Acta Orthop. Belg.

, 2021, 87 e-supplement 1, 103-110 ORIGINAL STUDY

Removal of volar plate after open reduction internal fixation of

distal radius fractures : clinical and radiographic analysis

Amir Shlaifer, Franck Atlan, Assaf Kadar, Oleg Dolkart, Yishai Rosenblatt, Tamir Pritsch

From the Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University,
Tel Aviv, Israel

The operative treatment of distal radius fractures Keywords : distal radius fracture ; volar plate ; implant
had evolved over the years. In the last two decades removal ; implant prominence.
anatomic locking plates were introduced and are
increasingly being used for this indication becoming
the most common surgical fixation for distal radius
fractures. This study investigated how often plate
removal is related to preventable reasons such as INTRODUCTION
plate and screw positioning, screw length, and quality
of reduction. Distal radius fractures are the most common
All patients who underwent volar plate removal in our upper extremity fractures with a reported incidence
institution between the years 2006-2014 were included of over 640000 cases a year in the US alone (1).
in this study. Patients’ charts were retrospectively Karl et al. (2) Reported a bimodal incidence of distal
reviewed, and preoperative radiographs were analyzed radius fractures with the highest rates in age groups
including plate to volar rim distance (PVR), plate
under 18 y/o and over 65 y/o, and lower rates in
to critical line distance (PCR), Soong classification,
implant position, and screw prominence.
the middle age groups. The operative treatment of
A total of 50 patients (26 males, 24 females) were distal radius fractures had evolved over the years. In
identified. Patients with subjective feeling of pro-
minent implant were found to be younger than the
rest of the cohort. In addition, this complaint was n Amir Shlaifer M.D. M.H.A.,
associated with ulnar prominence of the proximal n Franck Atlan M.D.,
n Assaf Kadar M.D.,
part of the plate due to malposition on the coronal
n Oleg Dolkart Ph.D.,
plane. Extensor tendon irritation was associated with n Yishai Rosenblatt M.D.,
prominence of the proximal screws. Only one case n Tamir Pritsch M.D.
was associated with flexor tendon irritation and there Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical
was no association to the Soong grade or PCL and Center, Sackler Faculty of Medicine, Tel Aviv University, Tel
PVR measurements. Aviv, Israe
We believe that good fracture reduction, correct Correspondence : Oleg Dolkart, Shoulder Unit, Orthopedic
plate positioning, and appropriate screw location Surgery Division, Tel-Aviv Medical Center 6 Weizman Street,
and length, can largely limit the need for volar plate Tel Aviv 6423906, Israel.
removal. E-mail : dolkarto@gmail.com
© 2020, Acta Orthopaedica Belgica.

Conflicts of interest: none Acta Orthopædica Belgica, Vol. 87 e-Supplement - 1 - 2021

