Biomechanics

10

Biomechanics of the Wrist J oint

The wrist complex is biaxial joint, with motions of flexion/extension
(volar flexion/dorsiflexion) around a coronal axis, and radial deviation/
ulnar deviation (abduction/adduction) around an anteroposterior axis.
[24]
In the normal wrist, the total arc of motion from full flexion to full
extension is approximately 150.
[24]
This motion is made up approximately
equally by motion at the midcarpal and radiocarpal joints. However, the
midcarpal joint contributes more to flexion (62%) than does the radiocarpal
joint as the wrist moves from neutral to full flexion. Conversely, as the wrist
moves from neutral to full extension, the radiocarpal joint contributes more
(62%) than the midcarpal joint.
[25]
Further, wrist radial-ulnar deviation is
contributed to by motion at the midcarpal and radiocarpal joints, with the
majority (55%) of this motion occurring at the midcarpal joint.
[26]
As the wrist moves from radial to ulnar deviation, the proximal row
extends as well as deviates ulnarly. As the wrist moves from ulnar to radial
deviation, the proximal row flexes and deviates radially. The distal row also
translates dorsally in ulnar deviation and volarly in radial deviation. This
translation may be the cause of proximal row extension and flexion.
[27]

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11


(Fig. 5) A, In radial deviation, the proximal carpal row deviates toward the radius, translates toward the
ulna, and flexes as seen by visualizing the lunate on the lateral radiograph. B, With the wrist in neutral, the
capitate, lunate, and radius are nearly colinear. C, In ulnar deviation, the proximal row deviates toward the
ulna, translates toward the radius, and extends as visualized by the lunate on the lateral radiograph.
[28]
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12

Biomechanics of Fracture Reduction

Traction, ligamentotaxis, periosteotaxis, and manipulation are the
mainstays of fracture reduction. The brachioradialis is the only muscle
attached to the distal radial fracture fragment. Sarmiento and colleagues
[29]

recognized the resistance and deforming force of the brachioradialis on the
distal radial metaphyseal or styloid fragment during the wrist flexion and
forearm pronation maneuvers of classically applied closed reduction
techniques. The brachioradialis also may remain a deforming force after
closed fracture reduction. They also reported and advocated fracture
reduction, positioning, and cast bracing with the forearm in a supinated
position to relax brachioradialis tension during and after fracture
reduction.
[29]
The rule of the majority, also known as the vassal rule, may be
helpful in assembling the fracture fragments. This rule states that the major
fragments should be realigned, and that the smaller or vassal fragments
follow the major fragments into position. Replacement of each of the
articular fragment components before definitive plate fixation may avoid
some of the difficulties that may be encountered in reducing ulnar die-
punch fragments after radial styloid fixation. Fluoroscopy or arthroscopy or
both may be useful in achieving fracture and articular alignment. Kirschner
wires may be used for provisional fixation before plate insertion.
[4]
Biomechanics of plate of the distal radius
Plate strength is proportionate to the cube of its thickness and
inversely proportionate to the cube of its length.
[30]
Screws enhance plate
strength and holding power at the plate-bone interface. Wider spacing of
screws in the stem increases the bending strength of plate-screw-bone
Biomechanics

13

fixation. The torsional strength of plate stem fixation is independent of
screw spacing and is proportionate to the number of screws holding the
stem.
[31]
Fixed-Angle Principle:

The working portion of a buttress plate is the bar - the distal
segment of the plate supporting the metaphyseal fracture fragment or
fragments. Support of the metaphyseal fragment and overall plate-bone
construct strength may be improved by blades affixed to the plates or screws
or pegs locked into the screw or peg holes of the bar by matching threads.
Each fixed-angle blade or locking screw or peg provides an additional point
of fixation within the plate and increases plate stability.
[30]
Fixed-angle
blades or locking screws or pegs in the bar of the plate provide additional
support for the articular surface of the distal radius against axial loads
compared with conventional screws.
[32]
Several plates have a fixed-angle
screw or peg option for the bar of the plate (Fig. 6). The increased stability
of fixed-angle blades or locking screws or pegs may be especially
advantageous in osteopenic bone.
[33]
The distal volar plate (DVP) (Hand Innovations, Miami, FL) and
similarly designed plates combine fixed-angle locking screws or pegs in the
stem of the plate with robust design so that they may be applied to the
palmar side of the distal radius for almost all fracture configurations
regardless of the direction of instability (Fig. 7).
[33]
The goal of this plate
design is consistently to avoid dorsal plate application and its consequences.
Fixed-angle pegs follow the articular contour, are directed to support the
articular surface, and help to ensure fixation of commonly found articular
fragments. The radial most pegs are directed into the styloid, and the ulnar
Biomechanics

