All right. Welcome, everybody. We'll just get started, if that's okay. My name is Seth Dodds. We're going to be talking about dorsal spanning plate fixation. We have a wonderful lineup of speakers who are still coming into the room now, which is fantastic. I'll be giving an introduction, and then I've asked Doug Hanel to talk about dorsal spanning plate fixation in the multi-trauma patient. David Roosh is going to talk about non-unions and dorsal spanning plate fixation. And then Tamara John, if she can get her talk up, will be talking about using dorsal spanning plate fixation in perilunate injuries, which I think is a great option for people. And then Andy Halim and Felicity Fishman here in the front row are going to be talking about whether we should be putting the plate on the second or third metacarpal, which should be a good debate. Awesome. Anyway, I'm going to give a brief introduction here about using dorsal spanning plate and what it is and when we should use it and why we should use it. I use the terminology spanning plate. You can also say bridge plate. It's really probably, I think, best thought of as an internal external fixator. I use this Synthi-specific plate just because I find it convenient and I'm comfortable with it. But there are a number of other plates on the market that are similar and have little different twists that can be used. The original technique was published by Burke and Singer in 1998 using maxillofacial plates, and then this plate was custom designed. I think in concept, I often think of it as this kind of advent in fracture repair. This is a pediatric femur where someone's placing a plate to bridge a fracture. Different at the wrist, we're not only bridging the distal radius fracture or the carpal injury, but we're also bridging the joint itself. So some of the concepts are a little different from this particular use. These are the reasons I tend to use dorsal spanning plate fixation. Open fractures, I use it as an alternative to external fixation depending on where the open wounds are. When you have severely comminuted distal radius fractures with or without bone loss, fractures with diaphyseal extension sometimes can also be useful with this technique. Most of the time I'm using it in the multi-trauma setting, which I believe the plate really allows early hand function and use, maybe not right after the operation, but two weeks later they can start using it to get out of bed, which really facilitates their overall functional recovery. I guess this technique has really, at least in my practice, has changed the use of the external fixator, which was often used previously, but certainly for open fractures and more mangled injuries, I find ways to be able to use this plate instead of an X-Fix. Obviously no external pins and rods makes it attractive to patients. Another thing that I haven't done in practice, at least that I can remember, is a primary fusion for distal radius fracture. I really will use this plate as an alternative to that, and I'll show you some cases where it works out nicely. The plate also, being on the dorsal aspect of the wrist, really eliminates any dorsal translation and dorsal tilt, which I think is great for the distal radius. Occasionally you may have a patient who has a contraindication to a vulvar plate, and this could be a good use of it as well. Maybe you don't want to make an incision right there. This particular fracture I think is a perfect one for dorsal spanning plate fixation, where you have really an intact vulvar cortex. Putting a plate there is really not going to do anything for this particular injury, and so being dorsal to contain not only the fracture, but also the wrist joint is really beneficial. Here's an example of using the dorsal spanning plate in a multi-trauma setting. This patient's got a tibial plateau fracture that you can see there, and many times even though the wrist looks smashed, if you reduce it relatively acutely, you can get it really nicely aligned. I like to use K-wires, as you'll see in many of my pictures, to augment the fixation construct, but the dorsal plate really allows you to mobilize these patients nicely and follow them along, of course. I tend to remove the plate at about three months. This is their post-removal x-rays. Here's another case example with a lot more disruption at the articular surface and an ipsilateral elbow injury, also an acetabular fracture. Again, I find when patients have a significant elbow injury, if you can allow them to be out of immobilization for their wrist, it allows them to rehab their elbow simultaneously, and I think can be particularly helpful so they don't have to wear a cast. This patient underwent a fracture repair. His scaphoid was also broken, and his elbow as well. Again, the dorsal spanning plate really can eliminate the need for long-term casting for this kind of fracture and allow patients to rehabilitate their elbow, which will be particularly important in this case. Similar kind of case where there's an elbow dislocation that's ipsilateral to this fracture. This patient also had a fracture on the other side that I think I treated with a volar plate, and I'll go through the technique I like to use here, but usually I use axial traction, and as you've already noted, I tend to go to the second metacarpal. In this case, I actually bone grafted the fracture because the patient was older and osteoporotic and got really nice-looking x-rays, which is great, and hinged x-fix for the elbow, which was terribly unstable. Another example of where you can use this kind of plate and fixation is when you're worried about radiocarpal instability. This patient, although maybe not looking like it from the original x-rays, had a volar ulnar corner fracture that was pretty unstable, and even