328

COPYRIGHT © 2011 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Volar Locking Plate Implant Prominence

and Flexor Tendon Rupture
By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington,

and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts

Background: Flexor tendon injury is a recognized complication of volar plate fixation ot distal radial fractures. A sus-
pected contributing factor is implant prominence at the vi/atershed line, where the flexor tendons lie closest to the plate.
Methods: Two parallel series of patients who underwent volar locked plating of distal radial fractures from 2005 to 2008
and with at least six months of follow-up were retrospectively reviewed. Group 1 included seventy-three distal radial
fractureii that were treated by three orthopaedic hand surgeons with use of a single plate design at one institution, and
Group 2 included ninety-five distal radial fractures that were treated by four orthopaedic hand surgeons with use of a
different piate design at another institution. On the postoperative lateral radiographs, a line was drawn tangential to the
mostvolarextent of the volar rim, parallel to the volar cortical bone of the radial shaft. Plates that did not extend volar to
this line were recorded as Grade 0. Plates volar to the line, but proximal to the volar rim, were recorded as Grade 1. Plates
directly on or distal to the volar rim were recorded as Grade 2.

Results: In Group 1, the average duration of follow-up was thirteen months (range, six to forty-nine months). Three cases
of flexor tendon rupture were identified among seventy-three plated radii (prevalence, 4%). Grade-2 plate prominence was
found in two of the three cases with rupture and in forty-six cases (63%) overall. In Group 2, the average duration of follow-
up was lifteen months (range, six to fifty-six months). There were no cases of flexor tendon rupture and no plates with
Grade-2 prominence among ninety-five plated radii.

Conclusions: Flexor tendon rupture after volar plating of the distal part of the radius is an infrequent but serious
complication. The plate used in Group 1 is prominent at the watershed line of the distal part of the radius, which may
increase the risk of tendon injury. We found no ruptures in Group 2, perhaps as a result of the lower profile of the plate.
Further studies are needed before recommending one plate over another. Regardless of plate selection, surgeons should
avoid impiant prominence in this area.
Level of Evidence: Therapeutic Levei III. See Instructions to Authors for a complete description of levels of evidence.

V
olar locking plate fixation of distal radial fractures has
become an increasingly common technique, and recent
randomized studies have supported its use'". Flexor
tendon injury is a recognized complication of this technique,
and the prevalence of rupture has been reported to be as high as
12%'. Whue steroid use was implicated in one small series\ a
major contributing factor has been reported to be implant prom-
inence at the watershed line^" (Fig. 1), where the flexor tendons
lie closest to the plate and bone. Several reports on flexor
tendon rupture have involved nonlocking T-plates' ' and older-
generation locking plates""" as well as secondary plate promi-
nence resulting from loss of reduction. Current-generation
locking platis also have caused tendon injury, particularly with
improper plate position" '^ prominent screw heads'' ' \ loss of
reduction", or inadvertent retention of drill guides'.
Flexor tendon rupture resulting from a properly seated
and well-fixed current-generation plate has not been explored.
The pLirpose of the present study is to describe our experience
with flexor tendon ruptures in two large series of distal radial
fractures, with a different single plate design used in each series
and with specific attention being paid to implant prominence
in relation to the watershed line.
Materials and Methods
I n Croup 1, all cases of distal radial fractures that were treated
with volar locked plating by three fellowship-trained or-

Disclosure: Th= authors did not receive any outside funding or grants in support of their research for or preparation ofthis work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Sur» Am. 2011;93;328-35 • doi;10.2106/JBJSJ.00193

 329
T H E JOURNAL OF BONE & JOINT SURGERY • JBIS.ORG VOLAR LOCKING PLATE IMPLANT PROMINENCE
VOLUME 93-A • NUMBER 4 • FEBRUARY 16, 2011 AND FLEXOR T E N D O N RUPTURE

Anterior and lateral photographs of a distal radial model, demonstrating the watershed iine (arrowheads).

thopaedic hand surgeons at one institution with use ofthe Acu-
Loc plate (Acumed, Hillsboro, Oregon) during a four-year
period (2005 to 2008) were identified with use of billing data
and were retrospectively reviewed. In Group 2, all cases of distal
radial fractures that were treated with volar locked plating by
four fellowship-trained orthopaedic hand surgeons at a dif-
ferent institution with use ofthe Hand Innovations DVR plate
(DePuy, Warsaw, Indiana) during the same four-year period
were retrospectively reviewed. The plates are shown at their
location of best fit on a radial model in Figures 2 and 3.

