metacarpal over Lister’s tubercle to the border of the muscle belly of the first extensor compartment. 2 1 Open the extensor retinaculum Open the extensor retinaculum using a longitudinal incision over the third compartment. Dissect the extensor pollicis longus (EPL) tendon and place it in a vessel loop for manipulation. 3 10 Dorsal Surgical Technique (continued) Compartment 3 Extensor pollicis longus Extensor retinaculum Compartment 4 Compartment 6 Ulna Cross-sectional view Compartment 1 Compartment 5 Radius Compartment 2 Continue to dissect Elevate the second and fourth dorsal compartments subperiosteally to preserve the integrity of these compartments so there will be no direct contact between the tendons and implants. On the ulnar side, continue to dissect toward the radial border of the DRUJ, preserving the ligament and joint capsule. On the radial side, dissect toward the brachioradialis tendon to place the dorsoradial plate correctly to support the radial styloid. 4 Reduce the fracture and apply dorsoulnar plate Reduce the fracture. Begin fixation on the intermediate column with the dorsoulnar plate, adapting it carefully to the surface of the bone. This plate supports the intermediate column and fixes the dorsoulnar fragment. Fix the plate preliminarily with a screw in the shaft fragment close to the fracture (buttress position). 5 11 Alternate technique As an alternative, the dorsoradial plate may be placed using a separate incision between the first and second extensor compartments. Use caution with the alternative approach to protect branches of the superficial radial nerve in the skin flap. The dorsoulnar plate may be placed through a separate incision into the fifth extensor compartment. The extensor retinaculum over the distal part of the third compartment may be preserved so that the tendon is guided along its course toward the thumb. For additional information on technique alternatives, see D. Rikli and P. Regazzoni, “The double plating technique for distal radius fractures,” Techniques in Hand and Upper Extremity Surgery, 2000, 4(2), 107–114. Position the dorsoradial plate For the radial column, position the dorsoradial plate beneath the second compartment to support the radial styloid. Fix it to the bone with a screw in the shaft close to the fracture. It should form an angle of approximately 70° –90° to the dorsoulnar plate. Confirm correct reduction and position of the plates with fluoroscopy. 6 Position plates with a 70° – 90° angle. 70°– 90° 12 Complete the fixation Complete the fixation. Using two screws in the distal fragment and two screws in the proximal fragment will usually provide sufficient stability. 7 Dorsal Surgical Technique (continued) Create a flap Create a flap with the extensor retinaculum by pulling it underneath the EPL and suturing it. The extensor retinaculum lies between the EPL and the dorsoulnar plate to avoid direct contact to the structures. 8 Close the incision Use the appropriate method for surgical closure of the incision. 9 13 Volar Surgical Technique Approach Make a longitudinal incision slightly radial to the flexor carpi radialis tendon (FCR). Dissect between the FCR and the radial artery, exposing the pronator quadratus. Detach the pronator quadratus from the lateral border of the radius and elevate it toward the ulna. 1 Leave the volar wrist capsule intact Leave the volar wrist capsule intact to avoid devascularization of the fracture fragments and destabilization of the volar wrist ligaments. Contour the plate Contour the plate carefully for position as distal as possible. If necessary, fine bending may be achieved using Threaded LCP Drill Guides [323.029]. Be careful to avoid overbending and damage to plate threads. 3 2 Threaded drill guides may be used for fine bending. 14 Volar Surgical Technique (continued) Insert distal screws Insert 2.4 mm locking screws into the distal part of the plate. 5 Close incision Use the appropriate method for surgical closure of the incision. 6 Initial plate placement. Determine placement and insert proximal screws After reducing the fracture, apply the plate and insert a 2.4 mm or 2.7 mm cortex screw into the long hole in the shaft. Adjust the plate position as necessary, and tighten the screw. Determine where locking or cortex screws will be used in the shaft of the volar plate. Insert these screws beginning with the most proximal screw. 4 15 Volar Plating For Dorsally-Displaced (Colles’) Fractures Apply the plate Apply the plate very distally using the technique described above. Screw the Threaded Drill Guide [323.029] into the middle distal plate hole and drill to the desired depth with the 1.8 mm Drill Bit with depth mark [310.509] at an angle of 10° – 15° from the articular surface. Insert locking screws Insert locking screws as needed in the distal end of the plate Reduce the fracture Reduce the fracture by positioning the plate onto the shaft. 