SCS™ Volar Distal Radius Plate System - Small Bone Innovations

SURGICAL
TECHNIQUE
SCS Volar Distal
Radius Plate System

SCS Volar Distal Radius Plate System
SURGICAL TECHNIQUE
CONTENTS
Introduction 1
Preoperative Planning 2
System Components 2
Surgical Procedure: Acute Fracture
1. Implant Sizing 3
2. Fracture Reduction 3
3. Incision 4
4. Exposing the Distal Radius 4
5. Drill Guide Placement 5
6. Drilling The Tine Holes 6
7. Plate Insertion 6
8. Final Reduction 7
9. Closure 7
10. Rehabilitation 7
Ordering Information 8
Indications and Contraindications 9

Introduction
The SCS (subchondral support) Volar Distal Radius Plate is
designed to internally fix the unstable distal radius with sufficient
stability to allow immediate rehabilitation.
The treatment of displaced distal radius fractures remains
problematic. Malunion, stiffness, and late arthritis are not uncommonly
associated with casting or external fixation.
As for all other juxta-articular and intra-articular fractures, optimal
treatment includes anatomic reduction and internal fixation
that is strong enough to allow immediate rehabilitation of all
joints. 1 However, in the distal radius metaphysis, screw purchase is
often not possible due to fracture geometry and/or osteopenia.
The SCS Volar Distal Radius Plate is designed to address these
challenges. Using the biomechanical principle of a bladed plate,
the patented tines of the 3-dimensional SCS Volar Distal Radius
Plate engage the distal fragments and carry load directly to the
diaphysis.This avoids reliance on weak distal metaphyseal screws
while providing the stability required for immediate postoperative
motion. The SCS Volar Distal Radius Plate was found to be
significantly stronger than the typical T-plate in resisting axial
load in cadaveric testing. 2,3
The majority of distal radius fractures in adults can be satisfactorily
treated by simple methods, such as casting or percutaneous
pinning. More complex fractures could be considered for open
reduction and internal fixation with the SCS Volar Distal Radius
Plate.
The SCS Volar Distal Radius Plate is designed with an established
12 o volar tilt to insure proper realignment of the distal
radius after fixation is obtained. The anatomically shaped plate,
with countersinking for the screws, assures a low profile. Right or
left, small and large configurations address the anatomic spectrum.
Constructed of clinically proven stainless steel, the tines
independently support the scaphoid and lunate fossae.
After anatomic reduction, specifically designed templates facilitate
accurate placement of pilot holes for the tines of the SCS
Volar Distal Radius Plate.
The SCS Volar Distal Radius Plate is useful for the management
of some unstable fractures, impending malunions, non-unions,
and osteotomies of the distal radius. By achieving stable internal
fixation and starting early rehabilitation, the cost and disability of
patient care can be reduced.
1

Preoperative Planning
The surgeon must develop a clear understanding of the exact
three-dimensional fracture geometry prior to surgery. After the
routine initial presentation x-rays (AP, lateral and oblique), additional
studies may be useful. Traction or closed reduction x-rays
may help define intra-articular extension. Distraction PA and lateral
views may reveal associated carpal injuries. 4 In some cases, a
computerized tomograph or magnetic resonance image may help
define the radiocarpal and distal radial ulnar joint (DRUJ) surface
anatomy.
The SCS Volar Distal Radius Plate x-ray templates will help estimate
the appropriate plate size and optimal plate position. For
malunions or non-reducible fractures, comparison views of the
unaffected side are helpful.
Occasionally, patients will present with substantial injury edema,
with or without median nerve irritation. These patients must be
carefully evaluated for acute carpal tunnel syndrome (CTS).
Compartment pressure evaluation and emergent EMG/NCV testing
can be of some benefit.
Principles of Treatment
> Anatomic reduction must be achieved
before attempting fixation.
> Intraoperative external distraction
is essential.
> Bone graft or bone graft substitute
should be used to fill metaphyseal
defects.
> Place stable internal fixation after
successful reduction.
> Evaluate and treat associated injuries.
> Start early motion of all joints.
Open carpal tunnel release (CTR) is indicated for the emergent
treatment of acute CTS. The much more common problem of
milder, median nerve irritation usually responds well to a stable
reduction of the distal radius with resumption of wrist and finger
motion.
System Components
The SCS Volar Distal Radius Plating System is designed using
SBI’s System Pack Technology. Each of the four choices of
implants comes in its own self-contained disposable instrument
package. The package contains the plate, screw driver / depth
gauge, required screws, K-wires, drill pin,
drill pegs and drill guide. The System
Pack is sold at a single cost, reducing
the costly efforts expended in tracking
individual screw and K-wire use. The
chances of infection are also reduced
due to the absence of a need to sterilize
a previously used instrument set before
surgery. Not only does this reduce the
chances of infection, it also reduces OR
cycle time and overall costs.
2 SCS Volar Distal Radius Plate System Surgical Technique