Fig. 2 Fig. 3
Fig. 2 Photograph of the Acu-Loc standard ieft volar distai radial plate at the position of best fit on a model.
Fig. 3 Photograph of the DVR standard left volar distal radial plate at the position of best fit on a model.
 330
T H E JOURNAL OF BONE & JOINT SURGERY • JBIS.ORG VOLAR LOCKING PLATE IMPLANT PROMINENCE
VOLUME 93-A • NUMBER 4 • FEBRUARY 16, 2011 AND FLEXOR TENDON RUPTURE

TABLE I Characteristics of Patients and injuries

Group 1 (Acu-Loc) Group 2 (DVR) P Value

No. of patients 72 93
No. of plated distal radii 73 95
Age* (yr) 60 (27 to 87) 55 (19 to 89) 0.04t
Ferr:ale sex (no. of patients) 57 (79%) 78 (84%) 0.69
Left side (no. of radii) 41 (56%) 48 (51%) 0.53
Open fracture (no. of radii) 2 (3%) 6 (6%) 0.47
AO type (no. of radii)
A 22 (30%) 19 (20%) 0.15
B 5 (7%) 14 (15%) 0.09
C 46 (63%) 62 (65%) 0.87

*The values are given as the mean. vi/ith the range in parentheses. tSignificant.

Patients with fewer than six months of follow-up were
excluded. Four other patients were excluded because of early
plate removal because of presumed metal allergy (one patient;
Group 1), n;vision fixation (one patient; Group 1), distal ra-
dioulnar joint impingement (one patient; Group 1), and deep
infection (one patient; Group 2). The final cohorts included
seventy-three plated distal radii in seventy-two patients in
Group 1 and ninety-five plated distal radii in ninety-three
patients in Group 2. There was a small but significant difference
between the groups with regard to average age, but there were
no significant differences with regard to sex, laterality, open
injury, or AO fracture type'" (Table I).
All procedures were performed with use of fluoroscopy.
Plate size and position were determined on the basis of the
anatomic fit ofthe plate, the need to secure fracture fragments,
and the medial-lateral boundaries ofthe bone. No specific at-
tempts were made to minimize volar prominence. The pro-
nator quadratus and the intermediate fibrous zone' (the tissue
between the pronator and wrist capsular attachments) were
routinely repaired over the plate, although the quality and
durability of the repair could not be retrospectively asses.sed.
There were no significant differences between the groups with
regard to additional procedures performed at the time of the
index operation, except that distal ulnar fixation was more
prevalent in Group 2 (Table II).
All radiographs were analyzed for evidence of loss of
reduction or implant prominence. The best available postop-
erative lateral radiograph was selected on the basis of the nar-
rowest projected profile of the plate. This view was confirmed
to be an appropriate lateral view by confirming projection of
the pisiform over the distal part ofthe scaphoid. On this view, a
"critical line" was drawn tangential to the most volar extent of

TABLE li Additionai Procedures at index Operation

Group 1 (Acu-Loc) Group 2 (DVR) P Value

No. of patients 72 93
No. of plated distal radii 73 95
Carpal tunnel release (no. of procedures) 3 11 0.10
Allo¡;raft bone (no. of procedures) 2 0 0.19
External fixation (no. of procedures) 2 1 0.58
Rad al styloid pinning (no. of procedures) 2 4 0.70
Scapholunate ligament repair fno. of procedures) 2 3 1.0
v-l

Ulneir fixation (no. of procedures) 12 0.02*

Distal radioulnar joint pinning (no. of procedures) 2 3 1.0
Scaphoid fixation (no. of procedures) 1 3 0.63
Phalanx fixation (no. of procedures) 0 1 1.0

•Significant.

