Minimally Invasive Surgical Treatment of Distal Radius ... · reduction (Fig. 2). Simple intra-articular fractures of the distal radius can also be treated with this device, but the

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Minimally Invasive Surgical Treatmentof Distal Radius Fractures

Phani K. Dantuluri and Jarrad Barber

Contents

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Preoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Necessary Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Operative Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Surgical Landmarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Preliminary Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Nail Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Follow-Up Results and Complications . . . . . . . . . . . . . 12

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

KeywordsDistal radius fractures • Anatomic reduction •Broach insertion •Canal finder insertion • Can-nulated drill insertion • Distal locking screw •Equipment • External jig • Follow-up resultsand complications • Indications • Operativesetup • Postoperative care • Preliminary reduc-tion • Preoperative planning • Proximal anddistal screw insertion • Proximal locking inser-tion • Surgical approach • K-wire fixation •MICRONAIL • Mini-C arm fluoroscopy •Radial styloid (RS)

Patient demand, surgeons’ interest, and evolvingtechnology have driven the trend towards mini-mally invasive surgery in order to improvecosmesis, minimize soft tissue trauma, and allowpotential superior fracture healing by minimallydisturbing the biological environment aroundfractures. Minimally invasive joint replacementsurgery, arthroscopic surgery, and locking screwtechnology have been some of the newer devel-opments in orthopedics that have significantlyaltered patient care and potentially the outcomesthat can be achieved. In this regard, fractures ofthe distal radius have also been reexamined to seeif minimally invasive surgery would be possiblein treating this increasingly common fracture ofthe upper extremity and one of the leading reasonsfor visits to the emergency room. Intramedullaryfixation of the distal radius has now been used forseveral years, and preliminary data have shown

P.K. Dantuluri (*)Division of Shoulder, Elbow, and Upper ExtremitySurgery, Resurgens Orthopaedics, Atlanta, GA, USAe-mail: [email protected]; [email protected]

J. BarberDepartment of Orthopaedic Surgery, Atlanta MedicalCenter, Atlanta, GA, USAe-mail: [email protected]

# Springer International Publishing Switzerland 2016G.R. Scuderi, A.J. Tria (eds.), Minimally Invasive Surgery in Orthopedics,DOI 10.1007/978-3-319-15206-6_34-1

1

mailto:[email protected]




that it is an effective treatment of extraarticular orsimple intra-articular fractures [1–5].

Standard treatment for distal radius fracturesnot too long ago was cast immobilization. Closedreduction and percutaneous pinning and externalfixation were some of the earlier methods used totreat fractures of the distal radius [6, 7]. However,there were limits to the types of fractures thatcould be treated closed, leading to increasing rec-ognition of the importance of restoring articularcongruity and fracture alignment [8, 9]. Thisneeded to be done in an open fashion, and openreduction and internal fixation becamemuchmorecommon. Various types of plate and screw con-structs were used to treat fractures of the distalradius. Plates were applied internally to the distalradius, as the idea of rigid fracture fixation with aninternal implant was appealing to surgeon andpatient alike [10].

This trend has accelerated rapidly over the lastdecade, and at this point, the most commonly usedimplant to treat fractures of the distal radius hasbecome the volar plate [11]. Other pioneers in thefield of upper extremity surgery have championedthe cause of column-specific fixation with smallerimplants addressing specific load-bearing areas ofthe distal radius in an attempt to provide morerigid fixation with smaller implants [12]. Thesemethods have all been tremendously successful intreating fractures of the distal radius; however,problems still remain [13].

There is a thin soft tissue envelope surroundingthe distal radius, and the neurovascular structuresare in very close proximity. Tendon and nervecomplications are quite common with surgery ofthe distal radius despite advances in implant tech-nology and lower profile implants [14,15]. Locking screw technology has definitelyimproved fracture fixation and allowed for lesscomplications as implants are lower profile; how-ever, significant problems remain with tendonirritation and rupture as well as nerve problems,scar formation, stiffness, and the occasional needto remove implants.

The only type of implant that could potentiallyavoid these types of complications is anintramedullary one, as the implant could be seatedcompletely underneath the cortical surface and not

cause impingement on neighboring soft tissue andneurovascular structures. In addition, theseimplants can be inserted in the most minimallyinvasive fashion.