though I had some fixation here, I still wanted to make sure that the carpus was maintained, and so I'll use this spanning plate if I'm concerned about radiocarpal instability and the volar ulnar corner. All right, I'm going to spend the next five minutes just talking about placing this plate. Where does it go, and how do I put it there? Again, I had mentioned that I like to use axial traction. I think it's a really lovely way to get your radius reduced, but it also holds the hand and wrist in place. You can see that here, the axial traction through these finger traps, but it just holds the hand really collinear, which I like, and I think it facilitates passage of the plate and a number of different things. I tend to just make two incisions, one over the index metacarpal and the other over the dorsal aspect of the distal one-third of the radius here. I tend to guide my incisions by fluoro. I'll put the plate down on the hand and mark exactly where I want to place the plate, putting some dots right through these holes so I can keep the incision small. At the hand, if you go to the second metacarpal, the incision is actually usually radial to the extensor tendons, so usually you're not affecting the index extensors too much. There's always a branch of the radial sensory nerve that wants to get in your way that you have to move aside. The plate is going to go here. One challenge with passage of this plate is that it really needs to go along the floor of the second dorsal compartment. As you can see in this image, there are these kind of synovial reflections and the compartment itself is relatively tight. Now, for most distal radius fractures, the compartment is going to be somewhat disrupted by the fracture, which makes passage of the plate a lot easier, but sometimes you need to, either using the plate or a hemostat or a tonsil, need to place an instrument to open your second dorsal compartment a little bit in order to pass this plate. Approximately, the incision is, again, just at the distal one-third of the forearm here. It's usually just proximal to the APL, but sometimes it can be where the APL is coming over depending on the size of the patient. I'll usually sweep the APL ownerly and then you'll be looking right at the ECRL and ECRB. There's a fascia right over these two tendons. Release that fascia and you can place this self-retainer right between these two tendons and have a very nice exposure to the dorsal aspect of the radial shaft. I would caution you to avoid being too radial here because the radial sensory nerve is going to be sitting just radially there where my adsen is. But if you're between the ECRL and ECRB, you're in a very safe zone and I tend to pass the plate from distal to proximal. There are other ways to do it, but I've found this easy in my practice. You really want to be along the floor of the second dorsal compartment and sometimes as you pass the plate, you'll actually see some of the periosteum being lifted up by the plate as it goes under and that's a good sign that you're going to be under the EPL. The EPL crosses over the second dorsal compartment, so as long as you're in the second dorsal compartment, you're going to be safe with the EPL every time. Here's an example of, whoa, sorry, active mouse, of passing this plate and you can see that there's a little hesitation right there as you're trying to go through the second dorsal compartment, but it usually can be passed pretty easily. The placement of the plate, once it's there, you'll want to obviously put some screws in. I use a non-locking screw proximally and a non-locking screw distally to secure the plate in place. I like to check my x-rays after that and make sure that I like where everything is and then I'll actually use locking screws to secure the plate to the bone. I get asked frequently why locking screws. My answer is that this is an internal-external fixator. I think using screws that are tightly, meaning you want to lock your pins to your bar in an external frame, and so I think using locking screws is totally fine here. Typically, I'll start these patients with early motion, their fingers and their forearm, depending on their DRUJ injury and stability, and I let them start weight-bearing right away with a walker, depending on their multi-trauma status. I usually limit their crutch weight-bearing to about a month. I typically remove the plate at three months. In some occasions, it'll be as late as six months or even a year, depending on the patient. I tend to wait until the patient is able to walk and no longer has a lot of other medical issues going on. This is an outpatient surgery. I don't think you need to obligate them to do it at a specific time, so rather I do it based on the patient's quality of life at the moment. If they're still in a wheelchair, I don't think it's necessary to take their plate out, and I do a bit of a manipulation depending on their injury. As you can see here on these fluoroscopes, I've found that most of the motion that these patients get tends to be mid-carpal, and that again may be a little bit injury-dependent. You can see the lunate right here. It's probably about 10 or 15 degrees extended, and in this flexion view, the lunate really looks like it's hanging right there. Maybe it's moved about 10 or 15 degrees, but most of the motion is going to be through the mid-carpal joint, which I actually personally think is very advantageous. It means that if you have a patient with a complex articular fracture, maybe there's some imperfections, that once you remove the plate, they're going to be moving at their mid-carpal joint. They're not going to be moving as much at the regular carpal joint. The degree of pain they have, the degree of arthritis that they get develops extremely slowly. There's only one