104 a. shlaifer, f. atlan, a. kadar, o. dolkart, y. rosenblatt, t. pritsch

the last two decades anatomic locking plates were the critical line(PCL) (19)), and Soong classification
introduced and are increasingly being used for this (14). Statistical analysis of the data was carried out
indication (3,4) becoming the most common surgical with Pearson Chi-Square test (χ2) for categorical
fixation for distal radius fractures (5-7). variables and student t test for scaled variables at a
Although volar plate fixation provides reliable significance level of 0.05.
and reproducible results (8,9), several complications
have been associated with their use including carpal RESULTS
tunnel syndrome (10),tendon injuries, both flexors
(11,12) and extensors (13), and intra-articular screw Fifty patients were included in the study. There
penetration (14,15). Part of the complications appear were 24 females and 26 males, with an average
to be implant related and therefore require its age at the time of implant removal of 46.7 years
removal. The reasons for implant removal following (range 17-82). The dominant hand was involved in
distal radius open reduction internal fixation (ORIF) 17 cases, seven patients had bilateral distal radius
were not widely described in the literature (8, 16-18). fractures and one patient had an open fracture.
The goal of our study was to identify and analyze The mechanism of the fractures was a fall on an
the reasons for volar plate removal following ORIF outstretched hand in 37 cases, car accident in 12
of distal radius fractures. Identifying preventable cases, and in one case this data was not available.
causes may potentially allow improving the surgical Fourteen cases had been acknowledged as work
technique of implant application, and consequently compensation. The distribution of fractures type
decrease the need for subsequent removal. according to the AO Müller classification is
presented in table 1. Seventy two percent of the
METHODS fractures had an intra-articular involvement. The
mean time from the occurrence of the fracture to
Following the approval of our institutional review ORIF was 9.6 days (range 0-29) and the mean time
board, we performed a retrospective study at a level between ORIF and implant removal was 81.39
I trauma center. All patients operated between 2006 weeks (range 3-431). Of the 50 implants that were
and 2014 for volar plate removal after ORIF of distal removed, Forty-two were locking and 8 were non-
radius fractures were identified. Exclusion criteria locking plates from different manufacturers.
were children with open physis and the associated
Table 1. — AO Müller classification
use of a dorsal plate. Patients’ medical records
were reviewed for age, gender, hand dominancy, Fracture Type Fracture Group
side of fracture, mechanism of injury, time between 1 2 3
injury to the operative fixation, reasons for implant 23A 0 10 3
removal, and time between the ORIF to implant 23B 1 1 12
removal. Radiographic analysis included review 23C 7 6 5
of two sets of radiographs for each patient, one According to the AO Müller classification number 2 indicates
taken after the initial trauma and the second taken Radius and Ulna, number 3 indicates distal segment, and the
before the removal of the implant. Each set included letters A,B,C indicate the fracture type (A – extra-articular, B –
postero-anterior (PA) and lateral views. In five partial articular, C – complete articular), the fracture group in
cases, patients underwent ORIF in other medical the upper row indicate the fracture comminution.
facilities, and consequently the radiographs after the
initial trauma were not available. We reviewed the The reasons for implant removal (one or more
postoperative radiographs for : secondary displace- per patient) are shown in table 2. Subjective feeling
ment, intra articular screw penetration, prominence of prominent implant leading to its removal was
of the screws at the dorsal aspect of the radius, plate significantly associated with younger age (39.3
position on the coronal plane, distance from the plate years Vs 49.3 years ; P=0.05), and with ulnar
to the volar rim (PVR), distance from the plate to prominence of the proximal part of the plate

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 implant removal after distal radius fracture 105

Table 2. — Reasons for implant removal the Soong grade was 1, PCL was 2.2mm, and PVR
Reason for implant removal Number of was 4.1mm.
patients (%) Intraoperative difficulties and complications
Subjective Pain 38 (76) during the implant removal included 2 cases of
reasons Stiffness 32 (64) iatrogenic injuries to the radial artery that were
Subjective prominent implant 13 (26) treated with immediate repair. In addition, in 3
Objective Articular collapse 12 (24) cases the use of a reversed threaded screwdriver
reasons Malposition 11 (22) was required to remove damaged screws. There was
Tenosynovitis/tendon lesion 9 (18)
no significant association between the occurrence of
Carpal tunnel syndrome (CTS) 2 (4)
an intra operative complication and time between
Infection 1 (2)
Non-union 1 (2)
ORIF and implant removal, (p=0.936) the type
of plate used(locking and not locking) (p=0.589),
or patients’ age (p=0.635). In 18 cases, additional
(p=0.037). Hand dominancy was not found to procedures were performed during implant
be significantly associated with any reason for removal ; these procedures are detailed in table 4.
implant removal (P>0.5). No correlation was found Those cases were not associated with increased rate
between any of the reasons for implant removal of intraoperative complication (p=0.642) or with
and the type of fracture according to the AO Müller any specific reason for implant removal (p>0.1).
classification or the type of plate (locking Vs Non-
locking). Six patients had a prominent screw into DISCUSSION
the Distal Radio-Ulnar Joint (DRUJ) and eight into Distal radius fractures are the most common
the Radio-Carpal joint. As expected, all patients upper extremity fractures with an increased in-
with prominent screws into joints had wrist pain cidence in recent years (20,21). As the operative
and stiffness. treatment, especially ORIF with volar plating, is

Table 3
Soong classification, PVR and PCL measurements

Soong grade 0 Soong grade 1 Soong grade 2 Total

Number of patients 5 22 23 50
PVR 4.2 (SD1.98) 5.23 (SD2.79) 3.71 (SD4.1) 4.1 (SD3.43)
PCL 1.29 (SD1.01) 4.06 (SD2.24) 4.76 (SD3.53) 4.21 (SD2.4)
PVR (Plate to Volar Rim) and PCL (Plate to Critical Line) are measured in mm. Plate prominence greater than 2.0 mm beyond
the volar critical line and plate position distal to 3.0 mm from the volar rim both were found by Kitay et al. to be highly sensitive
and specific for flexor tendon rupture (19).