As modern medicine has rapidly surged for-ward, a greater understanding of the basic scienceof fracture healing has resulted. It has becomeclear that preservation of the blood supply tofracture fragments can greatly aid in fracturehealing and lead to better clinical results. If onecould successfully reduce a fracture and maintainits alignment with a minimal amount of soft tissuetrauma while preserving the vascularity of frac-ture fragments, this would be optimal.

It has been known for quite some time thatintramedullary implants have become the stan-dard of care for diaphyseal fractures of the tibiaand the femur in patients who need operativefixation [16]. These have been shown to haveexcellent results. The benefits of intramedullaryfixation include less soft tissue trauma, preserva-tion of the vascularity of fracture fragments, andan implant that acts as a load-sharing device ratherthan a load-bearing one. Some prior investigatorshave examined the concept of intramedullary fix-ation for fractures of the distal radius, but nospecific completely intramedullary implant forthe distal radius had been developed until recently[17–24].

In an attempt to avoid many of the mentionedcomplications associated with the current surgicaltreatment of distal radius fractures, several inves-tigators in conjunction withWright Medical Tech-nologies, Inc. have developed a novelintramedullary device (MICRONAIL II) for fixa-tion of distal radius fractures (Fig. 1). This implantutilizes fixed-angle locking screw technology inconjunction with an intramedullary construct inorder to rigidly stabilize fractures of the distalradius while preserving fracture fragment vascu-larity and minimizing soft tissue trauma.

Indications

Intramedullary nail fixation is best indicated forextraarticular distal radius fractures that are unsta-ble and cannot be maintained with closed

2 P.K. Dantuluri and J. Barber

reduction (Fig. 2). Simple intra-articular fracturesof the distal radius can also be treated with thisdevice, but the fracture should have a minimumnumber of stable articular fragments and shouldnot have extensive articular comminution. Frac-tures should also not have excessive metaphyseal-diaphyseal comminution with proximal exten-sion, as the proximal fixation point for the devicecould be compromised, resulting in a loss of

reduction. The device is an excellent choice formalunion surgery and is best indicated forextraarticular malunions of the distal radius[31]. The device can provide an immediate rigidconstruct in malunion surgery and better disperseloading forces through the distal radius as it is aload-sharing device rather than a load-bearingone. This is of great benefit in malunion surgeryas the resulting cortical defect that exists aftersurgical correction can take several months toreintegrate, and during this time, plate and screwconstructs are subjected to tremendous loads thatcan lead to implant failure. It is necessary tocarefully evaluate the initial injury andpostreduction films to determine the appropriatepatients amenable to intramedullary fixation.

Preoperative Planning

The preoperative radiographic evaluation followsa detailed history and physical examination andincludes standard anteroposterior (AP), lateral,and oblique radiographs of the injured wrist(Fig. 3). Careful assessment of the ipsilateralupper extremity, particularly the elbow and fore-arm, is necessary to rule out more complex injurypatterns, e.g., Essex-Lopresti injuries. Furtherradiographs of the forearm and elbow can beacquired if deemed necessary from the physicalexamination and history. A thoroughneurovascular examination is of necessity, and acareful assessment of the associated soft tissueinjury is of paramount importance.

Contralateral radiographs of the opposite wristare recommended in order to carefully evaluateeach patient’s individualized anatomy of the distalradius and are useful in preoperative templating(Fig. 4) for implant selection. Postreduction radio-graphs, if available, should also be evaluated tofurther assess fracture stability. Prior history ofinjury or malunion of the injured distal radiusneeds to be addressed preoperatively as signifi-cant alteration in the normal parameters of thedistal radius may prevent implant insertion.

Fig. 1 MICRONAIL distributed byWrightMedical Tech-nologies, Inc., demonstrating purple distal fixed-anglelocking screws and gold proximal bicortical screws

Fig. 2 Virtual image demonstrating ideal intramedullarynail position

Minimally Invasive Surgical Treatment of Distal Radius Fractures 3

Necessary Equipment

The minimally invasive surgical technique forintramedullary nail fixation of distal radius frac-tures described below requires the following spe-cific equipment: (1) Wright MedicalIntramedullary Implant System, (2) one 0.62Kirschner wire and two 0.45 Kirschner wires,(3) K-wire driver, (4) drill, (5) small rongeur,and (6) intraoperative fluoroscopy.