patient that I can remember in my 15 years of practice that I've had to revise their radiocarpal joint after doing a dorsal spanning plate because of a articular step-off. Most patients with their step-offs or mild incongruencies really are pretty happy and are fairly pain-free, and again I think it's because they're moving through their mid-carpal joint rather than their radiocarpal joint. All right, this is one last example here of a 24-year-old who potentially has a relatively straightforward fracture on the right wrist, and then obviously a much more complex injury on the left wrist. He was right-handed, and so I decided to do dorsal spanning plate for his right wrist because I thought his left wrist recovery was going to be much more prolonged than it was. I needed a fuller plate on this fuller fracture fragment because it kept flipping out of the way, but you can see he's got a fairly good reduction here on the right. On the left, he's a little short but still reasonably aligned, and he's gotten—this is after plate removal, probably a month after plate removal—he's gotten fairly good motion on his spanning side, which is his right side, compared to his contralateral side where he had this open forearm injury. So it can be very effective as far as getting back your flexibility, and you can see this guy's really happy, which is good too. Anyway, I'm going to pass the baton here to my mentor, Doug Hannell, and he's going to talk about dorsal spanning plate fixation, the multi-trauma setting, and tell you how these people do as well over the term. And maybe I can help you by bringing it up, or maybe not. Is it going to happen? Files, let's try that. This one. The anticipation. Maybe it's not going to happen, or maybe I have to close something. There it goes. Magic. You must have a big talk. No. Good, actually. Great. Well, thank you, and thank you for giving my lecture. It's right there. So we're going to talk about complex and open distal radius fractures in multi-trauma patients. These are my disclosures. These are my designs that I participated in. I have no royalties from this. Birken Sanger introduced this in 1998. Is Dr. Sanger here? Stand up. Welcome. There you go. Rick Singer, right here. Bill Becton. And it's variously named. Now, the easiest way to find it on PubMed is by dorsal bridge plating, as introduced. The indications are listed here, and I was asked to talk about the multiply injured patient, many of which we just saw. My first case of this, this is in 2000. This is about six, seven months after being introduced to this by Dr. Singer. As one of my favorite ICU nurses is involved in a motor vehicle accident that resulted in C5 unstable fracture. All the things that are listed right here. And we're told that you are given 30 minutes, that classic maneuver back in 2000 where you were limited in the amount of time that you got at the first resuscitation in the amount of time you got to spend on extremities. This is no longer truly the case. But this is the first case that I did. I reduced it, pinned it. The external fixture that you see is opening and keeping open the first web space is there in a patient who has a burn. And she has a burn that was there. So this sits in place, plate removal at 110 days and these are her results from that. You know, why does this work? It works because if you wanted to make this a stronger construct, you'd spread your pins apart. You'd bring and move your crossbar as close to the bone as you can. And what does that really do? Dave Roush who sits right here addressed this both clinically and biomechanically and he says, you know, this plate as opposed to an external fixture addresses metadiophysial instability and it offloads the scaphoid and the lunate relative to their fossa, something that you can't do with an external fixture. We also use dorsal bridge plating to augment internal fixation as seen in this x-ray and as seen in the cases that we just looked at. So going back to my indications, I'd like to share two cases with you. The first case is a 19-year-old who falls 26 feet onto concrete. If you're wondering, this is, you know, your son, your daughter who falls 26 feet. The LD50 is this, it's 75%. Chance that this guy would survive this fall. And the reason that he did is he put most of it through his wrist and his upper extremities. So those are his injuries. His median nerve is out, his ulnar nerve is out or close to it. And we go after that. The fixation that I did, my approach to these is through a volar ulnar exposure, I reconstruct and I do this almost routinely. I reconstruct the volar ulnar corner of the wrist. And then I will restore the radial column and then I place a bridge plate as we did here. At 20 weeks post-injury, we removed the plate. He's unassisted weight-bearing. His median and ulnar nerves are coming back. They're improving. Two years post-op, he develops crepitence. And so I removed his implants and this is our result. He graduates, he gets a job, he gets married. He produces children that I get to release their trigger forms. So not bad. Case two. This is five days after injury. And this is a guy who is a 55-year-old, he's a machinist. A car stops abruptly in front of him on a freeway and he impacts at somewhere around 70 miles an hour. The most significant thing about this, he has a broken nose. And he knows that the thing that broke his nose was watching his radial diaphysis hit him in the face. They never, we didn't recover that radial diaphysis off the freeway, but he remembers that. So comes this and what are we going to do with this? He has his right upper extremity. That's treated in a standard fashion. He has convolution. Long as radius, we did not bone graft it primarily. And at 15 days, my partner, Jeff Friedrich and myself reconstructed