SCS Volar Distal Radius Plate System
TM
1
SURGICAL PROCEDURE: ACUTE FRACTURE
Implant Sizing
The SCS Volar Distal Radius Plate is provided in four configurations;
large and small sizes for left and right orientations.
Templates (attached to the outer package) are provided
for use with AP and lateral x-rays for assessment of
proper plate size (FIGURE 1).
FIGURE 1
2
Fracture Reduction
Anatomic reduction is desirable, but not always achievable
before attempting fixation with the SCS Volar Distal
Radius Plate. External distraction is often a useful tool to
help obtain and maintain reduction before and during
plate application. Options for intra-operative external distraction
include:
a. Sterile finger trap traction pulling in a volar
direction (FIGURE 2A), or;
b. A 2 or 4 pin adjustable external skeletal
fixator (FIGURE 2B)
Reduction without External Skeletal Fixation
After fracture exposure, when the volar cortex is noncomminuted,
manual anatomic reduction can usually be
accomplished by engaging the teeth of the volar fracture
line and then volar flexing the distal fragment to a limit
allowed by the dorsal periosteum. Occasionally, a freer
elevator must be inserted between the cortices to lever
the fracture into reduction. Reduction can be maintained
by placing a rolled towel under the hand and wrist or by
insertion of a .062” trans-styloid K-wire. In cases where
there is comminution of the volar cortex and/or articular
fractures, eternal distraction will usually be required to
maintain reduction until the plate is in place.
Reduction with External Skeletal Fixation
Using the limited open technique, place an appropriate
size half pin across both cortices of the radial diaphysis
about 8-10 cm proximal to the radiocarpal joint. The distractor
half pin should be placed proximal to the intended
proximal screw hole for the plate. The pin is inserted after
pre-drilling and protecting the superficial radial nerve.
Similarly place the second half pin through the base of the
second metacarpal and into the base of the third. Apply
the device, perform an initial closed reduction, and distract.
To facilitate difficult fracture reductions, the external
distractor can be repeatedly adjusted intraoperatively to
change wrist position while maintaining distraction.While
maintaining distraction, radiographic evaluation of carpal
alignment may demonstrate an associated intra-carpal
ligament injury or carpal fracture. K-wires (.045”) may be
used for provisional fixation between fragments to facilitate
plate application.
FIGURE 2A
FIGURE 2B
3

3
Incision
The surgical exposure utilizes a radial volar incision
through the flexor carpi radialis tendon sheath (FIGURE
3A). The distal end of the incision curves toward the radial
styloid and may be further extended by zig zag back
toward the ulnar side (FIGURE 3B). The incision passes
through the superficial and deep layers of the FCR sheath.
The FCR and FPL tendons are retracted ulnarly and the
radial artery radially. Some of the muscle fibers of the FPL
origin will need to be reflected from the radius for proximal
exposure. A palmar branch of the radial artery at the
level of the wrist crease may need ligation.
FIGURE 3A
FIGURE 3B
4
Exposing the Distal Radius
The pronator quadratus is reflected ulnarly from its radial
insertion exposing the entire distal radius ulnarly to the
distal radioulnar joint (FIGURE 4). Care should be taken to
sharply reflect the distal border of the pronator to facilitate
insertion of the drill guide. Partial release of the
fibroosseous sheath of the FCR will also facilitate exposure
of the ulnar side of the distal fragment. Occasionally,
access to the ulnar most drill hole of the plate has to be
between the flexor carpi radialis and the median nerve, in
which case the median palmer cutaneous branch must be
identified.
FIGURE 4
4 SCS Volar Distal Radius Plate System Surgical Technique