There was a significant association between pro- Table 4. — Additional procedures during implant removal
minence of the most distal diaphyseal screw and the surgery
occurrence of extensor tenosynovitis that required
Procedure Number of patients
implant removal (P=0.021). In cases of extensor Neurectomy of PIN and AIN and
tendon irritation the mean protrusion of the most 6
adhesion release of the Median nerve
distal diaphyseal screw was 1.7 mm compared Osteotomy of osteophyte that limited
5
to 0.688 mm in cases that did not demonstrate range of motion
irritation of the extensor tendons. Soong grade, PCL Carpal Tunnel Release 3
and PVR evaluations are detailed in table 3. Those Extensor tendon tenolysis 3
criteria were not found to be associated with any Arthroscopy (including TFCC repair) 3 (2)
reason for implant removal. One patient (2%) had Debridement 1
Darach procedure 1
flexor pollicis longus tendon irritation. In that case

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106 a. shlaifer, f. atlan, a. kadar, o. dolkart, y. rosenblatt, t. pritsch

Figure 1. — Ulnar prominence of the proximal part of the Figure 2. — Dorsal prominence of screw in the diaphysis of
plate indicate a rotation of the plate on the coronal axis. Figure 2: Dorsal prominence ofthe radius.
screw in the diaphysis of the radius.
Figure 1: Ulnar prominence of the proximal part of the plate indicate a rotation of the plate on the

coronal axis.
becoming more common (5-7), plate removal rate to re-operate on elderly patients with higher peri-
increases as well. Our study aimed to analyze the operative morbidity (22).
reasons for plate removal, and to identify predictive Subjective feeling of implant15 prominence was
parameters that could be adjusted to decrease plate associated with ulnar prominence of the proximal
removal rates. part of the plate and was significantly more common
The average patient age at implant removal in our in younger patients. To our knowledge, this reason
series was 46.7y/o ,which is significantly younger for plate removal was not previously reported.
than the mean reported age for ORIF of distal radius Ulnar prominence of the proximal part of the plate
fractures (6). This finding is in agreement with what is caused by a position which is not parallel to the
has been reported by Snoddy et al. (17). The mean coronal axis of the radius, and consequently may be
age at implant removal in their series of 33 cases associated with radial prominence of its distal part
was 46y/o. It might be explained by the finding that (figure 2), where the irritation is usually located. The
subjective feeling of implant prominence, which distal prominence of the plate may be overlooked
was a common reason for implant removal in our on plane radiographs due to the unique shape of the
series, was more common in younger patients. In radial metaphysis, and proximal ulnar prominence
addition there is a general reluctance of surgeons is easier to identify. The association between this
14
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 implant removal after distal radius fracture 107

Table 5. — Tendinous lesions reported in literature

Number of cases Number of Extensor lesions flexor lesions

tendinous lesions
(17) 33 9 8 1
(18) 37 7 7 0
{Rampoldi, 2007 #75} 90 5 3 2
(31) 114 17 6 11 (2 FPL tears)
(16) 28 9 2 7 (FPL tear, 2 FDP tears)
(14) 165 6 0 6 (FPL tear, FDP tear, FDP+FDS tear)
(37) 22 5 5 0
Current study 50 9 8 1