T H E JOURNAL OF BONE SÍ JOINI" SURGERY • IBIS.ORG
VOLUME 93-A • NUMBER 4 • FEBRUARY 16,
Radiograph illustrating the determination of implant prom-
inence with use of a line (the critical line) through the most
volar extent ofthe volar rim (red line), drawn parallel to the
volar cortical bone of the radial shaft (green line).
the volar rim, parallel to the volar cortical bone of the radial
shaft (Fig. 4). Plates that did not extend volar to the critical line
were recorded as Grade 0. Plates volar to the line but proximal
to the rim (such that the recess ofthe pronator fossa could be
clearly visualized) were recorded as Grade 1. Plates directly on
or beyond the rim were recorded as Grade 2. Medial or lateral
plate position was judged by noting any plate prominence
beyond the radial or ulnar margins of the bone on the best
available postoperative posteroanterior radiograph, which was
selected on the basis ofthe clearest view ofthe distal radioulnar
joint. Intraoperative tluoroscopic images were not routinely
available for comparison.
Continuous data were analyzed by means ofthe unpaired
t test with il two-tailed p value. Categorical data were analyzed
by means of the Fisher exact test with a two-tailed p value.
Approval from the institutional review board at each institu-
tion was obtained.
Source of Funding
No external funding source was used for this study.
Resuits
Group 1
T he average duration of follow-up for Group 1 was thirteen
months (range, six to forty-nine months). Three cases of
flexor tendon rupture (prevalence, 4%) were identified among
331
VOLAR LOCKING PLATE IMPLANT PROMINENCE
2011 AND FLEXOR T E N D O N RUPTURE
seventy-three plated radii at an average of twenty months
(four, thirteen, and forty-four months) postoperatively. The
average age of these three patients was seventy-nine years
(range, seventy-one to eighty-five years), and two of the pa-
tients were female. One of the three fi'actures was classified as
AO type A, one was classified as type B, and one was classified
as type C. The tendon ruptures involved the flexor pollicis
longus (one patient), the flexor digitorum profundus to the
index finger (one patient), and both the flexor digitorum
protundus and the flexor digitorum superficialis to the index
finger (one patient). Two ofthe three cases of tendon rupture
occurred in patients with Grade-2 volar prominence, whereas
the third occurred in a patient with (¡rade-1 volar prominence
as well as lateral prominence ofthe distal end ofthe plate. All
three patients underwent plate removal. Two patients had
tendon reconstruction resulting in satisfactory return of
function, whereas the third elected nonopeiative manage-
ment. At the time of reoperation, the ruptured tendons were
noted to have attritional changes and synovitis and the plates
were visually confirmed to be prominent; in one case, the plate
was not covered by the pronator distally. In two cases of rup-
ture, slightly prominent screw heads were also noted on radio-
graphs, although they were not mentioned in the reoperation
reports.
In addition to the three patients with tendon rupture,
two patients with type-A fractures and Grade-2 volar promi-
nence had plate removal because of tendon irritation. At the
time of reoperation, the involved tendons had attritional
changes and synovitis, and the plates were visually confirmed to
be prominent. No screw heads were prominent on radiographs
or mentioned in the reoperation reports. None of these five
patients (three with rupture, two with irritation) had additional
procedures or ancillary fixation at the time of the index
operation.
Review of radiographs showing the seventy-three plates
in Group 1 demonstrated Grade-0 prominence in fourteen
cases (19%), Grade-1 prominence in thirteen (18%), and
Grade-2 prominence in forty-six (63%). The typical appear-
ances ofthe different types of prominence are shown in Figure
5. The appearance in the five cases with flexor tendon com-
plications were not qualitatively different, other than the two
with slightly prominent screw heads, noted above, which did
not affect the grade of prominence. Medial or lateral plate
prominence was found in fourteen cases (19%). The overhang
involved the distal end ofthe plate in four cases, the proximal
end in nine, and both ends in one. One plate with lateral
prominence at the distal end was removed because of tendon
rupture, although volar prominence was found to be more
pertinent to the tendon injury. In no case was implant prom-
inence attributed to a loss of reduction or a change in implant
position during the course of postoperative radiographie
follow-up.
Subsequent operations, other than as listed above for
flexor tendon complications, included carpal tunnel release
in ten patients, extensor indicis proprius to extensor pollicis
longus transfer in three (due to spontaneous rupture, not
 332
THE JOURNAL OF BONE & JOINT SURGERY • JBJS.ORG VOLAR LOCKING PLATE JMPLANT PROMINENCE
VOLUME 93-A • NUMBER 4 • FEBRUARY 16, 2011 AND FLEXOR TENDON RUPTURE