5
Drill Guide Placement
If anatomic reduction is obtained, the drill guide will conform
to the volar surface of the distal radius. If complete
reduction is not obtained, insertion of the K-wires (and
subsequently, the tines) parallel to the articular surface will
allow final reduction to be achieved with the plate. This
means that the shaft of the drill guide (plate) will be at an
angle with the shaft of the radius equal to the required
angle of final correction. There are two radiographic markers
embedded in the stem of the drill guide. These markers
can be viewed fluoroscopically and assist in axial alignment
along the diaphysis of the radius.
FIGURE 5A
A K-wire or needle can be manually inserted into the radiocarpal
joint to identify the distal end of the radius. The
Trial/Drill Guide should be placed on the radius such that
the tine holes (larger holes) will be 1-3 mm proximal to the
subcondral bone of the distal radius and parallel to the
articular surface in the frontal (AP) and saggital (lateral)
planes (FIGURE 5A). The two k-wires from the System
Pack are inserted through the center k-wire holes in the
Drill Guide into the distal radius (FIGURE 5B). Fluoroscopy
is then used to examine the position of the k-wires relative
to the radiocarpal joint. Fluoroscopic views are taken in
the AP and lateral planes. The x-ray beam should be parallel
to the tine holes in the AP and both pins should be
superimposed on the lateral view. This will give an accurate
determination of tine placement with respect to the
articular surface (FIGURE 5C). The Drill Guide is designed
to insure that the SCS Volar Distal Radius Plate tines will
be parallel with the k-wires. Therefore, examining the k-
wire position provides an exact indication of the subsequent
tine placement. The k-wires should be approximately
1-3 mm proximal to the joint and it is acceptable if they,
or the tines, pass through any fracture lines. However, they
should not penetrate the radiocarpal joint. If placement of
the Guide needs to be altered, it can be moved 2 mm proximally
or 2 mm distally by reinserting it over the additional
k-wire holes in the Guide. Note: It will be easier to reinsert
the Guide over the two k-wires if one is cut to a shorter
length so that the Guide can be placed over each k-wire
separately.
FIGURE 5B
FIGURE 5C
X-RAY
22 º
FLUOROSCOPY PLATE
5

6
Drilling the Tine Holes
With Drill Guide placement verified using fluoroscopy, the
tine holes can now be drilled. Using the Drill Pin supplied
in the System Pack. The first tine hole is drilled (FIGURE
6A). A Drill Peg from the System Pack is then inserted
into the initial tine hole to stabilize the Drill Guide for
additional tine hole drilling (FIGURE 6B). A second tine
hole is drilled using the Drill Pin followed by inserting the
second Drill Peg. The Drill Guide is now fully stabilized
and the remaining tine holes can be drilled.
FIGURE 6A
FIGURE 6B
7
Plate Insertion
The Trial/Drill Guide and K-wires are now removed and
the SCS Volar Plate is placed on the radius by manually
inserting the plate tines into the drilled tine holes (FIG-
URE 7). The plate is designed so that a moderate pressure
will be required to push the square tines into the round
drill holes. During this process manual counterpressure
should be applied to the dorsum of the distal fragment.
FIGURE 7
With the tines situated parallel to the articular surface in
both the frontal (AP) and sagittal (lateral) planes, the shaft
of the plate is applied to the shaft of the radius and held
manually or with a bone clamp. This maneuver produces
the final anatomic reduction.
6 SCS Volar Distal Radius Plate System Surgical Technique

8
Drilling of the Proximal Screw Holes
With the plate flush on the palmar surface of the radius
shaft, the plate itself is used as a guide for drilling the
screw holes. Again using the System Pack Drill Pin, 2 or
3 cortical screw holes are drilled into the radius using the
holes along the shaft of the SCS Volar Distal Radius Plate
as a guide. The two cancellous screws in the distal end of
the plate are usually not required because the resolution
of forces pushes the distal fragment volarly.
Using the System Pack Screwdriver/Depth Gauge, the
required screw lengths are measured (FIGURE 8A) and
the appropriate screws inserted through the plate (FIG-
URE 8B).
FIGURE 8A
Following radius fixation, the DRUJ should be checked for
rotation and translational stability. Occasionally, repair of
the TFC or fixation of the ulnar styloid will be required.
FIGURE 8B
9
Closure
Insofar as possible, the pronator quadratus is closed over
the plate and sutured to its original insertion on the
radius margin of the distal radius (FIGURE 9). Soft tissue
and skin closure follows.
10
Rehabilitation
Postoperative splint or cast support is utilized as required
based on estimation of patient compliance, stability of
the fixation, and nature of soft tissue or skeletal injury of
the distal radioulnar joint. Active finger motion is begun
immediately. Intermittent protected active wrist motion
may be started in approximately 10 days depending on
fracture fixation. In general, the patient is told to lift nothing
heavier than a china dinner plate for the first month.
The progressive activity is allowed based on radiographic
evidence of fracture healing. Generally, 3-4 months are
required for disappearance of the fracture lines.
Radiographic evaluation is recommended at 10 days, 4
weeks, 8 weeks, and 3 months postoperatively.
FIGURE 9
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SCS Volar Distal Radius Plate System
Ordering Information
Cat No. Description Length Thickness Width at distal end
SCS-LSSP SCS/V Volar Distal Radius Plate, Left, Small 51mm 1.65mm 22mm
SCS-LLSP SCS/V Volar Distal Radius Plate, Left, Large 51mm 1.65mm 27mm
SCS-RSSP SCS/V Volar Distal Radius Plate, Right, Small 51mm 1.65mm 22mm
SCS-RLSP SCS/V Volar Distal Radius Plate, Right, Large 51mm 1.65mm 27mm
Each System Pack Contains:
1 plate as described above
3 cortical screws, 3.5mm x 12mm
3 cortical screws, 3.5mm x 14mm
3 cortical screws, 3.5mm x 16mm
3 cortical screws, 3.5mm x 18mm
1 cancellous screw, 4.0mm x 18mm
1 cancellous screw, 4.0mm x 20mm
1 cancellous screw, 4.0mm x 22mm
1 cancellous screw, 4.0mm x 24mm
1 combination screw driver and depth gauge (screw driver is 2.5mm hex)
2 K-wires, .035” diameter (used with trial template for fluoroscopy)
1 Drill Pin, .098” (2.5mm) diameter (to be used with trial template for drilling tine holes)
2 Drill Pegs, .098” (2.5mm) diameter (used to stabilize the trial template during drilling)
1 Trial Template/Drill Guide (specific to the implant configuration as described above)
X-ray template
Ancillary Equipment:
2.5mm drill bit for both cortical and cancellous screws (the drill pin provided in System Pack suffices)
Implant Dimensions:
It is difficult to detail this plate since it is anatomically designed in three dimensions. The dimensions stated above are to generally
describe the plates for ordering purposes. An x-ray template is provided with each System Pack so the proper size can be
determined pre-operatively.
8 SCS Volar Distal Radius Plate System Surgical Technique