this using a vascularized fibular graft and the way that we did it in sequence was we shortened the ulnar shaft. We put a dorsal bridge plate as our template, brought it out to length, fixed the articular surfaces with K-wires and put a vascularized graft in place as shown on the far right. Six weeks later, we take out the K-wires. Sixteen months, that's not a typo. At 16 months later, I agreed to take this plate off when I finally believed that I had incorporation of our vascularized fibular graft. We did. Without grafting, 16 months later on this radiograph, we have a healed distal radius fracture. So this is 26 months post and we've removed it. That's his range of motion. He's back to work doing what he does for a living. Now, looking at this and we haven't discussed this yet is that in an article that came out this summer there's a meta-analysis of bridge plating and it's done by Ferris and the guys at Walter Reed. And in this, you know, the most common complication you can see is hardware failure, a broken screw is hardware failure and infection. And in this and gathering this from all the articles that were written, I'm a marked contributor to this and those are my cases that I contributed to their meta-analysis. And finding this and my broken plates are the ones shown on the right, the fracture that's torn off from that plate and broken screws. So, you know, that's how I improved on that. You know, I thought I did until like the last three months of my practice. It's kind of like I've got an acute iatrogenic laceration of the ECRL and the ECRB demonstrating and pointing to those two tendons while a fellow was trying to put a plate in place and having somebody step on a bovie pebble. And then we had a patient who had a recent late injury, an EPL lacerate, a rupture in a patient who ruptured at three, four months out and that's the only time that I've seen it with bridge plating. And it was a very, very common new to decompress fracture. And then finally, I had a patient that my fellow stripped the screw as they were trying to take that out. And that's a complication because getting that screw out cost me about an hour of operative time getting the damn thing out. So, so it goes. This is one case that I really want that is not my case but I want to share with you. This is a case who 12 weeks post-injury felt their, the patient felt the spanning plate break, calls the treating physician or orthopedic surgeon who says, I'm on vacation, I'll be back in six weeks, I'll see you then. Four weeks later after rupturing it, after breaking the plate, she ruptured all four, all of her extensor tendons in her fourth dorsal compartment. So, the cautionary tale is this, is that I'm not sure this plate's a good plate for the fourth compartment. I think that it may be in the second compartment. I don't use any plates that have holes in the middle right over those centers. And if you do, then you really have to caution your patient. If you feel it break, here's my home phone number. I'll meet you in the ER. Don't eat or drink anything because that plate's going to come out tomorrow or the next day. And we'll do it emergently. So, indications, as we saw here, I still use it for multiply injured patients, extremely common knitted fractures. Thank you. Awesome. Thank you, Doug. Next up, Dr. David Roush is going to discuss dystorious non-unions and anything else he wants to discuss. All right. Thank you. So, I'll start with just a case presentation. So, a 45-year-old male, he has that metaphyseal fracture, undergoes what one might call maybe not adequate fixation and reduction, subsequently gets fixed with an attempt at bone grafting to get him out to length for operations. Later, has an infected non-union that goes on to severe causalgia and loss of function where he subsequently gets a fusion. So, this problem exists. It's funny, when you look in the literature, it really didn't become a problem until we started fixing all of these, right? I mean, it really wasn't a problem to get a distal radius to heal until vulvar plating became such a panacea, really, for these fractures. The original series, you know, that was presented is Tom Wright's series and only five patients. Those risk factors were considered to be smoking, alcohol abuse. And they were able to get three to heal and two went on to fusion. And that's kind of consistent with the literature. This is Carl Promersberger's series and 15 patients with a non-union. And they recommended the following, that if the non-union had less than five millimeters of subchondral bone supporting the articular surface, distal, then you could reconstruct it. If it was less than five millimeters, then they were not able to reconstruct it and they recommended a fusion. And so, that's kind of where I came into the scenario. This is Jesse's series with 23 patients, again, coming up with this sort of inflection point of about six millimeters of distal bone. And with less than that, then recommending a fusion. And I kind of was looking at it thinking, you know, the problem with it really turns out to be that why would you think a fusion is going to heal in the case of if you can't get the distal radius to heal? And so, we started looking at this with using a spanning plate either by itself or usually in conjunction with a volar plate. And this was Suhail Muthani's project when he was a fellow and this is the results. This is one such case and this is a woman who underwent late correction of a distal radius fracture. And one might argue that it was not adequately reduced, but certainly at this point, she's got hardware failure documented osteomyelitis. And then, you can see this, what Jesse and David have called the post-traumatic radial club hand. And it really is results in severe functional impairment