Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate.

PURPOSE: Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing. METHODS: Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement. RESULTS: No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group. CONCLUSION: There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group. CLINICAL SIGNIFICANCE: When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement.

Do Patients Want to Be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

PURPOSE: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome. METHODS: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated. RESULTS: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared. CONCLUSIONS: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions. CLINICAL RELEVANCE: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.

Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis.

Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.

Weight-Bearing Restrictions With Distal Radius Wrist-Spanning Dorsal Bridge Plates.

PURPOSE: The fixation of comminuted distal radius fractures using wrist-spanning dorsal bridge plates has been shown to have good postoperative results. We hypothesized that using a stiffer bridge plate construct results in less fracture deformation with loads required for immediate crutch weight bearing. METHODS: We created a comminuted, extra-articular fracture in 7 cadaveric radii, which were fixed using dorsal bridge plates. The specimens were positioned to simulate crutch/walker weight bearing and axially loaded to failure. The axial load and mode of failure were measured using 2- and 5-mm osteotomy deformations as cutoffs. Bearing 50% and 22% of the body weight was representative of the force transmitted through crutch and walker weight bearing, respectively. RESULTS: The load to failure at 2-mm deformation was greater than 22% body weight for 2 of 7 specimens and greater than 50% for 1 of 7 specimens. The load to failure at 5-mm deformation was greater than 22% body weight for 6 of 7 specimens and greater than 50% for 4 of 7 specimens. The mean load to failure at 2-mm gap deformation was significantly lower than 50% body weight (110.4 N vs 339.2 N). The mean load to failure at 5-mm deformation was significantly greater than 22% body weight (351.8 N vs 149.2 N). All constructs ultimately failed through plate bending. CONCLUSIONS: All constructs failed by plate bending at forces not significantly greater than the 50% body weight force required for full crutch weight bearing. The bridge plates supported forces significantly greater than the 22% body weight required for walker weight bearing 6 of 7 times when 5 mm of deformation was used as the failure cutoff. CLINICAL RELEVANCE: Elderly, walker-dependent patients may be able to use their walker as tolerated immediately after dorsal bridge plate fixation for extra-articular fractures. However, patients should not be allowed to bear full weight using crutches immediately after bridge plating.

The Management of Pediatric Open Forearm Fractures.

Open pediatric forearm fractures are common injuries that present to emergency departments across the United States. A total of 32% to 80% of all open pediatric fractures involve the forearm. Standard treatment for these injuries includes prompt intravenous antibiotic administration, tetanus prophylaxis, and usually bedside irrigation as a temporizing measure. Gustilo and Anderson type 2 and 3 open pediatric forearm fractures are generally managed with formal irrigation and debridement and fracture stabilization in the operating room. Management of Gustilo and Anderson type 1 open pediatric forearm fractures is not standardized, and level I evidence is currently lacking. Based on the existing data available, early antibiotic administration, bedside irrigation, and fracture stabilization in the emergency department may be a safe and effective initial treatment for these injuries, conferring a low risk for subsequent infection.

Relative Contributions of the Midcarpal and Radiocarpal Joints to Dart-Thrower's Motion at the Wrist.

PURPOSE: To identify the relative contributions of the radiocarpal (RC) and midcarpal (MC) joints to dart-thrower's motion (DTM) of the wrist. METHODS: Six cadaveric upper extremities were fixed to a custom-designed loading jig allowing for pure moment-rotation analysis in 24 different directions of wrist motion. Each specimen was tested in 3 states: intact, simulated radiocarpal fusion (sRCF) and simulated pancarpal fusion (sPCF). Moments of ± 1.5 Nm were applied at each of 24 directions for each state and the resulting wrist rotation recorded. Data from each specimen were reduced to compute the range of motion (ROM) envelopes and the orientation of the ROM for the 3 different states. RESULTS: The ROM was significantly decreased in the sRCF and sPCF groups compared with the intact group in the directions of the pure extension, radial extension, ulnar flexion, and ulnar deviation. No significant difference in ROM was detected between the sRCF and sPCF groups in any direction. The ROM envelopes for the intact, sRCF, and sPCF groups were all oriented obliquely to the axis of pure wrist flexion-extension near a path of ulnar flexion-radial extension, consistent with prior reports on DTM. CONCLUSIONS: Although both simulated fusion types decreased ROM compared with the intact wrist, the principal direction of wrist motion along the path of DTM was not significantly altered by simulated RCF or PCF. CLINICAL RELEVANCE: These findings suggest that the RC and MC joints can each contribute to a similar mechanical axis of motion located along the path of DTM when the other joint has been eliminated via fusion. Surgical options such as partial wrist fusions may maintain the native wrist's mechanical axis if either the RC or the MC joint is preserved, despite significant reduction in overall ROM.

