this is Bobby Jabra and this video shows
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our an approach to ORF of distal radius
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fracture using a hybrid FC our carpal
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tunnel approach as well this is a
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standard distal radius fracture I tend
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to use an incision that allows for a
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release of the carpal tunnel through the
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same incision and this has been
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described in a recent article in the
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Journal of hand surgery
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I use a Bruner type incision along the
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course of the FCR with the with equal
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limbs and centered the first point of
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the limb is centered on the radial
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styloid a closed reduction has been
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performed to to allow for ease of
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exposure and now open reduction incision
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is made along this prune or incision
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with care to elevate flaps and allow for
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and obtain hemostasis until the FCR
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tendon is exposed just like a standard
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Henry approach the FCR a tendon is
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exposed coagulate the volar branch of
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the radial artery and carefully carry
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out the dissection distally the FCR
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tendon is exposed and retracted radially
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to reflect to protect the radial artery
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skin flaps are often sutured back you
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can use a fairly small incision to
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perform the carpal tunnel release and
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plating of the fracture the FCR a sheath
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is divided proximally and then a
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standard approach through the floor of
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the FCR a tendon is performed this is
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done carefully and the FPL a tendon has
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identified care should be taken to
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prevent injury to the immediate nerve
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during this portion of the procedure the
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FPL is carefully identified and
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retracted to confirm that it is the FPL
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tendon as shown here and then the FPL is
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retracted on early to protect the median
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nerve
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Digital palpation you can see that the
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carpal tunnel cannot be entered now
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the superficial and deep limbs of the
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transverse carpal ligament attach on
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lung the radial aspect of the wrist and
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by dividing the sheath distally under
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direct visualization the FCR tendon
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sheath distally under direct
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visualization as well as the FPL sheath
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distantly under visualization you can
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release both the superficial and deep
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limbs of the transverse carpal ligament
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this should be done carefully to protect
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the median nerve often the thenar
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muscles should be divided superficial to
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the limbs of the transverse carpal
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ligament and retracted as shown by the
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elevator so you can visualize from
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proximal to distal the transverse carpal
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the radial aspect of the transverse
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carpal ligament based on our anatomic
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studies the recurrent motor branch is
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approximately 11 millimeters distal to
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the transverse carpal ligament on the
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radial side of the wrist at this level
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so it's you can carefully divide the
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ligament as long as it's done on direct
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visualization you can palpate the band's
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until you release the ligament and once
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this is accomplished you can carry
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easily feel and you will easily enter
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into the carpal tunnel and you will feel
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release of the transverse carpal
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ligament this allows for a gentle and
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easy retraction of the carpal tunnel
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contents ownerle without excessive
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traction on the median nerve a standard
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Henery approach is then used with a L
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type incision along the pronator
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quadratus the distal aspect of the L
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incision is long the ridge of the distal
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radius the this is done carefully to
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prevent in an injury to prevent injury
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to the radial artery the pronator
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quadratus is elevated with a period
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priory osteo elevator to expose the
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distal radius by releasing the carpal
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tunnel through the same incision
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excellent exposure of the volar aspect
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of the distal raises
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it's possible particularly the owner
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most corner of the distal radius next
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the brachioradialis is released to
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remove any deforming forces along the
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radial styloid and this is done
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carefully also to prevent injury to the
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radial artery once this is completed the
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fracture can be reduced as shown here
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and again the excellent exposure can be
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obtained of the owner aspect of the
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distal radius open reduction is
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performed and secured with provisional K
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wires k wires are placed
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I prefer placing them through one
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through the radial styloid and then one
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longitudinally from roller to dorsal to
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maintain height and also the distal the
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pin is started at the volar ridge so
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this can help determine your the distal
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aspect of the plate a volar plate is
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then placed and I take time to make sure
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that it is centered on the distal radius
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both along the shaft and along the
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distal aspect of the radius and I secure
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this with pins and obtain fluoroscopic
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images to make sure the plate is
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positioned appropriately I then place
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the two locking threaded screws in the
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two central holes to secure the distal
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fragment by doing this is done
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particularly when there's significant
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volar comminution dorsal comminution
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and i need to correct volar tilt that
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plate can be used to do that in this
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manner so by placing the distal screws
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into the distal fragment this locks the
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distal fragment and then by bringing the
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shaft the plate the shaft portion of
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plate of the plate to the bone the
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contour of the plate allows for
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improvement
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you're volar tilt the screws the shaft
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screws are placed in a sequential manner
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using standard AO technique as shown
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cortical scoot screws are used for this
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portion of the case as long as bone
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quality is adequate once this is
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completed the two distal threaded pins
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are placed one in the radial styloid and
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one in the ulnar most aspect of the
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plate and often variable angle screws
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are needed if there are multiple
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fracture fragments and it is necessary
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to place screws into all these fragments
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final fluoroscopic images are obtained
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in including multiple views to ensure
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that appropriate Hardware placement and
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no intra-articular Hardware the pronator
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quadratus is repaired if possible and
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once this is completed the tourniquet is
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deflated and hemostasis obtained and the
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wound is closed and the patient placed
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in a bulky dressing with a volar splint