Abstract
Introduction
Hardware prominence is one of the major established complications following volar plating of distal radius fractures. The purpose of this cadaveric study is to compare two conventional fluoroscopic imaging views (carpal shoot-through view [CSV] and dorsal horizon view [DHV]) with ultrasound (US) to establish the best intraoperative imaging modality for surgeons to use to identify penetration of screws through the dorsal cortex and/or into the distal radioulnar joint (DRUJ).
Materials and Methods
Twelve human cadaveric limbs were included in the study, instrumented with distal radius plates via a volar approach. The three imaging modalities, CSV, DHV, and US, were compared in terms of detecting prominent screws during volar plate fixation. Six surgeons with varying levels of expertise performed the evaluations. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and the area under the receiver operating characteristic curve were computed for every surgeon and imaging method.
Results
The CSV was found to be more sensitive compared with the DHV and US for detecting dorsal cortex penetration (99% vs. 94% vs. 56%, respectively). The DHV was found to be more sensitive in recognizing DRUJ screw penetration compared with CSV and US (89% vs. 78% vs. 11%, respectively). US evaluation demonstrated considerably lower diagnostic utility compared with CSV and DHV. Surgeon's ability to perform as well as confidence in evaluating for screw penetration was highest with the CSV view.
Conclusion
Fluoroscopic imaging, particularly the CSV, demonstrates greater diagnostic reliability compared with US for intraoperative detection of prominent screws following volar plate fixation of the distal radius. CSV was also identified as the most reproducible examination for all levels of expertise with minimal formal training required.
Level of Evidence
Therapeutic level V.
Keywords: screw, penetrance, distal radius, volar plating, cadaver
Hardware prominence is one of the major established complications following volar plating of distal radius fractures. In particular, dorsal prominence of screws is the leading risk factor associated with postsurgical extensor pollicis longus tendon rupture and has also been shown to cause ruptures of other extensor tendons. 1
In response to this, multiple intraoperative fluoroscopic views have been described to identify dorsal prominence of screws, including the dorsal horizon view (DHV) 2 and carpal shoot-through view (CSV). 3 Additionally, advanced modalities such as ultrasound (US) have been described with high degrees of accuracy in detecting postoperative dorsal screw prominence; however, its utility for intraoperative assessment performed by surgeons is uncertain. 4 5 6 7 Computer tomography (CT) scan is the most accurate imaging modality, but it is generally not available for intraoperative use, is associated with significantly higher degrees of radiation exposure, and can be costly to employ routinely. 8 Three-dimensional fluoroscopy has also been described, but again, this equipment may not be widely available to surgeons performing distal radius fixation. 8 Dorsal gross dissection would be the most reliable way for confirmation of prominent screws; however, this can be associated with surgical morbidity which is not warranted if there are other reliable alternatives.
In addition to dorsal screw prominence, there are also described complications of intra-articular penetration of screws into the radiocarpal and/or distal radioulnar joint (DRUJ). 1 Articular wrist views are generally considered accurate at detecting penetration into the radiocarpal joint. 9 The DRUJ, however, may be more difficult to assess due to its morphology. The concavity of the sigmoid notch may inadvertently conceal screw penetration that is not evident on traditional fluoroscopic imaging. If this is missed it may result in preventable pain, joint damage, and degenerative wear.
The purpose of this cadaveric study is to compare two conventional fluoroscopic imaging views (CSV and DHV) with US to establish the best imaging modality to be utilized intraoperatively to identify occult penetration of screws through the dorsal cortex and/or into the DRUJ.
Materials and Methods
The study was approved by the Institutional Review Board of the Ryan Paul and Jonathan Persitz hospital. Twelve upper extremity cadaveric specimens without gross evidence of forearm or wrist abnormalities were used in this study. The specimens were stored at −20 °C prior to the study and then thawed at room temperature for 24 hours before being utilized.