due to the shortening and the loss of the axial alignment of the forearm. And so, step one is to just get the forearm back lined up with the hand and you can see here what that looks like with the distal ulnar resection at the same time. And then, the patient is able to actually start moving, right? The patient can go to therapy and start getting her digits moving. And then, plate removal is at six months. But again, extensive occupational therapy for MP and IP motion. And here's her result. She's obviously very pleased from the expression on her face. But you can see the functional recovery is quite good because her hand works. This is a second patient from this series. This is actually one of my early ones, 45-year-old laborer, full form of scaffold, has that fracture which is open. And he undergoes IND followed by placement of an X-Fix with repair of the ulna and an open carpal tunnel release. At 14 weeks post-op, he is taken back and bone grafted and plated using graft resorption. And he then presents with frank pus and a MRSA infection. So, he undergoes resection as you can see from this. This is similar to Dr. Handel's case. Fairly long segment of metadiophysial bone loss. So, that's all removed. A cement spacer is placed followed by a tricortical graft which is placed after six weeks of IV antibiotics. And this is the outcome with radiographic healing at four months. And then here he is after plate removal. Interesting is that he actually is a worker's comp case. And so, he thought that I had fused his wrist. And so, there was going to be 40% of his hand. And so, that was fine. And he comes back in for his rating. And I said, well, you know, I could take this plate out and maybe he gets a motion, maybe, you know. And so, this is his motion. And he's kind of pissed actually because his workman's comp payout goes, actually goes down rather substantially. But he had to come back for something else. And here he is at five years post-treatment, again, with I think a functional restoration of wrist motion. So, in conclusion, I think the size of the distal fragment has been documented. It should probably be bigger than five to six millimeters, although I have done intra-articular non-unions with it. The distal excision can be frequently necessary because the soft tissue has really contracted. And by the time that you're trying to get this back out to length, you can actually get some extensor tightness trying to do that. So, maybe less is more. And I think the use of a spanning plate should be, I'm sorry, the use of a volar plate should be considered when you're putting this on to neutralize it. So, thank you. I appreciate your attention. Thank you. Great. Thank you. We're a little bit ahead of time. Any questions from the crowd? Yes. I tend to get a CT scan for the more complicated ones with a lot of bone loss. Dr. Handel, your thoughts about removing the plate? As mentioned, if they are dependent on their economies of weight-bearing, the weight-bearing... This is you. This is you. Okay. Jesus. Nice. I would add open fractures, too, are going to be a little bit more delayed in their healing, and I would err towards longer. Some people have been taking them out sooner and having some success. I mean, we all know a metaphyseal dysradious fracture can heal relatively quickly, but sometimes it's better. Once you've taken a plate out and you realize you have to fix the bone again, then you stop taking it out too early. Yeah, I think the plate breaking before three months would be really, really uncommon. Usually that happens in patients. And in my experience, it's been more than six months. And they do feel it. And when they call, just like Dr. Handel said, you should get them in, get them in a splint, and get them protected. I've had one plate that bent rather than broke. He kept it for 18 months. I said, why do you like your hand like this? What is wrong with you? He's like, I thought that's how it was supposed to be. I was like, no. Yes. It's great to hear. Perfect. Love it. Any other questions? One more question? Awesome. All right. Next up is Dr. Tamara John. She's practicing in Fort Lauderdale just north of me. Perfect. And she's going to talk about perilunates. Yes. Thank you very much. Okay. I have no disclosures. Thank you. So in terms of the outline, I'm going to talk about perilunate dislocations, a general overview, a little bit about carpal anatomy, and then perilunate injury treatment options in general, what can we do for these high-energy injuries. And specifically, dorsal spanning plates, using them as an augmentation for stabilization of perilunate fracture dislocations. So in general, these are really rare injuries that account for less than 10% of all wrist injuries in general. They usually result from a very high-energy mechanism, so a fall from height, motor, cycle accident, car accident. So these are very severe carpal injuries that can carry somewhat of a guarded prognosis. So they're frequently missed injuries, but it's really important for us to recognize and treat them promptly. So in terms of the carpal anatomy, the carpal bones are tightly linked by a combination of capsular and interosseous ligaments. So the capsular ligaments actually start on the radius and then insert onto the carpus, and the interosseous ligaments go from carpal bone to carpal bone. So the lunate is the keystone of the carpus and acts as an intercalated segment, which is why we focus so much on the lunate facet fragment and distal radius fractures, making sure that that is well aligned. So if the lunate becomes unstable, the stability of the entire carpus is at risk. So the proximal row is allowed to move in synchrony because of the strong interosseous ligaments holding the bones together there. And then the proximal row is