14

most pegs are directed into the dorsal ulnar edge of the radius to incorporate
styloid and dorsal die-punch fragments. Failure to incorporate the dorsal
die-punch fragment may lead to loss of reduction and arthrosis. The distal
palmar edge of the plate supports palmar die-punch fractures, which also
may be incorporated with pegs.
[34]





(Fig. 6) A, Threaded standard screw. B, Partially threaded standard screw. C, Threaded locking screw. D,
Locking peg. Arrows pointing to C and D indicate a space between the locking plate and the bone.
Standard holes and flexible bushings in locking holes allow 15 degrees of screw angulation from the
perpendicular position. (Universal Distal Radius System; courtesy of Striker Leibinger Micro Implants,
Portage, MI.)
[4]






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(Fig. 7) A, First-generation DVP plate. B, Undersurface first generation DVP plate with a row of locking
pegs (arrow in B) designed to parallel and support the subchondral portion of the articular surface of the
distal radius. C, Second-generation DVP plate. D, A proximal row of screws (arrow 1) or pegs (arrow 2)
may be inserted to incorporate or support the dorsal lip or fragments of the distal radius. (Courtesy of Hand
Innovations, Miami, FL.)
[4]

Biomechanics

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Locking Plate Stems and Combination Plate Holes
(Combiholes)


The fixed-angle principle also may be applied to the plate stem.
Elliptical plate holes (combiholes) have been added to the stems of the
AO/ASIF distal radius locking plate set (Fig. 8) (Synthes, Paoli, PA).
Combiholes allow the option of inserting either a fixed-angle locking
screw or a conventional screw. Standard screws compress the plate onto the
bone and stabilize the fracture owing to friction between the plate and the
bone. Locking screws inserted into the stem of the plate provide an
additional point of fracture fixation, prevent screw toggle, and increase plate
resistance to axial loads compared with conventional screws, owing to
locking screw head thread engagement in corresponding threads within the
locking plate hole. Distal radius locking plates are precontoured and do not
have to be shaped to or rest flush on all parts of the bone and, in essence,
may act as an internal fixator (i.e., an implanted external fixator) (Fig. 9).
This feature makes locking plates more biocompatible with the bone. A
locking plate might be envisioned as the ultimate external fixator with the
plate (connecting bar) placed extremely close to the mechanical axis of the
bone, maximizing its stability. Locking plate stems may be especially
advantageous in osteopenic bone.
[30]
The pullout strength of a unicortical screw from bone is about 60%
compared with a bicortical screw. The surgeon must decide whether to
engage one or both cortices. Unicortical drilling may minimize damage to
the endosteal circulation of the distal radius and eliminates the need to
measure screw length.
[30]

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(Fig. 8) A to C, Combihole (A) allows engagement of a conventional screw (B) or a locking screw (C).
Arrow 1, The smooth portion of the combihole accommodates a standard screw head. Arrow 2, The
threaded portion of the combiholeaccommodates a locking screw head. Arrow 3, Space between the
fixed-angle locking plate and the bone surface. Standard screw holes or bushings incorporated in locking
plate holes may allow a few degrees of angulation from the vertical position. (Courtesy of Synthes, Paoli,
PA.)
[4]




(Fig. 9) Small fragment locking T-plate used as an internal fixator with a small space between parts of
the plate and the bone (arrows). (Courtesy of Synthes, Paoli, PA.)
[4]
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Rationale and Basic Biomechanics:

Although the concept of volar plating could be initially attributed to
Lanz and Kron
[35]
back in 1976 for plate fixation after osteotomy of
malunited distal radius fractures, the volar approach remained restricted to
fixation of volar rim fractures in the acute setting only.
[36]
Volar plating was
first recommended for fixation of both typical and atypical distal radius
fractures by Georguoulis and associates in 1992.
[37]
This was published in a
little-known journal and was not widely accepted for dorsally displaced
fractures until the landmark paper by Orbay and Fernandez in 2002.
[38]
Volar
plating offers many advantages when used in dorsally displaced fractures.
The key to its success is to ensure that this was a locking plate, hence
creating a fixed-angle device that would maintain the reduction and
eliminate screw toggle (Fig. 10). Volar plating also provides the opportunity
to release the pronator quadratus muscle, which is often trapped in the
fracture and can be a cause of pronation contracture.
[39]
A nonlocking plate when used in buttress mode can resist only
moderate axial and bending forces. Thus, a simple nonlocking volar plate
used in a dorsally displaced fracture without any bony contact in the
opposite cortex is subject to much higher axial and bending loads, leading to
failure. Therefore, a stable and strong volar fixation of a dorsally displaced
fracture is only possible with a fixed-angle locking plate that can resist such
high forces. Fixed-angle implants transfer load stress from the fixed distal
fragment to the intact radial shaft, thus enhancing peg/plate/bone construct
stability (Fig. 11), unlike rigid internal fixation devices that rely mainly on
the frictional force between plate and bone to achieve fixation.
[39]