Cadaver Preparation
Preparation of the specimens was conducted by an independent upper extremity fellowship-trained surgeon. Volar plate fixation of each wrist was performed via a modified Henry approach to the distal radius using DePuy Synthes 2.4 mm Variable Angle LCP Distal Radius Plating System. Plate location was proximal to the watershed line, as recommended by the manufacturer, and the four distal most screws were placed in different preset configurations ( Fig. 1 ).
Fig. 1.
Distal radius locking plate is situated on the radius proximal to the watershed line.
The screw configurations included (1) no screw penetration, (2) dorsal screw penetration, and (3) screw penetration into the DRUJ. Length of the proud screws was 2 mm beyond the cortex. Appropriate screw length was determined by the depth gauge provided in the manufacturer's surgical instrumentation tray. Confirmation of screw prominence took place via gross dissection.
Observers
Six surgeons performing the evaluations were further divided into three groups based on training: (1) two experienced orthopaedic surgeons with specific fellowship training in upper extremity, (2) two experienced orthopaedic surgeons with nonupper extremity fellowship training, and (3) two surgeons in an ongoing upper extremity fellowship.
Cadaveric Evaluation
Screw configuration was determined by a computer-generated random sequence using R environment version 4.2.2 (Lucent Technologies, Inc., New Jersey, United States) for each cadaver. All surgeons were blinded to the configurations. Each surgeon evaluated a series of six cadavers (24 screws) for each of the three imaging modalities with a total of 144 screws evaluated per modality. Each of the six surgeons evaluated the 6 out of the 12 cadavers in a randomized order.
Imaging Modalities
One Philips BV300, mobile C-ARM fluoroscopy (Philips Healthcare, Andover, Massachusetts, United States) and three portable SonoSite M-Turbo US systems (Fujifilm Sonosite, Inc., Bothell, Washington, United States) were used to conduct this study.
To obtain the DHV, the operator placed the forearm in pronation and elbow flexion of ∼70° with maximal wrist flexion under an image intensifier (C-ARM; Fig. 2 ). 2 To obtain the CSV, the operator placed the forearm in supination and elbow flexion of ∼70°, with maximal wrist extension under the C-ARM ( Fig. 3 ). 3 US assessment was performed using a higher frequency linear probe (6–15 mHz), with the dorsal aspect of a pronated wrist resting on a table, and was examined in both the sagittal and transverse planes ( Fig. 4 ). Every surgeon received a comprehensive instructional manual outlining each technique a week prior and once more on the evaluation day. However, none had specific supplementary training in point-of-care ultrasonography.
Fig. 2.
Dorsal Tangential View. The operator is placing the forearm in supination and elbow flexion of ∼70° with maximal wrist flexion under an image intensifier (C-ARM).
Fig. 3.
Carpal shoot-through view. The operator is placing the forearm in supination and elbow flexion of ∼70°, with maximal wrist extension under the image intensifier (C-ARM).
Fig. 4.
Dorsal screw penetration is detected using an ultrasound scanner with the higher frequency linear (HFL) probe (6–15 mHz) placed in the sagittal plane.
Statistical Analysis
Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and the area under the receiver operating characteristic curve (ROC) were computed for every surgeon and imaging method. These calculations were based on a comparison with the established gold standard of dissection and direct visualization of the radiocarpal and radioulnar joints in each specimen. Moreover, each surgeon was asked to rank the modalities in order (from one to three) based on their ability to perform the technique and their own confidence in interpreting the images.
Results
This study included a total of 12 upper extremity cadavers with 48 screws in different configurations and cortex penetration. Each surgeon evaluated six cadavers (a total of 24 screws) with a sum of 144 screws for all surgeons combined for each modality.
Regarding screw penetration detection (either dorsal cortex or DRUJ), the CSV was found to be more sensitive with higher PPV and PLR than the DHV and US (sensitivity: 99% vs. 94% vs. 56%; PPV: 82% vs. 74% vs. 56%; PLR: 4.5 vs. 2.83 vs. 1.25, respectively; Fig. 5 ). Similar trends were also found in terms of specificity rates between modalities. The area under the ROC curve demonstrated a higher diagnostic reliability of the CSV compared with either the DHV or US (0.89 vs. 0.81 vs. 0.56, respectively; Fig. 6 ). Additional diagnostic parameters including PLRs and confidence interval for each diagnostic parameter are displayed in Table 1 .