Lateral radiog;raphs of a distal radial fracture treated with an Acu-Loc plate demonstrating (A) Grade-0 prominence (dorsal to critical line), (B) Grade-1
prominence (volar to critical line, proximal to volar rim), and (C) Grade-2 prominence (volar to critical line, at volar rim).

related to the implant), removal of ulnar implants in one, and
removal of intra-articular screws in one.
Group 2
The average duration of follow-up for Group 2 was fifteen
months (range, six to fifty-six months). No flexor tendon
ruptures were identified among ninety-five plated radii. One
plate was removed at five months postoperatively because of
irritation of the flexor pollicis longus. In that case, the patient
had Grade-J prominence radiographically, which was con-
firmed on inspection during reoperation. No screw heads were
prominent.

Lateral radiographs of a distal radial fracture treated with a DVR plate, demonstrating (A) GradeO
prominence (dorsai to criti cal line)and(B) Grade-1 prominence (volarto critical line, proximal to volar rim).

T H E JOURNAL OF BONE & JOINT SURGERY • IBIS.ORG
VOLUME 93-A • NUMBER 4 • FEBRUARY 16,
TABLE III Results
No. of patients
No. of plated distal radii
Duration of follow-up* fmo}
No. of prominent plates, volar
Grade 0
Grade 1
Grade 2
No. of prominent plates, medial-lateral
No. of cases with flexor tendon rupture(s)
No. of cases of flexor tendon irritation leading to removal of implant
*The values are given as the mean, with the range in parentheses. tSignificant.
Review of radiographs showing the ninety-five plates in
Croup 2 demonstrated Crade-0 prominence in forty-seven
cases (49%), Crade-1 prominence in forty-eight (51%), and
Crade-2 prominence in none. The typical appearances are
shown in Figure 6. Medial or lateral plate prominence was
found in fifteen cases (16%). The overhang involved the distal
end of the plate in seven cases, and the proximal end in the
other eight. Five of the fifteen cases of medial-lateral promi-
nence led to subsequent plate removal, although none were
associated with preoperative or intraoperative findings of plate-
related tendon irritation. In no case was implant prominence
attributed to loss of reduction or change in implant position
during the course of postoperative radiographie follow-up.
Subsequent operations included carpal tunnel release in
five patients and ulnar implant removal, ulnar styloid excision,
forearm fasciotomy closure, wrist fusion, first dorsal com-
partment tenolysis, iliac crest bone graft for delayed union, and
revision plating with iliac crest bone graft for nonunion in one
patient each.
Comparison
The comparison of results is shown in Table III. Croup 1 had
significantly more plates with Crade-2 volar prominence and
nearly significantly more flexor tendon ruptures. Medial-lateral
prominence and tendon irritation leading to removal of im-
plants were not significantly dift^erent betv^een the groups.
Discussion
hile flexor tendon injuries have been reported in asso-
W ciation with a variety of plates and with other contrib-
uting factors such as loss of reduction and poor plate position,
the final common pathway appears to involve prominent im-
plants at the watershed line of the distal part of the radius. This
line has been described as "a transverse ridge located within
2 mm of the joint line on the ulnar side of the radius, and
[within] 10-15 mm.. .on the radial side...'"''. As the most
prominent part of the volar surface of the distal part of the
333
VOLAR LOCKING PI.ATI; IMPLANT PKOMINKNCE
2011 AND FLEXOR TENDON RUPTURE
Group 1 (Acu-Loc) Group 2 (DVR) P Value
72 93
73 95
13.0 (6 to 49) 15.1 (6 to 56) 0.22
14 (19%) 47 (49%) <0.0001t
13 (18%) 48 (51%) <0.0001t
46 (63%) 0(0%) <0.0001t
14 (19%) 15 (16%) 0.68
3 (4%) 0 (0%) 0.08
2 (3%) 1(1%) 0.58