attached to the distal row by capsular ligaments. So disruption to any of these structures can cause great instability in the wrist. So going over the Mayfield classification, so perilunate instability starts on the radial side of the wrist and progresses toward the ulnar side of the wrist. So initially you have injury to the scapholunate ligament, and then lunocapitate dissociation, and then stage three is lunotriquetral dissociation. And then lastly, stage four is when the lunate dislocates into the carpal tunnel, and one commonly tested fact is that when this happens, the attached ligament is the short radiolunate ligament. And this is just a picture kind of showing that, the dislocation into the carpal tunnel with the attached short radiolunate ligament. So greater arc injuries are perilunate carpal fractures with potential ligamentous damage. So lesser arc injuries are more purely ligamentous disruptions without a fracture. So greater arc injuries are named by their associated fractured bones, so a scaphoid fracture with a perilunate dislocation would be called a transscaphoid perilunate fracture dislocation. And then collectively the greater arc and lesser arc regions are called the vulnerable bones, and this is where the vast majority of the carpal fractures and dislocations will occur. So basically inadequate x-ray evaluation is a very common cause of these misdiagnoses. So you want at least two views of the wrist, a PA and a true lateral, and the main finding on the lateral x-ray is a loss of colinearity among the radius lunate and capitate. So this is a photo here, a lateral x-ray, where you have a perilunate dislocation, where the capitate and radius are dorsal to the lunate, and they all should normally be in a straight line. And you may also see the loss of a normal scapholunate intercarpal angle, which is normally between 30 and 60. So if the SL ligament is torn, you'll see that increase. So the scaphoid will tilt volarly, and then the lunate will extend, leading to a larger IC angle. So on the AP, on the right-hand side, you can see the arcs of Golula, and they can be disrupted or not be smooth, like they are in this picture. And you can have the carpal bones of the proximal and distal rows kind of overlapping. Also the lunate, which is normally a trapezoid shape, can also appear triangular or basically wedge-shaped. And you can get oblique x-rays to kind of get a better idea of what you're seeing, because sometimes, again, it can be very difficult. But basically that's what we do, and CT is plus or minus if we really don't understand the fracture pattern or which bones are involved. So basically early surgery is preferred if swelling is not excessive. Typically close reduction prior to surgery is performed in order to establish the overall alignment and decrease pain, decrease swelling, and nerve compression. So if you have any persistent median nerve symptoms, even after close reduction, immediate surgery is recommended. And for surgery, it says here on my slide, close versus open reduction, percutaneous pinning, but most times you are going to be opening because you'll be fixing the SL ligament, either fixing or reconstructing it. And then some people actually fix the LT as well, depending on the injury and then the stability. So basically the post-op course for traditional perilunate ORIF is going to be ORIF, you're going to fix the ligament or reconstruct it, followed by immobilization for 8 to 10 weeks, so non-weight bearing. And then you go back to the OR to remove the K wires, and again, this is a prolonged immobilization for the patient, and you are returning back to the OR, just to remove the pins. So the thought is, what if we fixed this injury, fixed the ligament, but then added a dorsal spanning plate, instead of casting? So the advantages to this would be immediate load bearing, and there are certain patient-specific situations where that would be advantageous. And it's a rigid construct to really protect and immobilize your K-wire fixation. It's essentially an X-fix with a bar-to-bone ratio of zero. So you have a very rigid construct. It facilitates early rehab, as we just said. But the disadvantages, you do have to go back to the OR, which you're doing anyway, to remove your pins for plate removal. It may cause a longer index procedure, so it takes a little bit longer to put that plate on. Not much longer. And then you have additional incisions. So this was a study we did comparing radiographic outcomes in patients treated with traditional ORIF and casting, compared with those treated with ORIF and dorsal spanning fixation. So the SL and LT intervals were measured immediately after index procedure, and then after scheduled hardware removal. So there were 13 patients in the traditional group and 15 in the dorsal spanning group. So there were no clinically significant differences noted in the SL or LT intervals between the two groups. So in conclusion, dorsal spanning plate fixation placed at index surgery with early load bearing for the treatment of perilunate dislocation is not inferior to the current mainstay treatment, which is cast immobilization with the ORIF. And there was no increased carpal instability compared to ORIF and casting. And these are just pictures here. X-rays on the top show the patient who just had ORIF and removal of the K wires. You can see that the SL ligament was repaired. And then below it, same thing, but they placed a dorsal spanning plate instead, which was removed at the time of about three months. So in summary, dorsal spanning plate fixation for the treatment of these dislocations, it does facilitate early rehab. And again, in certain situations, for example, if a patient is caring for their family member full-time at home, they may want the added stability of that