The Detection of Prominent Hardware in Volar Locked Plating of Distal Radius Fractures: Intraoperative Fluoroscopy Versus Computed Tomography.

OBJECTIVES To assess the utility of the dorsal tangential view (DTV) in detecting intraoperative dorsal screw penetration in distal radius fractures treated with volar locked plating. DESIGN Retrospective cohort study. SETTING Academic level 1 trauma center. PATIENTS/PARTICIPANTS Skeletally mature patients where open reduction internal fixation with volar locked plating was the definitive treatment. A total of twenty-six patients were evaluated. INTERVENTION Intraoperative anteroposterior, lateral, 20 degree tilted lateral, and DTVs were obtained through fluoroscopy in all wrists. Screw exchange and position by fluoroscopic view was recorded. A computed tomography (CT) was taken postoperatively to identify residual prominent screws. MAIN OUTCOME MEASURES Data points included frequency of screw exchange by standard fluoroscopic views, the DTV, and residual prominent screws detected by CT. RESULTS Eight constructs of thirty (27%) had prominent screws evident on the DTV but not seen on standard fluoroscopic analysis. CT identified 5 additional screws with ≥1 mm dorsal penetration not identified by the DTV. All except 1 screw was in the second dorsal wrist compartment. The DTV was 67% sensitive with a negative predictive value of 97%. CONCLUSION It is risky and unnecessary to place bicortical screws in the distal part of a volar plate. Given that the DTV view was not sufficient to avoid dorsal screw prominence, distal screws should be intentionally 2-4 mm shorter than measured. Recent studies propose bicortical distal locking screws are not needed for sufficient construct stiffness in volar locked plating. We suggest caution when using this view to verify acceptable placement of screws in proximity to the second dorsal compartment. LEVEL OF EVIDENCE Diagnostic level III. See Instructions for Authors for a complete description of levels of evidence.