INDICATIONS
> Comminuted extra-articular distal radius fractures*
> Comminuted dorsal marginal articular distal radius
fractures*
> Comminuted combined intra-articular, extra-articular
distal radius fractures*,**
> Failed original fracture fixation**
> Osteotomy and repair of distal radius malunion**
CONTRAINDICATIONS
> Bone, musculature, tendons, or adjacent soft tissue
comprised by disease, infection, or prior implantation
which cannot provide adequate support or fixation for
the prosthesis.
> Any active or suspected infection in or around the
thumb joint.
> Skeletal immaturity.
* Which cannot be satisfactorily stabilized by cast methodology
** Denotes need to consider the addition of bone graft, bone substitute and or supplemental fixation.
The SCS Volar Distal Radius Plate System was designed under exclusive license from the University of Minnesota, Department of Orthopaedics, and in conjunction with
Matthew D. Putnam, MD and David Gesensway, MD.
Proper surgical procedures and techniques are necessarily the responsibility of the medical professional. Each surgeon must evaluate the appropriateness of the surgical
technique used based on personal medical training and experience.
The contents of this document are protected from unauthorized reproduction or duplication under U.S. federal law. Permission to reproduce this document (for
educational/instructional use only) may be obtained by contacting SBI.
Prescription Information
The SCS (Sub-Chondral Support) Volar Distal Radius Plate System is intended for internal fixation of the fractured distal radius.
The SCS Volar Distal Radius Plate System is comprised of a Distal Radius Plate, a drill guide, cortical and cancellous screws and instruments necessary for plate fixation. To assure proper implantation of the
device, the use of the drill guide is required. The SCS Volar Distal Radius Plate and screws are single use only and should not be reused. The SCS Volar Distal Radius Plate is not designed as a permanent
implant.
Caution
U.S. Federal law restricts this device to sale by or on the order of a physician.
References
1. Putnam MD, Seitz WH Jr. Advances in Fracture Management in the Hand and Distal Radius. Hand Clinics,
Vol. 5, No. 3, August 1989.
2. Gesensway D, Putnam MD, Mente PL, and Lewis JL. Design and Biomechanics of a Plate for the Distal Radius. Journal of Hand Surgery, 20A: 1021-7, 1995.
3. Gesensway D, Putnam MD, Nelson EW, Mente PL, and Lewis JL. Biomechanics of Dorsal Plating of the Distal Radius. In: Vastamaki M, ed. 6th Congress of the International Federation of Societies for Surgery of
the Hand (IFSSH). Helsinki, Finland: Monduzzi Editore, 1995: 153-156.
4. Green DP. Carpal Dislocations and Instabilities. In: Green DP, ed. Operative Hand Surgery, 3rd ed. NY:
Churchill Livingstone, 1993: 875.
5. Weil C and Ruby LK. The Dorsal Approach to the Wrist Revisited. Journal Hand Surgery, 13A: 911-12, 1986.
6. Dellon AL. Partial Dorsal Wrist Denervation: Resection of the Distal Posterior Interosseus Nerve. Journal of Hand Surgery, 10A: 527-33, 1985.
7. Seitz WH Jr., Putnam MD, and Dick HM. Limited Open Surgical Approach for External Fixation of Distal Radius Fractures. Journal of Hand Surgery, 15A: 288-293, 1990.
9

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