extremity right after surgery. Polytrauma patients, and it is a rigid construct that really protects your ligament repairs. No real added trip to the OR because you're going anyway to remove the pins. And again, significant benefit for polytrauma patients. I have on here young and active patients. That's also a subset of patients who might benefit from this if they want to return to load-bearing sooner. And it is not inferior to our current standard of care, which is non-weight-bearing for eight to ten weeks in a cast. So that's it for me. Excellent. Great. Okay. Next up. So we're going to venture into two separate theories. One is going to the second metacarpal, and the other is going to the third metacarpal. You've already heard a lot of opinions about it, but now you can hear a definitive answer from Dr. Halim. Thank you. All right. So I have no disclosures except that I will say that spanning plates are definitely like my top three favorite case, so I have lots of strong feelings about this. Also that I was trained in great part by Seth Dodds, so I may have feelings about the second metacarpal that are similar to his. The other thing I'll mention is that I will indicate these whenever I possibly can. The indication that wasn't specifically mentioned that I love these for are geriatric fractures, and that's for a couple reasons. One, you can depend on that nice diaphysial bone of the metacarpal and the radial shaft rather than their metaphyseal kind of crappy bone. And you also, I actually tend to not immobilize these patients for very long at all. Certainly for patients who are quite elderly but really need their stabilization, you can put them in a soft dressing pretty quickly, let them start moving their fingers. So I love it for my elderly patients. Okay. So talking about the metacarpal. So the second metacarpal is definitively the metacarpal you should use when you're spanning a distal radius fracture. So as has been mentioned before, there's essentially no risk to the EPL tenant as long as you are correctly placing that plate within the second dorsal compartment and down along the bone. There's no third incision required. And remember, we're bridging these fractures, and so to depend on the fracture hematoma, fracture callus, it's really ideal to not be disrupting those fracture planes. So not making a third incision both means saving surgical time and also not messing with your fracture site. The second metacarpal also maintains a position of ulnar deviation, which I'll talk about in a couple minutes, and potentially has some improved ability to help your radial height and inclination. When I first started in practice, I used the third metacarpal for some crazy reason, but now I correctly use the second. And in this example you can see that with that second metacarpal, I got much better improvement of radial height. Okay, so this is a photo taken from an anatomic study done at USC, but it just illustrates that when you place the plate from the second metacarpal, you're beneath that EPL tendon, as opposed to potentially entrapping it, which would really require that third incision over the distal radius in order to retract the EPL and make sure it's protected. As was also mentioned, if the plate does fatigue or break, when you're in the fourth compartment, you do potentially have risk to damaging all of those extensors. Now, certainly if you're in the second dorsal compartment and you have plate breakage, you can absolutely also injure the second dorsal compartment. However, reconstructing all four extensor tendons to the fingers is potentially a worse problem to be dealing with. I've only seen a plate breakage in one patient who was lost to follow-up and showed up like six months later, but I would agree that you've got to take those patients quickly to remove the plate. The ergonomic position of the hand, if everybody wants to think about how you hold your hand when you're brushing your teeth or combing your hair, most of our ADLs are actually done in some degree of ulnar deviation. Putting the hand in ulnar deviation by fixing to the second metacarpal allows for much improved, in theory, ability to perform ADLs while that plate is in place. Again, a lot of these patients are polytrauma patients, patients who maybe have some disability or are geriatric patients who really need all of the help they can get to be able to get their ADLs done. It may be their only good hand that they have. Potentially it allows for easier crutch use. Power grip is about the same whether you're in neutral or slight ulnar deviation. And then, as I mentioned, distracting through the second metacarpal pulls on that radial column, so in theory you can actually improve your radial height and inclination a little bit. Alright, I think that's all. Seth asked to just include a case or so. This was just one that I did a couple weeks ago. I also really like these for very distal or sheer type fractures of the distal radius. This was a 32-year-old man who fell on his handle playing softball and this is with spanning. Beautiful. Thank you. Alright, next up for counterpoint, Dr. Felicity Fishman. I'm sorry, your talk is not opening. Saboteur. Okay, here we go. Alright, so I am going to prove to you that spanning to the third if not better is at least equivalent to the second. I have no disclosures. So Andy did not mention that I was actually also her attending, so on both shoulders you have someone whispering about the second, someone whispering about the third. It looks like temporarily she has gone to the dark side but perhaps we'll win her back over. So I wonder if it's a little bit about where you trained. And so we can see here Dr. Dodds is a disciple of Dr. Hannell and has argued about going to the second. I trained at Duke, so as you can see