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Radiographic Detection of Long Screw Placement During Volar Plating of the Distal Radius
J. Sullivan, MD; Cari Lee Cordell, MD; William Lanzinger, MD; Terry Light, MD; M. Bednar, MD; R. Bindra, MD
Department of Orthopaedics, Loyola Medical Center, Maywood, IL

Background: Insertion of a long screw remains one of the commonest technical errors during volar plating for distal radius fractures. Intraoperative detection of penetration of the dorsal cortex using standard radiographic views is difficult due to the irregular shape and dorsal prominence of Lister’s tubercle. The purpose of this study was to examine the sensitivity of detection of long screw insertion using multiple rotational radiographic views of the volar-plated cadaveric distal radius.  

Methods: Ten intact fresh frozen cadaveric specimens underwent volar plating of the distal radius using the CoverLoc® plate (Tornier Inc, MN).  Screws were sequentially placed in the distal-most row from radial to ulnar (styloid, scaphoid facet, scapholunate ridge and lunate facet of radius respectively). 3 lengths of screw were inserted in each hole: the measured length and +/- 2 mm. Using a mini C-arm (Fluroscan, Hologic Inc) static fluoroscopic images were obtained after each screw insertion- PA, lateral, tilt view, 300 supinated and 300 pronated and hyper-pronated view. The radiographs were reviewed in a blinded fashion by three fellowship-trained hand surgeons who were asked to report whether the screw was short, long or indeterminate. CT scans were obtained to confirm the correct screw length.

Results: Collectively, the reviewers reported screw length 53% correctly, 26% incorrectly, and 21% inconclusively. Screws were increasingly more difficult to analyze going from radial to ulnar. The supinated radiograph was most sensitive in detecting long styloid (82%) and scaphoid facet (89%) screws. The true lateral view was most sensitive in detection of long screws in the scapholunate ridge of the radius (75%) and the tilt view for detection of long screw in the lunate facet (46%). Interobserver overall agreement was 65% and fixed marginal kappa analysis demonstrated only moderate agreeability among all investigators (k=0.46).

Conclusions: Intraoperative radiographic determination of long screw insertion is challenging. This study suggests that the addition of a supinated oblique view will help to detect long screws placed in the radial side of the distal radius. Even with multiple views, however, sensitivity of detection of long screws is 89% at best. Surgeons should accurately measure screw length using a depth gauge and only use radiographs as an adjunct for detection of long screws.



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