radius, the watershed line is anatomically closest to the flexor
tendons.
In the present study of the Acumed Acu-Loc and the
DePuy Hand Innovations DVR plates, all three cases of tendon
rupture were associated with the Acu-Loc plate. The implants
in these cases projected volar to the volar rim as the result of an
intentional design feature of this plate. The product literature
for this implant emphasizes the unique distal extent of the
plate, stating that the plate is "designed to be placed more distal
than many other volar plates...'"', which brings the plate
closer to the rim. This distal design characteristic was con-
firmed in a cadaver study'", which demonstrated that the Acu-
Loc plate "fit best at the watershed line, which pushes the
theoretical limit set by the surrounding soft tissues." A partic-
ular area of concern is at the radial styloid, where the watershed
line is more proximal (Fig. 1 ) but where theflangeof the plate
extends distally, over and beyond the line (Fig. 2). This ex-
tension of the plate is also noted in the product literature,
stating that "the plate surface is angled upward to accommo-
date and support the radial styloid.""
Casaletto et al.'*, in a recent clinical study involving 201
procedures performed with use of the same Acu-Loc plate,
reported five cases of flexor poUicis longus rupture (2.5%),
which parallels the findings of our series. The authors identified
plate position as the major factor, but they characterized this
positioning as "technical error" in placement by the surgeon.
In particular, they stated that they did not analyze the cases
without rupture to determine whether prominence might be
related to plate design rather than the result of surgeon error.
In the present study, we evaluated all cases with and without
rupture and found that prominence is indeed typical. Future
versions of this plate should address this tactor.
In contrast, in the same report, Casaletto et al.' found no
ruptures in association with forty procedures performed with
use of the DVR plate. Another clinical series of eighty-seven
patients involving the DVR similarly demonstrated no tendon
ruptures'\ The DVR plate, among others, is specifically de-
 334
T H E JOURNAL OF BONE & JOINT SURGERY • JBJS.ORG
VOLUME 93-A -NUMBER 4 • FEBRUARY 16, 2011
signed to have a low distal profile' and is diminutive at the
radial styloid rather than prominent (Fig. 3). This was con-
firmed in the previously mentioned cadaver study'", which
demonstrated that the distal edge sits between 1.25 and 1.45 mm
proximal to the watershed line. The DVR achieves distal fixa-
tion with screws angled distally, which may obviate the need
to position the plate itself distally. Previous studies' '' have
demonstrated that this plate is effective for securing fractures
overall, although far distal fractures have not been analyzed
separately.
To our knowledge, the only published reports of tendon
rupture asscciated with the DVR plate have involved volar
malposition"". Interestingly, one of those reports" also im-
plicated volar malposition in a tendon rupture from an Acu-
Loc plate, which we believe was design-related. The finding of a
single case of flexor pollicis longus irritation resulting in im-
plant removil in our DVR cohort suggests that this problem
may occur e\'en with a low-profile implant, but with a possibly
lower frequency. While both plates in our study demonstrated
the potential to be placed without prominence, the contour of
the DVR appears to be more conducive to optimal placement
than the contour of the Acu-Loc, again consistent with ca-
daveric data'\ We also noted that even when the Acu-Loc plate
appears to have Grade-0 prominence (Fig. 5) and the volar-
ulnar rim appears to be clear of the implant, the plate may still