from Dr. Roosh's slides that the third is sort of where you span if you trained in that area. So why span to the third? You have a stiffer construct inflection, you get a direct reduction of your articular surface through that third incision, you have better support and offload that lunate facet. As Andy pointed out you have equivalent grip strength and neutral and you have a similar complication profile. So we'll go through some of these studies to again prove all these points that I just noted. So as we've all talked about the original technique was spanning from the third metacarpal and this was through a longer incision. You identify and protect that EPL, expose your fracture, reduce it, use some bone graft and your K-wires. And again the placement of the plate here is carefully adjacent to the first and second compartments and in the floor of the fourth compartment. So as we go through these biomechanical studies you'll see again that the third metacarpal is where you should be placing your plate. In this cadaveric study they looked at an extra-articular distal radius model, spanned either the second or the third and tested it in flexion and extension. And what they found was that the construct was stiffer in flexion because of the increased contact of the distal radius at that portion of where the plate is being placed, but that there were no differences in any other parameters in terms of the fracture reduction. When we look at this biomechanical study they changed the model so that it was similar to what we were actually fixing with these plates. So an intra-articular distal radius model and looked at axial load. So again spanning between the second and the third and then in the third group they used another screw that helped to specifically support the lunate facet. And what they found was that the spanning plate that was placed to the third resisted fracture displacement more effectively than when spanning to the second. And then if you add that extra screw supporting the lunate facet that it was even better in terms of the stability. In this cadaveric study they looked at the carpal parameters to see if height, tilt, inclination, or translocation was affected if you were spanning to the second or the third and they found no difference in this study. And here most recently published in JHS they looked at radiographic parameters in terms of your reduction and they looked at right after the plate was placed, right before the plate was removed and then at final radiographic follow up and they found equivalent results in terms of the maintenance of the fracture reduction if you were spanning to the second or if you were spanning to the third. Here we can see a paper from Dr. Dodds that was again arguing for the second because of placing the hand in the position of power grip but we know that power grip is essentially equivalent whether you're in neutral or whether you're ulnarly deviated. So I would argue that placing these patients in a position that is neutral similar to many other procedures that we do for hand surgery at least temporarily is certainly not detrimental to their healing or use of their hand. As we mentioned in the question and answer portion of the ICL already, when you place your plate to the third metacarpal you're going in that intermediate column and you're really helping to support the lunate facet and offloading that articular surface which is often the keystone to your reconstruction. The third incision although Andy argued it takes extra time in the operating room, sometimes can be very helpful if you don't perfectly reduce your fracture with ligamentotaxis and so you can use the access there to help support your articular surface with bone graft and augment your ability to reduce the articular surface. You don't always have to take a look at it through that incision but you're certainly making that incision in order to be able to protect the EPL. And finally the study that Dr. Halim showed giving the third metacarpal a bad name, I would argue that people who are doing this technique to the third metacarpal are not doing a two incision technique so you're visualizing the EPL to make sure it's protected so I don't have an issue with this paper, it just doesn't really affect or worry me about the safety because I'm using the third incision in order to protect my EPL. The risk profile when looking at many different studies that have analyzed this is essentially the same. You have the superficial neuritis that we talked about and needing to manipulate the branches of the superficial radial nerve. You can get extensor tendon adhesions in either even with the second metacarpal that's placed a little more radial. For the third metacarpal sometimes you get a temporary extensor lag because of the fact that the plate is directly underneath the tendon at that level and at the second metacarpal you do have the potential for ECRL injury as you're placing the plate. So in summary when you place your plate to the third metacarpal you have increased stiffness with flexion and generally less displacement of the fracture with axial load. You can better support the intermediate column and offload the lunate facet. You can have direct articular visualization through the third incision that you're going to make anyway and again I would caution you to use that third incision and truly the fracture pattern and your preference should dictate your choice because they're essentially equivalent but there's definitely nothing wrong with spanning to the third and I think it's better. Thank you. This is my true passion. Applause

dorsal spanning plate fixation

dorsal radius fractures

rigid construct

early hand function

multi-trauma patients

non-unions

perilunate injuries

immediate load bearing

early rehabilitation