Fig. 5.
Fluoroscopic carpal shoot-through view demonstrating no screw prominence.
Fig. 6.
Area under ROC curve across tested modalities. CSV, carpal shoot-through view; DHV, dorsal horizon view; ROC, receiver operating characteristic curve; US, ultrasound.
Table 1. Comparison of diagnostic parameters between modalities.
| Diagnostic parameter | Carpal shoot-through view | Dorsal horizon view | Ultrasound |
|---|---|---|---|
| Penetration detection (dorsal and DRUJ) | |||
| Sensitivity %(CI) | 99 (0.8–0.99) | 94 (0.73–0.99) | 56 (0.31–0.78) |
| Specificity %(CI) | 78 (0.52–0.94) | 67 (0.41–0.87) | 56 (0.31–0.78) |
| PPV %(CI) | 82 (0.6–0.95) | 74 (0.52–0.9) | 56 (0.31–0.78) |
| NPV %(CI) | 99 (0.77–0.99) | 92 (0.64–0.99) | 56 (0.31–0.78) |
| PLR (CI) | 4.5 (1.9–10.7) | 2.83 (1.46–5.5) | 1.25 (0.65–2.42) |
| Area under ROC | 0.89 | 0.81 | 0.56 |
| Dorsal penetration | |||
| Sensitivity %(CI) | 99 (0.66–0.99) | 99 (0.66–0.99) | 56 (0.21–0.86) |
| Specificity %(CI) | 78 (0.52–0.94) | 67 (0.41–0.87) | 56 (0.31–0.78) |
| PPV %(CI) | 69 (0.39–0.91) | 60 (0.32–0.84) | 39 (0.14–0.68) |
| NPV %(CI) | 99 (0.77–0.99) | 99 (0.74–0.99) | 71 (0.42–0.92) |
| PLR (CI) | 4.5 (1.9–10.68) | 3 (1.56–5.77) | 1.25 (0.57–2.73) |
| DRUJ penetration | |||
| Sensitivity %(CI) | 78 (0.4–0.97) | 89 (0.52–0.99) | 11 (0.001–0.48) |
| Specificity %(CI) | 78 (0.52–0.94) | 67 (0.41–0.87) | 56 (0.31–0.78) |
| PPV %(CI) | 64 (0.31–0.89) | 57 (0.29–0.82) | 11 (0.001–0.48) |
| NPV %(CI) | 88 (0.62–0.98) | 92 (0.64–0.99) | 56 (0.31–0.78) |
| PLR (CI) | 3.5 (1.38–8.89) | 2.67 (1.33–5.33) | 0.25 (0.04–1.7) |
Abbreviations: CI, confidence interval; DRUJ, distal radioulnar joint; NPV, negative predictive value; PLR, positive likelihood ratio; PPV, positive predictive value; ROC, receiver operating characteristic curve.
In a subanalysis comparing the diagnostic reliability of identifying the location of screw penetration (dorsal vs. DRUJ), the CSV and DHV were found to be equally sensitive when evaluating for dorsal cortex penetration and more sensitive than US (sensitivity: 99% vs. 99% vs. 56%; PPV: 69% vs. 60% vs. 39%). The DHV was found to be more sensitive in detecting DRUJ screw penetration, however, compared with either CSV or US (sensitivity: 89% vs. 78% vs. 11%, respectively; Fig. 7 ). The CSV remained more sensitive than either DHV or US in identifying the exact screw which was penetrating (sensitivity: 83% vs. 78% vs. 42%; Table 1 ).
Fig. 7.
Fluoroscopic dorsal horizon view demonstrating no screw prominence.
Stratifying the observers by level of training and experience, all groups had similar sensitivity employing CSV. The more experienced group had slightly higher sensitivity when employing DHV. US was found to be the least sensitive of the modalities tested for all groups ( Table 2 ).
