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Screw Penetration through Dorsal Cortex during Volar Plate Fixation of the Distal Radius: A Cadaveric Investigation
Kyle Stoops, MD; Nicolette Clark, MD; Brandon Santoni, PHD; Amy Bauer, MSII; Christopher Shoji, MD; Francisco A. Schwartz Fernandes, MD, MS, MBA
University of South Florida, Tampa, FL

Introduction: The surface of the distal radius is irregular, making it difficult to discern penetrating screws through the dorsal cortex during volar plate fixation. Undetected screw penetration or drill plunging puts the extensor pollicis longus (EPL) tendon at risk for injury or even rupture. Intra-operative detection of possible screw penetration is important since it can be corrected. This study was designed to investigate the incidence of screw penetration through the dorsal cortex of the distal radius relying solely on the careful use of the depth gauge to determine the screw length.
Methods: Ten fresh frozen human cadaver arms were instrumented with a commercially available distal radius volar plate system under direct supervision of a fellowship trained upper extremity specialist. Plates were sized to best fit the contour of each specimen. Pending on plate width, 7-8 screws were placed in each plate; 1 proximally and 6-7 distally. Screw lengths were measured twice using a standard depth gauge to improve accuracy. After plate fixation was complete the specimens were dissected dorsally to investigate for screw penetration through direct visualization. Screws protruding into soft tissues from dorsal penetration were removed and replaced with screws of proper length.
Results: Ten cadaveric specimens had a total of seventy-four screws placed into a volar distal radius locking plate. Seven (9.5%) of the screws had to be replaced secondary to dorsal penetration into soft tissue. Five of the seven screws were noted to be in direct contact with the EPL tendon. Protruding screws had to be reduced on average 2mm.
Conclusion: Relying on the depth gauge alone to determine screw length resulted in 9.5% of volar plate screws penetrating the dorsal cortex and protruding into the surrounding soft tissue. Interestingly, approximately 72% of the screws penetrating the dorsal cortex were in plate positions that put the EPL at risk. Use of the depth gauge alone provided accurate measurement for the majority of the screws placed, however this data supports the need for proper intra-operative radiographs to guide screw length and placement.

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