Biomechanics

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(Fig. 10) Schematic diagram showing volar fixation maintaining the anatomy of the radius but screw toggle
leads to plate motion relative to the shaft, which can lead to late failure.
[40]






(Fig. 11) Schematic diagram showing fixed-angle implant transferring load stress from the fixed distal
fragment to the proximal radial shaft.
[40]


Biomechanics

20

The ideal volar implant should have a design compatible with the
volar articular surface of the radius and should provide concomitant angular
and axial stability while stabilizing the dorsal surface.
[41]
The distal volar
plate (DVR Hand Innovations, Depuy Orthopedics, Warsaw, Indiana) has
two parallel rows, and the orientation planes of their respective pegs
specifically match the complex three-dimensional shape of the radial
articular surface.
[40]
The primary row pegs are directed obliquely from proximal to
distal to support the dorsal aspect of the articular surface. They are angled
accurately to provide support for the radial styloid and the dorsal ulnar
fragment. These pegs are most effective in supporting the dorsal aspect of
the subchondral plate and hence avoid the re-displacement of the dorsally
displaced fractures. Concurrently, their action induces a volar force that
tends to displace the fragments in a volar direction, an effect that must be
opposed by a properly configured volar buttressing surface.
[40]
To enhance fracture fixation in cases of severe comminution,
volar instability, or osteoporosis, an additional row of pegs originating from
a more distal position on the plate and having an opposite inclination to the
proximal row was conceived. The distal row is directed in a relatively
proximal direction and crosses the proximal row at its midline and is
intended to support the more volar and central part of the subchondral bone.
It prevents the dorsal rotation of a volar marginal fragment and volar
rotation of severely osteoporotic or unstable distal fragments with central
articular comminution, thus neutralizing volar displacing forces of the pegs
in the proximal row.
[40]
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21

Newer generation of volar plates have now introduced the concept of
variable-angle locking screws and/or pegs. This provides the distinct
advantage of being able to vary the plate placement with the locking screws
adjusting to the necessary angle to be placed in the strongest subchondral
bone.
[40]

Volar Versus Dorsal Plating:

The approach is generally dictated by the location of major fracture
fragments and the direction of displacement. However, orthopaedic and
upper extremity surgeons continue to move away from dorsal plating where
complications can include extensor tendon rupture and hardware irritation.
Volar plating is generally welltolerated. Fixation of dorsally angulated and
comminuted fractures is also possible with newer fixed angle devices.
[42]

Although overall satisfactory outcomes have been reported with
dorsal plating systems, disadvantages of dorsal plates include the need for
mobilization of extensor tendons to achieve proper plate placement, possible
tendon irritation or rupture, and the possibility of additional surgery to
remove the symptomatic dorsal plate, some reporting up to 30%.
[43]
Tendon
rupture has been reported as early as 8 weeks and as late as 7 months after
surgery. To prevent tendon injury, some recommend that a portion of the
extensor retinaculum be interposed between the plate and the tendon sheaths,
or that dorsal plates be removal routinely.
[44]



Biomechanics

22

The advantages of a volar exposure and plating include the following:
1. Dorsally displaced fractures are simpler to reduce because the volar
cortex is usually disrupted by a simple transverse line.
2. Anatomic reduction of the volar cortex facilitates restoration of radial
length, radial inclination and volar tilt.
3. The avoidance of dissection dorsally helps to preserve the vascular
supply to the dorsal fragments.
4. Because the implant is separated from the flexor tendons by the
pronator quadratus, the incidence of flexor tendon complications is
lessened
5. When stabilized with a fixed angle internal fixation device, shortening
and secondary displacement of articular fragments is improved, and the
need for bone grafting is reduced.
[43]

Several studies have compared outcomes of dorsal versus volar
plating of distal radius fractures. Ruch and Papadonikolakis
[45]
performed a
retrospective review of 34 patients, 20 of whom had undergone dorsal
plating and 14 of whom had volar plating. The authors found that both
groups of patients had similar DASH scores, but the functional outcome in
terms of Gartland and Werley scores was better in the volar plating group. In
addition, there was a higher rate of volar collapse and late complications in
the dorsal plating group compared with the volar plating group.
[45]