Surgical Technique

Operative Setup

The versatility of the intramedullary system is thatnail fixation can be performed if necessary in themultiply injured patient, in the supine, lateraldecubitus, or prone positions. If there is no con-traindication, surgery is most easily performedwith the patient in the supine position. A standard

Fig. 3 Initial injury films demonstrating dorsal angulation, radial shortening, and loss of radial inclination

Fig. 4 Contralateral uninjured wrist X-rays are used as a template to determine the accuracy of intraoperative reductionof the injured extremity


arm board is attached to the side of the operatingroom table and is used to support the operativeextremity (Fig. 5). However, a hand table can alsoalternatively be used, but the single-arm board isthe more versatile as it can be moved out of theway during the procedure when the fluoroscopicunit is in use. A mini-C arm fluoroscopy unit ispreferred due to its decreased radiation exposure,but a standard fluoroscopy unit can be used aswell.

Surgical Landmarks

Once the patient has been properly positioned andthe arm prepped and draped in the usual sterilefashion, several key surgical landmarks should beidentified. The radiocarpal and radioulnar jointsshould be palpated and identified. The tip anddorsal and volar contours of the radial styloidshould also be identified. If excessive soft tissueswelling makes this difficult, fluoroscopy can be

used to determine these critical landmarks, andthese areas can be marked on the skin to aid inthe proper placement of surgical incisions.

Surgical Approach

Prior to the sterilely draped injured extremitybeing properly positioned on the arm board, thearm board should be adequately covered with asterile drape, allowing the surgeon to grasp thearm board and move it without the risk of contam-ination. The fluoroscopic unit is then used toassess the fracture to confirm that it can easily bereduced or is able to be reduced with minimalpercutaneous incisions. After it has been con-firmed that the fracture can be reduced anatomi-cally, the tip of the radial styloid is palpated andidentified. A 2- to 3-cm longitudinal incision isthen made centered over the tip of the radialstyloid and midline between the dorsal and volarcontours of the styloid (Fig. 6). Surgical

Fig. 5 Patient positioning with a single-arm board for theinjured extremity demonstrated. This allows for easyplacement of the injured wrist on the mini-C-arm to obtain

accurate fluoroscopic images with minimal repositioningof the injured wrist


dissection proceeds carefully at this point, and anybranches of the radial sensory nerve that are in thefield are identified and carefully retracted. Noskeletonization of these nerve branches shouldbe done, and they should be retracted with theirneighboring fat and vessels to avoid any radialsensory nerve problems postoperatively.

After the edges of the first and second dorsalextensor tendon compartments are identified, theperiosteum between them is then incised in linewith the skin incision, and the cortical surface ofthe radial styloid is exposed just enough for theentrance hole for the intramedullary nail. Theperiosteum should be preserved if possible sothat it can be closed over the entrance hole laterto prevent any adherence of the tendons or nervebranches to the nail underneath, which should berecessed below the cortical surface of the styloid.

Preliminary Reduction

It is of benefit to the surgeon to have an anatomicreduction of the fracture, which is held withK-wire fixation prior to nail insertion for a numberof reasons. First, once the external jig is in place, itcan be difficult to visualize the joint line andalignment of the fracture as both the jig and thenail are radio-opaque. Second, the nail may have a

degree of intramedullary fill, which, while helpingthe stability of the fracture reduction, can preventany fine tuning of the reduction once the implantis in place, particularly in terms of dorsal or volartranslation or restoration of volar tilt. Thus, it isrecommended that the fracture be anatomicallyreduced and held prior to nail insertion.

This can generally be easily done and fluoros-copy should be used to verify the anatomic reduc-tion. Once the fracture is reduced, the distalfragment is then preliminarily pinned with a 0.62K-wire inserted through the radial styloid withfixation in the shaft proximally. This K-wireshould inserted, if possible, in the volar portionof the styloid so that it will not interfere withinsertion of the nail, but provides very stablefixation of the distal fragment and also helps toprotect and retract the tendons of the first dorsalextensor compartment and sensory branches ofthe radial sensory nerve (Fig. 7). This can be adifficult K-wire to insert, but is well worth theeffort as it makes the rest of the procedure mucheasier.