Table 2. Comparison of diagnostic parameters between modalities based on surgeon's level of experience.
| Diagnostic parameter | Carpal shoot-through view | Dorsal horizon view | Ultrasound |
|---|---|---|---|
| Fellowship trained upper extremity surgeons | |||
| Sensitivity %(CI) | 99 (0.54–0.99) | 99 (0.54–0.99) | 50 (0.12–0.88) |
| Specificity %(CI) | 83 (0.36–0.99) | 83 (0.36–0.99) | 67 (0.22–0.96) |
| PPV %(CI) | 86 (0.42–0.99) | 0.86 (0.42–0.99) | 60 (0.15–0.95) |
| NPV %(CI) | 99 (0.48–0.99) | 99 (0.48–0.99) | 57 (0.18–0.9) |
| PLR (CI) | 6 (1–35.91) | 6 (1–35.91) | 1.5 (0.38–6) |
| Fellowship trained nonupper extremity orthopaedic surgeons | |||
| Sensitivity %(CI) | 99 (0.54–0.99) | 99 (0.54–0.99) | 50 (0.12–0.88) |
| Specificity %(CI) | 83 (0.36–0.99) | 83 (0.36–0.99) | 50 (0.12–0.88) |
| PPV %(CI) | 86 (0.42–0.99) | 86 (0.42–0.99) | 50 (0.12–0.88) |
| NPV %(CI) | 99 (0.48–0.99) | 99 (0.48–0.99) | 50 (0.12–0.88) |
| PLR (CI) | 6 (1–35.91) | 6 (1–35.91) | 1 (0.32–3.1) |
| Surgeons with ongoing upper extremity fellowship training | |||
| Sensitivity %(CI) | 99 (0.54–0.99) | 83 (0.36–0.99) | 67 (0.22–0.96) |
| Specificity %(CI) | 67 (0.22–0.96) | 33 (0.04–0.78) | 50 (0.12–0.88) |
| PPV %(CI) | 0.75 (0.35–0.97) | 56 (0.21–0.86) | 57 (0.18–0.9) |
| NPV %(CI) | 99 (0.4–0.99) | 67 (0.09–0.99) | 60 (0.15–0.95) |
| PLR (CI) | 3 (0.97–9.3) | 1.25 (0.64–2.44) | 1.33 (0.5–3.55) |
Abbreviations: CI, confidence interval; NPV, negative predictive value; PLR, positive likelihood ratio; PPV, positive predictive value.
Surgeon Confidence
All surgeons reported a similar pattern of their confidence levels in while employing each modality. All surgeons indicated that CSV was the easiest technique to perform, and they also felt the most confident in interpreting its results.
On the other hand, US was reported to be the most technically demanding modality with surgeons reporting less confidence in interpreting its results.
Discussion
This study demonstrated that the CSV is the most effective view for excluding dorsal cortex penetration, whereas the DHV is superior for detecting DRUJ penetration. Additionally, the CSV is noted for its high reproducibility across various expertise levels, requiring only minimal formal training.
Attritional rupture of extensor tendons following volar plate fixation of distal radius fractures is considered as a serious complication. The initial injury predisposes the extensor tendons to rupture via direct injury, fracture fragments, and hematoma. 10 Surgery further increases this risk when the dorsal cortex is penetrated by a screw. 11 When relying only on the depth gauge to determine proper screw length, Stoops et al found that around 9.1% of locking screws placed in were too long and protruded into soft tissues. 12 Dolce et al found similar percentage, as 9.4% of the screws evaluated in their study were found penetrating through the dorsal cortex after initial measurement and placement. 13 Obtaining reproducible intraoperative fluoroscopic views which adequately show the dorsal cortex of the distal radius can be challenging. Standard lateral views have been reported to be less accurate at detecting screw penetration due to the height of Lister's tubercle and the depth of the groove for the extensor pollicis longus, both of which can vary significantly between individuals. 14 15
There are many published fluoroscopic techniques for evaluation of dorsally penetrating screws following volar plating distal radius fractures. 2 12 16 On the contrary, evaluation of screw prominence into the DRUJ has only been described in one study wherein 10 orthopaedic surgeons were asked to review fluoroscopic images of synthetic distal radius sawbones models with an applied distal radius volar locking plate and screws. 17 To the best of our knowledge, the current study is the first cadaveric study evaluating both dorsal and DRUJ penetrating screws following volar plating of the distal radius.
