this is Rashad Akos today discussing
00:03
open reduction internal fixation of
00:05
distal radius fracture using a bowler a
00:08
tee plate here we have illustration of
00:11
an extra articular distal radius
00:13
fracture here we can see the apex of
00:16
bowler angulation and dorsal comminution
00:18
so we use the standard FCR approach the
00:23
FCR is identified proximally and
00:25
distally and here traced occasionally
00:30
we'll make an oblique incision at the
00:31
wrist crease for further distal
00:34
visualization the skin is incised and
00:40
here we can see visualization of the FCR
00:43
attending through our incision the FCR
00:48
is further released approximately the
00:57
the sheath is released for further
01:00
mobilization in here distally the sheath
01:02
is released into the flexor portion of
01:07
the wrist the tendon is then mobilized
01:13
on early this allows for vision
01:15
visualization of the posterior sheath of
01:19
the FCR and now we can see the FPL of
01:26
the thumb flexor
01:33
if we extend more only we can see area
01:38
where the median nerve is visualized we
01:42
now are drawing our distal most edge of
01:44
the pronator quadratus tendon in the
01:46
area of the watershed and extending it
01:49
along the radial border approximately we
01:52
then use a knife and sharply extend our
01:54
incision down to bone along the radial
01:57
border we then use an elevator to
02:00
elevate the pronator quadratus up
02:02
ownerle distally we continue to elevate
02:06
and here we've encountered the fracture
02:08
site we then remove the brachioradialis
02:11
from the rate of ward of the distal
02:13
radius starting approximately hugging
02:15
the bone and extending distally as you
02:22
can see that brachioradialis has a quite
02:24
long insertion quite a long insertion it
02:28
is in a release from the distal fragment
02:29
here care is taken to ensure that the is
02:33
completely released and we can see the
02:35
first dorsal extensor compartment
02:37
through the wound now a curette is
02:40
utilized to free up the fracture site
02:44
and then once the fracture site is
02:49
further visualized
02:56
we'll extend our free right elevator
03:00
across the fracture site now using a
03:03
lobster claw we're able with traction
03:05
and supination to free up the fracture
03:08
fragments this allows for a pulling of
03:14
the proximal portion out of the wound
03:16
removing any of the hematoma clot from
03:20
the end of the bone and then placement
03:23
of this portion back into the wound and
03:26
reduction being obtained as such in
03:35
order to maintain reduction the wrist is
03:38
slightly flexed and a towel roll is
03:41
placed behind the wrist in order to
03:43
facilitate this here with the forest
03:47
floor scan we're using a K wire to give
03:51
us temporary fixation of the distal
03:54
fragment here we've confirmed placement
04:01
of our K wire and now we're using a
04:04
standard tee plate which is noted in the
04:08
small frag set here we can see our
04:12
distal holes and their alignment because
04:15
of the distal the bowler alignment of
04:17
the distal radius a flexion moment a
04:19
flexion is moment is placed on the
04:21
distal most portion of the plate this
04:24
allows for adequate placement of the
04:26
plate against the bone using a 2 5 drill
04:29
bit a screw is is drilled hole is
04:33
drilled and the screw will be placed in
04:35
an oblong hole on the plate itself this
04:40
allows for proximal fixation of the
04:42
plate but it allows for movement of the
04:44
plate proximally and distally is needed
04:47
here we have confirmation of our
04:50
alignment and positioning of our plate
04:51
and now the screw is tightened
04:57
the distal holes are locking holes and
05:00
so using the locking tower we now using
05:03
the 2.8 drill bit and we will go by
05:07
cortically here on the radial styloid
05:12
take note that we're using our finger
05:15
dorsally to feel when we go through the
05:18
dorsal cortex depth gauge is utilized
05:22
and then the screw is advanced again
05:24
attempting to feel if the screw is too
05:26
prominent the remainder of the distal
05:32
screws are then placed because of our
05:35
positioning of our plate we have to
05:38
confirm that the screws are
05:39
extra-articular throughout the remaining
05:42
shaft screws are then placed we drill
05:45
them both at the same time for
05:47
efficiency purposes they're measured
05:49
with a depth gauge and three final
05:51
cortical screws replaced the K wires and
05:56
removed we then confirm our alignment on
06:00
AP and lateral views roller tape tilt
06:05
has been restored and I length have been
06:08
restored as well
06:10
we irrigated and now we attempt to close
06:12
the pronator quadratus using a tool
06:15
Vicryl we grab the fashio of the muscle
06:21
and will not reproach meet it distally
06:26
we then now grab a portion of the
06:28
brachioradialis which was released and
06:30
approximated to the fashion of the
06:32
pronator quadratus as well this closes
06:36
down the radial border the goal being
06:40
here to apply adequate soft tissue
06:42
coverage to the plates to ensure no
06:45
friction on the flexor tendons as they
06:47
cross over the plate extending into the
06:49
wrist skin is enclosed using a 3-bike
06:52
roll suture after irrigation two to
07:00
three sutures are all that is necessary
07:04
and then depending on the amount of
07:07
swelling
07:08
either a 3o nylon suture in a running
07:13
interrupted mattress or simple mattress
07:14
type fashion or running some particular
07:17
suture placed