A second percutaneous 0.45 K-wire is theninserted dorsally, typically between the fourthand fifth dorsal extensor compartments. A small1-mm stab incision can be made here to ensurethat the correct interval has been entered and thatthe K-wire does not entangle tendons or sensory

Fig. 6 Lateral view of injured extremity demonstrating contours of radial styloid (RS) and proposed surgical incision


nerve branches. Typically, a guide can be sliddown over the K-wire once it is in the proper4–5 interval prior to insertion to prevent any softtissues from wrapping around the wire. ThisK-wire should capture the dorsal ulnar corner ofthe distal fragment and, in conjunction with the0.62 K-wire through the radial styloid, providerigid 90/90 fixation of the distal fragment (Fig. 8).

It is recommended to achieve this anatomicrigid 90/90 fixation prior to nail insertion, aswhile insertion of the nail should be a gentleprocess, it can disrupt the preliminary reductionif inadequate K-wire fixation is achieved. The

rigid 90/90 fixation provided by the two K-wiresbest resists any displacement forces createdthrough the nail insertion process (Fig. 9).

If the reduction of the fracture cannot beachieved by closed means, one can utilize theanticipated small dorsal incision for the proximallocking screws as a window to help with thereduction without making any additional inci-sions. The nail can be placed on the dorsal surfaceof the skin in its expected intramedullary positionwith the wrist in a posteroanterior position on thefluoroscopic unit. Fluoroscopy will reveal theanticipated incision site for the proximal locking

Fig. 7 Demonstration of surgical exposure and placement of 0.62 K-wire volarly in the styloid

Fig. 8 Preliminary reduction maintained with dorsal ulnar and radial styloid K-wires providing rigid 90/90 fracturefixation


screws. A Freer elevator can then be insertedthrough this incision to help reduce difficult frac-tures, particularly in the region of the sigmoidnotch as well as simple articular fractures. Oncereduction has been achieved, the K-wires shouldbe inserted as previously described.

Nail Insertion

At this point, the tip of the radial styloid is iden-tified and a cortical window is made in the styloidapproximately 5 mm proximal to the tip of the

styloid. This cortical window must be made prox-imal enough in the styloid to prevent violation ofthe articular surface of the scaphoid facet withsuccessive broaching, but not be too proximal toprevent adequate subchondral support with thedistal locking screws. An awl or the cannulateddrill bit can be used to make this entrance hole inthe styloid (Fig. 10). Fluoroscopy should be usedat this critical step to ensure the proper entrancehole for insertion of the intramedullary implant.

After the cortical window has been made, asmall rongeur can be used to expand the windowtypically in the proximal direction longitudinally

Fig. 9 Fluoroscopic images demonstrating typical K-wirepositions to maintain preliminary reduction. Note volarposition of 0.62 K-wire in the lateral view and note the

dorsal ulnar position of the 0.45 K-wire in theposteroanterior (PA) view

Fig. 10 Guide wire placedin tip of styloid forcannulated drill insertion tocreate entrance hole forimplant insertion


in line with the radius for about 5 mm in order toallow atraumatic broach insertion. A small canalfinder is then inserted gently into theintramedullary canal (Fig. 11). It is critical thatthe canal finder should stay along the radial cortexduring insertion in order to prevent penetration ofthe ulnar cortex of the radial shaft. Using fluoros-copy to ensure proper entry, a small broach is theninserted across the fracture site and advancedproximally across the metaphyseal-diaphysealjunction (Fig. 12). Increasingly larger broachesare then inserted sequentially until the broach islarge enough within the canal to resist spinningwhen rotational torque is applied as well as pro-vide reasonable intramedullary fill. Preoperative

templating using the contralateral wrist radio-graphs should also provide the surgeon with valu-able information as to which size of the implant isthe likely size that will be used.