3 2 1 15° 16 Volar Plating For Dorsally-Displaced (Colles’) Fractures (continued) Insert locking or nonlocking screws Insert at least two screws, either locking (2.4 mm) or nonlocking (2.4 mm or 2.7 mm), into the shaft. 4 Close incision Use the appropriate method for surgical closure of the incision. 5 References 1. D. Rikli and P. Regazzoni, “Fractures of the distal end of the radius treated by internal fixation and early function,” Journal of Bone and Joint Surgery, 1996, 78B, 588 – 592. 2. D. Rikli and P. Regazzoni, “The double plating technique for distal radius fractures,” Techniques in Hand and Upper Extremity Surgery, 2000, 4(2), 107 – 114. 3. R. A. Berger, A. T. Bishop, “A fiber-splitting capsulotomy technique for dorsal expoure of the wrist,” Techniques in Hand and Upper Extremity Surgery, 1996; 1: 1 – 9. 4. M. Jakob, D. A. Rikli, P. Regazzoni, “Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients,” Journal of Bone and Joint Surgery, Br 2000 Apr; 82(3): 340 – 4. 5. R. Peine, D. A. Rikli, R. Hoffman, G. Duda, P. Regazzoni, “Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study,” Journal of Hand Surgery, [Am] 2000 Jan; 25 (1): 29 – 33. 6. D. Ring, J. B. Jupiter, J. Brennwald, U. Buchler, H. Hastings 2nd, “Prospective multicenter trial of plate for dorsal fixation of distal radius fractures,” Journal of Hand Surgery, [Am] 1997 Sept, 22(5): 777 – 84. 7. F. Fitoussi, W. Y. Ip, S. P. Chow, “Treatment of displaced intra-articular fractures of the distal end of the radius with plates,” Journal of Bone and Joint Surgery, [Am] 1997 Sept, 79(9): 1303 – 12. 8. D. L. Fernandez, J. B. Jupiter, Fractures of the distal radius. A practical approach to management, Springer Verlag, New York, 1996: 317 – 337. 9. T. E. J. Hems, H. Davidson, A. C. Nicol, D. Mansbridge, “Open reduction and plate fixation of unstable fractures of the distal radius: a biomechanical analysis and clinical experience,” Journal of Bone and Joint Surgery, 2000, 82(B): 83. 10. D. L. Fernandez, “Distal Radius and Wrist,” AO principles of fracture management, ed. T. P. Ruedi, W. M. Murphy, New York, Thieme, 2000. 11. D. S. Ruch, T. A. Ginn, “Open Reduction and Internal Fixation of the Distal Radius,” Operative Techniques in Orthopedics, 2003 April; 13(2): 138 – 143. Postoperative Postoperative Postoperative 17 Illustrated Cases Dorsal approach A 24-year-old male who fell at work from a height of 2.5 meters (about 8 ft). Intra-articular fracture with fragments into metaphysis. The fracture could not be reduced by closed means. Preoperative lateral view Preoperative AP view 18 Illustrated Cases (continued) Dorsal approach Comminuted intra-articular fracture; radiocarpal joint reconstruction using dorsal approach. Preoperative lateral view Preoperative Postoperative Postoperative Preoperative AP view 19 Preoperative Postoperative Postoperative Volar approach Comminuted intra-articular fracture; radiocarpal joint reconstruction using volar approach. Preoperative lateral view Preoperative AP view Postoperative Postoperative 20 Illustrated Cases (continued) Volar approach A 34-year-old woman with reverse Barton fracture. Preoperative lateral view Preoperative AP view Postoperative Postoperative 21 Volar approach A 38-year-old construction worker with dorsally- displaced (Colles’) fracture. Preoperative lateral view Preoperative AP view Postoperative Postoperative Postoperative 22 Volar approach A 58-year-old woman with a volar comminuted fracture with full return of motion and function. Preoperative lateral view Preoperative AP view Illustrated Cases (continued) 23 LCP® Distal Radius Plate Set Graphic Case 690.384 Instruments 311.43 Handle, with quick coupling 314.467 StarDrive Screwdriver Shaft, T8, 105 mm 314.468 Holding Sleeve, for 314.467 323.029 Threaded LCP® Drill Guide, 1.8 mm, 2 ea. 310.509 1.8 mm Drill Bit with depth mark, quick coupling, 110 mm, 2 ea. 323.202 2.4 mm Universal Drill Guide 323.26 2.7 mm Universal Drill Guide 314.02 Small Hexagonal Screwdriver with holding sleeve 310.19 2.0 mm Drill Bit, quick coupling, 100 mm, 2 ea. 310.530 2.4 mm Drill Bit, quick coupling, 100 mm, 2 ea. 310.26 2.7 mm Drill Bit, quick coupling, 100 mm, 2 ea. 319.006 Depth Gauge, for 2.0 mm and 2.4 mm screws 319.01 Depth Gauge, for 2.7 mm screws 329.12 Bending Pliers, 2 ea. 398.95 Termite Forceps, 90 mm 399.97 Reduction Forceps, with points 398.41 Reduction Forceps with points, broad 399.48 Periosteal Elevator, 3 mm, curved blade, straight edge 399.481 Periosteal Elevator, 3 mm, curved blade, round edge 399.18 Hohmann Retractor, small, 6 mm width Also Available 304.206 LCP® Distal Radius Plate Implant Module 304.206.11 LCP® Distal Radius Plate Implant Module Lid 690.384.11 Lid for LCP® Distal Radius Plate Set Graphic Case (690.384) 690.384.40 Screw Rack, for LCP® Di