be prominent at the radial styloid, which is more difficLilt to
visualize.
Direct comparison of tendon rupture rates among plates
is difficult because the duration of follow-up is often variable
and there may be a wide range of time before rupture occurs. In
our series, rupture occurred as late as forty-four months, and
other reports have described rupture occurring as late as six
years . As the duration of follow-up in our series was relatively
short, the true prevalence of flexor tendon injuries may be
higher. Furthermore, patients may be seen for follow-up else-
where, or not at all, regarding tendon-related complications.
Nevertheless, as the duration of follow-up was not significantly
different between the groups, this loss to follow-up may have
affected both groups equally. There was also a trend toward
somewhat longer follow-up in the DVR group, which would
favor the detection of more complications in that group. At the
very least, w(.' can state that the DVR had fewer flexor tendon
complicatiors within the follow-up period of our study.
Other limitations of the present study include the ret-
rospective design and the inability to standardize and evaluate
repair of the pronator quadratus. Little is known about the
quality and durability of pronator repair after this procedure,
which is likely quite variable and perhaps is also affected by
References
1. Rozental TD, lîlazar PE, Franko 01, Chaci<o AT, Earp BE, Day CS. Functional
outcomes for uni.table distal radial fractures treated with open reduction and in-
ternal fixation or closed reduction and percutaneous fixation. A prospective ran-
domized trial. J Bone Joint Surg Am. 2009;91:1837-46.
2. Wei DH. Raizman NM, Bottino CJ, Jobin CM, Strauch RJ. Rosenwasser MP.
Unstable distal radial fractures treated with external fixation, a radial column
VOLAR LOCKING PLATE IMPLANT PROMINENCE
AND FLEXOR TENDON RUPTURF,
plate prominence. With regard to our study size, larger num-
bers are likely necessary to identify any risk factors that may
exist among the cases with complications. In the Acu-Loc
group, the average age was higher among patients with rupture
than among those without; however, fracture type, additional
procedures, and ancillary fixation did not appear to correlate
with tendon complications, nor was any steroid use found
among the patients' regular medications. Finally, other factors
such as metallurgy and screw head prominence and design,
including head shape, driver mechanism, and locking mecha-
nism and performance, also may warrant investigation.
The technique of volar plate fixation for distal radial
fractures can be complex. Recent studies have shown the im-
portance of multiple obliquefluoroscopicviews intraoperatively
in order to avoid intra-articular screw penetration and dorsal
screw tip prominence'" '. Flexor tendon rupture is another
complication that is infrequent yet serious and may potentially
be avoided with attention to the fluoroscopic findings. Our
study suggests that plate designs should minimize prominence
at the watershed line, although further studies are needed
before recommending one plate over another. Regardless of
plate selection, however, it is incumbent on the surgeon to take
steps to avoid improper plate position, loss of reduction, and
screw head prominence. Direct visualization and palpation of
the plate may be helpful. As this fracture fixation technique
becomes more widespread, we further recommend that pa-
tients and surgeons remain vigilant for symptoms of tendon
irritation indefinitely after surgery, particularly when implant
prominence is recognized, and consider plate removal if
indicated. •
Maximillian Soong, MD
LaJiey CJinic, 41 Mall Road,
Burlington, MA 01805.
E-mail address; nicsoong@gmail.com
Brandon E. Earp, MD
Albert Leung, BS
Philip Blazar, MD