After the last broach has been removed, theimplant is then mounted on the external jig andthen gently inserted following the path of the priorbroach (Fig. 13). The nail should be carefullyinserted toward the sigmoid notch far enoughmedially into the radius so that no part of thenail is protruding above the radial cortex(Fig. 14). This will prevent any contact betweenthe nail and the undersurface of the tendons ofeither the first or second compartment. In addi-tion, the nail is inserted gently proximally enough

Fig. 11 Canal finderinsertion. Note that thecanal finder hugs the radialcortex to prevent ulnarcortical perforation andimplant malposition

Fig. 12 Broach insertiondemonstrating an expectedposition of theintramedullary nail


Fig. 13 Close-up view ofexternal jig demonstratingscrew alignment guides forproximal and distal screwinsertion

Fig. 14 External jig in place with intramedullary nail insertion with care taken to ensure that the nail is fully insertedbelow the cortical surface and all tendinous and neurovascular structures are protected

Fig. 15 Drilling for distallocking screws with care toavoid penetration ofradiocarpal and radioulnarjoints


so that the distal-most locking screw will be justunderneath the subchondral bone supporting theradiocarpal articular surface. A K-wire or a drillbit can be inserted through the distal-most drillguide and then checked under fluoroscopy toensure that the distal-most locking screw will bein the desired subchondral position (Fig. 15).

At this point, the distal locking screw holes aredrilled and measured and three distal lockingscrews are inserted into the nail with the distal-most screw inserted first (Fig. 16). Fluoroscopyshould also be used when measuring the length ofthe screws to ensure that they do not penetrate thesigmoid notch and enter the distal radioulnar joint

(Fig. 17). It is important to remember that thesigmoid notch has a concavity for the distal ulnaso that a screw may appear to be safely out of thedistal radial ulnar joint on the fluoroscopic view,but may still actually be penetrating this joint.Therefore, it is best to have these screws err onthe side of being 2 mm short and be sure to checkfor crepitus. Once all of the distal locking screwshave firmly locked into the nail, the fracturereduction should be carefully assessed (Fig. 18).If there has been a slight loss of reduction of thefracture due to nail insertion, an attempt can nowbemade to gently reduce the fracture anatomicallyprior to proximal screw insertion.

Fig. 16 Distal lockingscrew insertion

Fig. 17 Insertion ofremaining distal lockingscrews keeping them shortof the sigmoid notch toavoid intra-articularpenetration


At this stage, a 0.45 K-wire is then insertedthrough the dorsal cortex and the nail to rigidlyhold the implant in place and prevent subtle dis-placement of the implant within the canal or lossof reduction. The proximal screws can then beinserted through two small 1-cm incisions or onesingle 2-cm dorsal incision. The appropriate drillguide and sleeves are used to drill and insert theproximal screws (Fig. 19). These screws achievebicortical purchase and lock the implant in place.It is important to prevent any soft tissue such asextensor tendons from being trapped under thescrew heads. Also, it is critical not to compromisepurchase of the proximal locking screws byovertightening as there are only two proximallocking screws and they are crucial in maintainingimplant position and proximal fixation, especiallyif there is not good intramedullary fill of theimplant. A good technique to avoid strippingthese screws is retracting the drill guides for thelast few turns so that this can done under directvisualization so that it is clear when the screwheads are down tight on the dorsal cortex of theradius.

Final fluoroscopic images are used to verifythat the reduction of the fracture has been accom-plished and that the implant and all screws are inappropriate positions (Fig. 20). If any periosteumremains intact, it is then closed over the corticalwindow in the radial styloid if possible to preventany contact of the nail with the surrounding softtissues. The deeper subcutaneous tissues areclosed with 2.0 Vicryl suture, and the skin isclosed with 3.0 Monocryl subcuticular suture(Fig. 21). Benzoin and Steri-Strips are thenapplied, and patient’s arm is placed into a tempo-rary short-arm splint for comfort.

Postoperative Care

Patients are instructed to begin immediate postop-erative finger, elbow, and shoulder range ofmotion to avoid stiffness and reduce swelling.Patients are typically seen for their first postoper-ative visit at a week to 10 days. At that visit, theyare given a removable orthoplast short-arm splintonly for comfort. At this point, unrestricted active

range of motion is allowed for the wrist as welland patients are also instituted in occupationaltherapy to monitor and aid in their rehabilitation.Patients are followed with serial radiographs toevaluate bony union, which typically occurs atapproximately 6 weeks postoperatively. Longernails are now available in current sets (Fig. 22)to provide better proximal fixation when needed.Having three proximal screws allows superiorfixation of the implant and prevents proximalmigration of the nail (Figs. 23 and 24). In addition,a radiolucent guide is now currently used, whichallows better visualization of the fracture lines andallows superior fracture reductions (Fig. 25). Inthis example case, one can see the excellent visu-alization of the distal radius afforded by the radio-lucent guide, particularly on the lateral view,allowing anatomic reductions of both theradiocarpal and distal radioulnar joints (Fig. 26).