There are many similarities between the various wrist views described in the literature. The DHV is also referred as the skyline view 16 or the dorsal tangential view 11 of the wrist, with subtle variations in the way they are performed. Skyline view comprises forearm supination and wrist flexion with the fluoroscope positioned vertically with the beam aimed along the longitudinal axis of the forearm, whereas the dorsal tangential view requires forearm pronation and wrist flexion with the fluoroscope positioned horizontally.
Ultrasonography is a safe method that has been described in the literature for the detection of screw penetration and the follow-up of complications such as attritional tendon rupture following screw penetration. 18 On the other hand, no studies so far have compared the sensitivity of US, DHV, and CSV in detecting dorsal or DRUJ screw penetration.
Optimal implementation of US for the detection of dorsal screw penetration has a definite learning curve. Watchmaker et al 19 found that US examination time required to detect occult penetration of screws after volar plate fixation of the distal radius, took only a few minutes for surgeons who were experienced in musculoskeletal ultrasonography but was longer for general trauma surgeons without US experience. In the current study, US evaluation had the lowest overall sensitivity in all categories, specifically in detecting DRUJ penetrating screws with rate of 11%. Moreover, US received the lowest operator confidence rank from all surgeons. This study suggests that this modality is not reliable in the hands of surgeons without specific training in point-of-care ultrasonography. In contrast, all surgeons irrespective of training background expressed the highest confidence when performing CSV, suggesting this view to be accessible to all surgeon groups with minimal formal training required.
Surgical experience in fixation and evaluation of hardware position has an important role in clinical outcome and complication rate. In a cadaveric study by Thomas et al, 20 hard-copy digital images of cadaveric distal radii with screws of different lengths penetrating the dorsal cortex were shown to experienced hand surgeons with >3 years of experience and surgeons with ongoing hand fellowship training. The experienced evaluators were able to detect incorrect screw positions with ∼88% accuracy at all locations (compared with 62% for inexperienced evaluators). In our current study, the detection rate of penetrating screws was similar between all surgeon groups using CSV, whereas higher sensitivity and specificity rates were observed in the more experienced group when employing DHV. US was shown to be the least sensitive across all surgeon groups irrespective of level of education.
There are some limitations to this study. We found that surgeon experience contributes to the accuracy in performing and interpreting the DHV and US. Sixty-six percent of the surgeons who participated in this study did not have previous experience with using the above views in clinical practice. To address this issue, we supplied all surgeons with an orientation package that included short literature review, pictures, and position descriptions 1 week before the study as well as on the day of the study. Despite this, we believe that the current study captures the expected range of hand and general orthopaedic surgeons with differing levels of experience, who surgically manage distal radius fractures. Another limitation is that radiographic evaluation took place in “laboratory conditions,” and all plates and screws were introduced to nonfractured radius bones. This may be different than traumatic condition, as dorsal comminution, displacement, and nonanatomic reductions may distort the anatomy of Lister's tubercle, the dorsal cortex, and the DRUJ.
Conclusion
The findings of the current study suggest that the CSV is the most sensitive view to “rule out” dorsal cortex penetration, while the DHV is best used to identify DRUJ penetration. The CSV represents the most reproducible examination for all levels of expertise with minimal formal training required. US evaluation had the lowest sensitivity and specificity in all categories, demonstrating that this modality is not recommended for routine intraoperative screw penetration assessment unless surgeons have specific training in point-of-care ultrasonography for this purpose.
Conflict of Interest None declared.
Ethical Approval
This study was approved by the local Institutional Review board.
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