reason for plate removal to younger patients age is their study on cadaveric forearm model found that
probably related to their higher activity level. In unicortical locked fixation and bicortical non-locked
an attempt to limit plate prominence in the coronal fixation both appear to afford adequate construct
plane, we currently position the distal part of the stability for a simple forearm fracture model in the
plate on the ulnar aspect of the distal radius, and its immediate postoperative stage. In addition, Overtuf
proximal part parallel to the long axis of the bone. et al. (28) demonstrated biomechanical equivalence
In addition, we choose the narrowest plate that will between bicortical and unicortical-abutting locking
provide adequate stable fixation to the fracture. screw-plate fixation in radial diaphyses. In order to
Although several studies reported no benefit in minimize tendon irritation, the use of unicortical
repairing the pronator quadratus (23) following volar abutting locking screws should be considered in
plate fixation of distal radius fractures, in light of proximal plate fixation, especially for the most
our current study, we believe that implementation distal diaphyseal screw.
of this technique for plate coverage should be Flexor tendon complications are reported less
considered in young patients with higher level of frequently than extensor tendon complications,
physical activity. their distribution are shown in table 5. Kitay et-
Tendon irritation and related problems are the al. (19) compared lateral radiographs of 8 patients
leading complication following ORIF of distal with flexor tendon rupture to 17 matched control
radius fracture in almost all series (10,17,18,24,25). In patients in an attempt to find an association between
our series tenosynovitis was the reason for implant plate position and flexor tendon rupture. Based
removal in 18% of the patients. In all but one, the on their findings they recommended on elective
extensor tendons were involved and there was no implant removal for symptomatic patients with
case of tendon rupture. These findings are similar to plate prominence greater than 2.0mm volar to the
the findings of Lutsky et-al. (18) who reviewed 37 critical line (PCL) and plate position within 3mm of
patients who underwent implant removal following the volar rim (PVR). We found in the current study
volar plating of distal radius fractures and found that PCL was higher or equal to 2mm in 42 patients
19% incidence of tenosynovitis or tendon lesion (avg. 4.12 ± 2.4 ) and PVR was less than 3mm in
without any case of flexor tendon rupture. The most 13 patients (Avg. 4.1 ± 3.43). Although PCL and
significant factor associated with extensor tendon PVR were high and low respectively in the only
irritation in our series was the amount of dorsal patient in our series with flexor tendon irritation,
prominence of the most distal diaphysial screw no statistically significant association was found
(figure 1). Wall et-al. (26) recommended uni-cortical between these criteria and the reason for implant
fixation of the epiphyseal screws to minimize removal.
extensor tendon complications, since the effect of Intra articular screw placement was diagnosed
grabbing the dorsal cortex has been proven to be in 14 patients (6 DRUJ, 8 Radio-Carpal Joint),
negligible on construct strength. Pater et al. (27) in and all had pain and joint stiffness. In order to

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108 a. shlaifer, f. atlan, a. kadar, o. dolkart, y. rosenblatt, t. pritsch

maximally support the articular surface the most Limitations

distal screws should ideally be inserted underneath
the subchondral bone (3). Consequently, very distal Our study has several limitations including its
fractures with intra articular comminution pose the retrospective nature, and the fact that the study
greatest risk for this complication and the most population only included patients that had their
ulnar screw has the highest risk for intra articular implant removed, without a comparison to the entire
penetration (29). The incidence of intra-articular patient population who had distal radius fracture
screw penetration is rarely reported in the literature. fixation with volar plates. Nevertheless, this is one
Both Marsland et al. (30) and Arora et al. (31) reported of the few and largest series of volar plate removal.
on one intra-articular screw penetration that was Since the popularity of volar plate fixation of distal
diagnosed and corrected intraoperatively. Soong radius fractures is constantly increasing, analyzing
et al. (14) reported on eight cases of intra-articular the reasons for its removal is of clinical importance.
screw penetration out of 594 distal radius plating,
and Pace et al. (32) reported on 8 intraarticular screw CONCLUSIONS
penetration out of 128 cases. In order to reduce the
incidence of this unfortunate complication, several Although the use of volar locking plates for the
authors suggested multiple fluoroscopic views to treatment of distal radius fractures is considered
better demonstrate the joint line (32-34). Recently we a reliable procedure, surgeons must be aware of
started to use locking distal pegs (available in some the factors that are associated with the increased
distal radius plating systems) in questionable cases, need for implant removal, especially those that
in an attempt to reduce radiocarpal irritation. can be adjusted. According to the current series,
Intraarticular screw penetration can also occur these factors included younger age, initial plate
postoperatively due to secondary collapse of the malpositioning in the coronal plane, and screw
subchondral bone which was originally supported malpositioning (intra-articular penetration, or
by the stiff construct of the locking mechanism. dorsal prominence). Based on our findings, in
Esenwein et al. (15) reported on 9 cases of secondary order to decrease the need for implant removal we
collapse out of 665 cases of distal radius fractures suggest to position the plate parallel to the long
treated with fixed angle locking plates. This finding axis of the radius with its distal part positioned
is similar to the results of Soong et al. (14) who as ulnar as possible on the metaphysis, to use the
reported 1.2 % loss of fixation (7 of 594 cases). narrowest plate available without compromising
The Intraoperative complication rate in our series fracture fixation stability, and to carefully position
was 4% and 6% (respectively) and included two and measure the screws to avoid joint protrusion or
cases of arterial injury and three cases of damaged screw prominence that may lead to tendon irritation.
screws. Intraoperative complications during implant Finally, when locking and tightening the screws,
removal has been described by others. Bae et al. (35) care must be taken to avoid damage to their heads,
described significant difficulties in screw removal that may lead to future difficulties in cases of need
due to stripping of hexagonal screw heads in 24 of implant removal.
out of 279 3.5mm locking screws. Van Nortwick et
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