Follow-Up Results and Complications

Initial series had shown, at least in short-termfollow-up, that distal radius fractures could besuccessfully treated with intramedullary fixation.Tan et al. presented a prospective study of 23 con-secutive fractures treated with intramedullary fix-ation using the MICRONAIL [25]. This studyshowed that outcomes were excellent at 6-monthfollow-up in terms of maintenance of alignment ofthe distal radius, range of motion, and improve-ment of grip strength. Early successful outcomesled to increased interest in the intramedullary fix-ation of distal radius fractures. Currently, there areseveral designs now available for surgeons toconsider including Wright, Sonoma, Targon, etc.However, some studies [1] suggest that there maybe higher complication rates with intramedullaryfixation including radial sensory nerve injuries,loss of reduction, and intra-articular screw pene-tration. In contrast, several studies have showncomparable outcomes to volar plating with noincreased complication rate [2–5, 27, 30]. In addi-tion, there has been a study [31] that has shownthat the IM nail can even be used successfully inthe treatment of distal radius malunions. Analysisof the current studies available in the literature


seems to suggest that most of the complicationswith IM nailing occur during nail insertion withradial sensory nerve injuries and either loss ofreduction or intra-articular screw penetration dueto attempting to fix more complex intra-articularfracture patterns with an IM nail. If intramedullarynail fixation is properly indicated forextraarticular and simple intra-articular patternsand meticulous care is taken during nail insertion,it appears that several studies have shown that IMnailing can be an effective treatment method for

distal radius fractures with a low complicationrate.

Conclusion

Despite the success of open reduction and internalfixation of distal radius fractures, problems per-sist, including loss of reduction, hardware failure,tendon and nerve injuries, and infection. Signifi-cant scarring of tendons and neurovascular struc-tures can occur with extensive surgical dissection,

Fig. 18 Fluoroscopicimage after completed distallocking screw insertiondemonstrating ideal distallocking screw positions

Fig. 19 Proximal lockinginsertion demonstratinghow the drill guide can bewithdrawn for the final fewturns to allow directvisualization and avoidstripping of the screws


leading to limitation of function. The thin softtissue envelope surrounding the distal radius andthe close proximity of tendons, nerves, and vas-cular structures to the distal radius may contributeto the development of some of these complica-tions. Minimally invasive surgical fixation of thedistal radius has been developed using anintramedullary nail as a treatment option for frac-tures of the distal radius in an attempt to minimizethese potential complications. However, meticu-lous surgical technique is critical when using an

intramedullary nail to prevent some of the com-plications that have been reported in early series[1]. It is clear that when careful surgical techniqueis combined with proper patient selection, excel-lent outcomes can be achieved in patients withdistal radius fractures treated with intramedullarynail fixation [27].

Fig. 20 Completed intramedullary fixation of distal radius fracture demonstrating anatomic reduction and ideal implantplacement

Fig. 21 Postoperative closure demonstrating 2.5-cm incision for nail insertion


Fig. 22 Second-generationintramedullary nail designincludes longerintramedullary nailsallowing better proximalfixation when needed

Fig. 23 Improvedproximal fixation is allowedby having three proximalscrews when needed


Fig. 24 Example ofsecond-generationintramedullary designdemonstrating variousimplant sizes including animplant with three proximalscrews which can be usedwhen necessary

Fig. 25 Example of the radiolucent guide in place dem-onstrating the views afforded of the distal radius. Muchmore of the bony landmarks of the distal radius can bevisualized with the radiolucent guide, which will allow forsuperior fracture reductions and more precise screwplacement


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Minimally Invasive Surgical Treatment of Distal Radius ... · reduction (Fig. 2). Simple intra-articular fractures of the distal radius can also be treated with this device, but the