The distal-medial pilot hole: A simple way to ease volar plate positioning in extra-articular distal radius fractures

Volar plating is one of the most used surgical treatments for dorsally displaced extra-articular distal radius fractures. However, the reduction of the dorsal tilt can be difficult. It usually requires a flexion maneuver of the wrist while maintaining and screwing the plate, which is cumbersome. Plate positioning also is a crucial step and is sometimes difficult because of the large size of the plate relative to the width of the distal radius. We use an epiphysis-first technique. We place all the epiphyseal screws before reduction, and then we take advantage of the anatomical shape of a locking plate to automatically reduce the dorsal tilt by fixing the proximal radius to the plate with cortical compression screws. To ensure easy and accurate positioning of the plate, we drill a distal medial pilot hole in a free-hand fashion 10 mm proximal to the watershed line and 10 mm lateral to the medial rim of the radius, without positioning the plate. This allows a clear view of the location of this first hole. The locking plate is then applied to the distal radius with help of a monocortical non-locking screw, and it is controlled under fluoroscopy. When this medial pilot hole is properly positioned and the plate correctly tilted on the anteroposterior view, the remaining epiphyseal holes are filled with locking screws. Then the plate is fixed on the proximal radius with bicortical compression screws, allowing an automatic reduction of the epiphyseal dorsal tilt. We believe this technique is a safe and reproducible way to position volar plates and to reduce anatomically the dorsal tilt in extra-articular posteriorly displaced distal radius fractures (AO A2 and A3). Furthermore, the automatic fracture reduction provided by this technique decreases operation time and radiation.