Arch Hand Microsurg AHM Archives of Hand and Microsurgery 2586-3290 2586-3533 Korean Society for Surgery of the Hand; Korean Society for Microsurgery 10.12790/ahm.2019.24.2.112 Hand Comparison of Skyline View and Intraoperative Computed Tomography for Detecting Protruded Screws during Volar Plating of Distal Radius Fractures Lim Kyeong Hoon Kang Hong Je Department of Orthopedic Surgery, Wonkwang University School of Medicine, Iksan, Korea. Corresponding author: Hong Je Kang. Department of Orthopedic Surgery, Wonkwang University Hospital, 895 Muwang-ro, Iksan 54538, Korea. TEL: +82-63-859-1360, FAX: +82-63-852-9329, kanghongje@hanmail.net 06 2019 30 05 2019 24 2 112 119 06 11 2018 15 02 2019 19 02 2019 Copyright © 2019 by Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. 2019 Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose

The aim of our study was to compare and analyze intraoperative fluoroscopy (skyline view) and mobile cone-beam computed tomography (CBCT) for detecting protruded screws in volar locked plating used for distal radius fractures.

 Methods

We carried out a prospective analysis of 35 patients who had undergone both intraoperative fluoroscopy and mobile CBCT. The patients had all undergone volar locking plate fixation for a distal radial fracture at our institution between January and May 2017. Skyline view and mobile CBCT were carried out and protruded screws were replaced. Screw tip cortex distance (STCD) was measured using skyline view and mobile CBCT and compared with each area of the distal radius.

 Results

Three screws were found to be protruding after skyline view, and further seven screws were found to be protruding after computed tomography (CT) scan. The mean STCD for each compartment was 3.8±0.6 mm, 3.5±1.8 mm, 2.2±1.3 mm, 3.7±1.6 mm, and 3.9±1.4 mm in the skyline view, respectively, and 3.5±0.7 mm, 0.8±1.6 mm, 0.9±1.1 mm, 2.1±1.6 mm, and 3.7±1.9 mm in the CT scan, respectively (p<0.05). The mean STCD of all screws was 1.2 mm longer in the skyline view than in the CT scan.

 Conclusion

The skyline view showed approximately 1-2 mm difference compared to CBCT; therefore, it would be better to insert the screw 2 mm shorter than seen in the skyline view.

 Distal radius fractures Skyline view Cone-beam computed tomography Wonkwang University https://doi.org/10.13039/501100002569 ACKNOWLEDGEMENTS

This paper was supported by Wonkwang University in 2019.

The authors have nothing to disclose.

 Downing ND Karantana A A revolution in the management of fractures of the distal radius? J Bone Joint Surg Br 2008 90 1271 1275 Al-Rashid M Theivendran K Craigen MA Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures J Bone Joint Surg Br 2006 88 1610 1612 Arora R Lutz M Hennerbichler A Krappinger D Espen D Gabl M Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate J Orthop Trauma 2007 21 316 322 Benson EC DeCarvalho A Mikola EA Veitch JM Moneim MS Two potential causes of EPL rupture after distal radius volar plate fixation Clin Orthop Relat Res 2006 451 218 222 Kang JW Park JW Complications of distal radius fracture J Korean Orthop Assoc 2013 48 165 174 Tarallo L Mugnai R Zambianchi F Adani R Catani F Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events J Orthop Trauma 2013 27 740 745 Rhee PC Dennison DG Kakar S Avoiding and treating perioperative complications of distal radius fractures Hand Clin 2012 28 185 198 Ozer K Wolf JM Watkins B Hak DJ Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius J Hand Surg Am 2012 37 963 967 Ozer K Toker S Dorsal tangential view of the wrist to detect screw penetration to the dorsal cortex of the distal radius after volar fixed-angle plating Hand (NY) 2011 6 190 193 Granville-Chapman J Hacker AG Keightley A Sarkhel T Monk J Gupsta R The distal radius skyline view: validation of a new technique for determining dorsal screw penetration in locked volar plating of the distal radius Orthop Proc 2012 94 (SUPP_XXXII) 16 Riddick AP Hickey B White SP Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation J Hand Surg Eur Vol 2012 37 407 411 Ganesh D Service B Zirgibel B Koval K The detection of prominent hardware in volar locked plating of distal radius fractures: intraoperative fluoroscopy versus computed tomography J Orthop Trauma 2016 30 618 621 Vaiss L Ichihara S Hendriks S Taleb C Liverneaux P Facca S The utility of the fluoroscopic skyline view during volar locking plate fixation of distal radius fractures J Wrist Surg 2014 3 245 249 McKay SD MacDermid JC Roth JH Richards RS Assessment of complications of distal radius fractures and development of a complication checklist J Hand Surg Am 2001 26 916 922 Wall LB Brodt MD Silva MJ Boyer MI Calfee RP The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates J Hand Surg Am 2012 37 446 453 Thomas AD Greenberg JA Use of fluoroscopy in determining screw overshoot in the dorsal distal radius: a cadaveric study J Hand Surg Am 2009 34 258 261 Hill BW Shakir I Cannada LK Dorsal screw penetration with the use of volar plating of distal radius fractures: how can you best detect? J Orthop Trauma 2015 29 e408 e413 Brunner A Siebert C Stieger C Kastius A Link BC Babst R The dorsal tangential X-ray view to determine dorsal screw penetration during volar plating of distal radius fractures J Hand Surg Am 2015 40 27 33 (A) Skyline view of the distal radius. (B) Skyline view was taken on the C-arm with wrist flexion of 75°. Mobile cone-beam computed tomography (CBCT) (Phion™; NanoFocusRay Co., Ltd.) available in the operating room. Mobile CBCT has its own shielding structure so that it prevents radiation exposure to other part of the body. The distance between the tip of the screw tip and dorsal cortex (STCD) was measured and compared for each compartment. (A) Skyline view. (B) Mobile cone-beam computed tomography. Up down arrows: STCD. (A) Extensor compartment of radial dorsal cortex. (B) The dorsal cortex of radius was divided into five areas (1, 2, 3, 4, 5) and mean screw tip cortex distance was compared for each compartment. Comparison of screw tip cortex distance measured by skyline view and mobile cone-beam computed tomography (CBCT). The screw in the circle is not protruded in skyline view, whereas it is protruded in the mobile CBCT. (A) Skyline view. (B) Mobile CBCT. The number of screws replaced and detected protrusion
Area Total
1 2 3 4 5
No. of screws inserted 35 35 35 35 35 175
No. of protruded screws detected with skyline view 0 1 1 1 0 3
No. of protruded screws detected with CBCT 1 2 2 2 0 7

CBCT: cone-beam computed tomography.

 STCD measured by skyline view and mobile CBCT (mm)
Area Total
1 2 3 4 5
Skyline view 3.8±0.6 3.5±1.8 2.2±1.3 3.7±1.6 3.9±1.4 3.4±1.5
CBCT 3.5±0.7 0.8±1.6 0.9±1.1 2.1±1.6 3.7±1.9 2.2±1.8
Difference 0.3±0.7 2.7±0.2 1.3±0.2 1.6±0.4 0.3±1.2 1.2±0.7
p-value 0.007 <0.001 <0.001 <0.001 0.193 <0.001

Values are presented as mean±standard deviation.

STCD: screw tip cortex distance, CBCT: cone-beam computed tomography.