Department of Orthopaedic Surgery,
Brigham and Women's Hospital,
75 Francis Street, Boston, MA 02115
Gavin Bishop, MD
Boston University Orthopaedic Surgery Residency,
715 Albany Street, DOB-808, Boston,
MA 02118
plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am.
2009:91:1568-77.
3. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a
volar loci<ing screw plate system. Int Orthop. 2003:27:1-6.
4. Beil JS, Wolistein R, Citron ND. Rupture of flexor poiiicis iongus tendon: a com-
plication of voiar plating of the distal radius. J Bone Joint Surg Br. 1998:80:225-6.
 335
T H E JOURNAL OF B O N E & J O I N T SURGERY • IBIS.ORG
V O L U M E 9.3-A • N U M B E R 4 • FEBRUARY 16, 2011
5. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable
distal radius fractures. Clin Orthop Relat Res. 2006:445:58-67.
6. Bergiund LM. Messer TM. Compiications of volar piate fixation for managing
distal radius fractures. J Am Acad Orthop Surg. 2009:17:369-77.
7. Koo SC. Ho ST. Delayed rupture of flexor poillcis longus tendon after volar plating
ofthe distal radius. i-(and Surg. 2006:11:67-70.
8. Duncan SF. Weiland AJ. Delayed rupture ofthe flexor pollicis longus tendon after
routine volar placement of a T-plate on the distal radius. Am J Orthop (Belle Mead NJ).
2007:36:669-70.
9. Nunley JA, Rowan PR. Delayed rupture of the flexor pollicis longus tendon after
inappropriate placement of the pi plate on the volar surface of the distal radius.
J Hand Surg Am. 1999:24:1279-80.
10. Klug RA. Press CM. Gonzalez MH. Rupture of the flexor pollicis longus tendon
after volar fixed-angle plating of a distal radius fracture: a case report. J Hand Surg
Am. 2007:32:984-8.
11. Cross AW. Schmidt CC. Flexor tendon injuries follovi/ing locked volar plating of
distal radius fractures. J Hand Surg Am. 2008:33:164-7.
12. Casaletto JA. Machin D. Leung R. Brovi^n DJ. Flexor pollicis longus tendon rup-
tures after palmar plate fixation of fractures of the distal radius. J Hand Surg Eur Vol.
2009:34:471-4.
13. Adham MN. Porembski M. Adham C. Flexor tendon problems after volar plate
fixation of distal radius fractures. Hand (N Y). 2009:4:406-9.
VOLAR LOCKING PLATE IMPLANT P R O M I N E N C E
AND FLEXOR T E N D O N RUPTURE
14. Arora R. Lutz M, Hennerbichler A. Krappinger D. Espen D, Gabi M. Complications
following internal fixation of unstable distal radius fracture with a palmar locking-
plate. J Orthop Trauma. 2007:21:316-22.
15. Bhattacharyya T, Wadgaonkar AD. Inadvertent retention of angled drill guides
after volar locking plate fixation of distal radial fractures. A report of three cases.
J Bone Joint Surg Am. 2008:90:401-3.
16. Müller ME. Nazarian S, Koch P, Schatzker J. The comprehensive classification
of fractures of long bones. New York: Springer: 1990.
17. Acumed Acu Loc technique guide. Document #HNW00-01-C. 2009 Jul. p 3.
18. Buzzell JE, Weikert DR, Watson JT. Lee DH. Precontoured fixed-angle volar distaL
radius plates: a comparison of anatomic fit. J Hand Surg Am. 2008:33:1144-52.
19. Chung KC, Watt AJ, Kotsis SV, Margaliot Z. Haase SC. Kim HM. Treatment of
unstable distal radial fractures with the volar locking plating system. J Bone Joint
Surg Am. 2006:88:2687-94.
20. Soong M. Got C. Katarincic J, Akelman E. Ruoroscopic evaluation of intra-
articular screw placement duhng locked volar plating of the distal radius: a cadaveric
study. J Hand Surg Am. 2008:33:172a3.
2 1 . Maschke SD, Evans PJ. Schub D, Drake R. Lawton JN. Radiographic evaluation
of dorsal screw penetration after volar fixed-angle plating of the distal radius: a
cadaveric study. Hand (N V). 2007:2:144-50.
Copyright of Journal of Bone & Joint Surgery, American Volume is the property of Journal of Bone & Joint
Surgery, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email articles for
individual use.