Crush Injuries of the Hand.

Crush injuries of the hand are a rare but devastating phenomenon, with historically poor outcomes. A compressive force, usually caused by a high-energy mechanism such as a motor vehicle or industrial accident, crushes and transiently increases the pressures within the hand. This force acts on the incompressible blood in the vasculature and leads to a dramatic rise in tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves, and soft tissues. A wide zone of injury results from a delayed inflammatory reaction involving the zone bordering the crushed cells, which may initially belie the severity of the injury. As such, these injuries go on to produce tremendous inflammation and swelling, potentially followed by compartment syndrome or other vascular damage, infection, neurological injury, and tissue necrosis. Crush injuries with minimal skin disruptions can be particularly challenging to accurately diagnose and manage. This paper provides a review of the initial evaluation of hand crush injuries as well as short- and long-term management strategies.

Flexor Tendon Repair With Looped Suture: 1 Versus 2 Knots.

PURPOSE: To assess the strength of flexor tendon repair with looped suture. We hypothesized that, after passing the intact looped suture in the desired repair configuration, splitting the loop and tying 2 independent knots would increase the strength of flexor tendon repair. METHODS: Thirty-two flexor tendons were harvested and were sharply transected in zone II. The tendons were repaired with a 4-strand core suture repair using 3-0 looped nonabsorbable nylon suture. The harvested tendons were randomly assigned and repaired with either a 1- or a 2-knot construct. The repaired flexor tendons were fixed in a servohydraulic material testing system and were loaded to failure either with uniaxial tension or cyclically. RESULTS: The average force at failure was 43 N for the 1-knot repair and 28 N for the 2-knot repair. The mode of failure of 15 of the flexor tendon repairs that were cyclically loaded to failure was suture pull-out. The average number of cycles and force in cyclic testing that caused failure of flexor tendon repairs was 134 cycles and 31 N for tendons repaired with looped 3-0 suture tied with 1 knot and 94 cycles and 33 N for tendons repaired with looped 3-0 suture tied with 2 knots. CONCLUSIONS: Our hypothesis was disproved by the results of this study. CLINICAL RELEVANCE: This study suggests that, when using looped suture, tying 2 independent knots instead of tying a single knot does not increase the strength of the flexor tendon repair.

In vivo kinematics of the thumb carpometacarpal joint during three isometric functional tasks.

BACKGROUND: The thumb carpometacarpal (CMC) joint is often affected by osteoarthritis--a mechanically mediated disease. Pathomechanics of the CMC joint, however, are not thoroughly understood due to a paucity of in vivo data. QUESTIONS/PURPOSES: We documented normal, in vivo CMC joint kinematics during isometric functional tasks. We hypothesized there would be motion of the CMC joint during these tasks and that this motion would differ with sex and age group. We also sought to determine whether the rotations at the CMC joint were coupled and whether the trapezium moved with respect to the third metacarpal. METHODS: Forty-six asymptomatic subjects were CT-scanned in a neutral position and during three functional tasks (key pinch, jar grasp, jar twist), in an unloaded and a loaded position. Kinematics of the first metacarpal, third metacarpal, and the trapezium were then computed. RESULTS: Significant motion was identified in the CMC joint during all tasks. Sex did not have an effect on CMC joint kinematics. Motion patterns differed with age group, but these differences were not systematic across the tasks. Rotation at the CMC joint was generally coupled and posture of the trapezium relative to the third metacarpal changed significantly with thumb position. CONCLUSIONS: The healthy CMC joint is relatively stable during key pinch, jar grasp, and jar twist tasks, despite sex and age group. CLINICAL RELEVANCE: Our findings indicate that directionally coupled motion patterns in the CMC joint, which lead to a specific loading profile, are similar in men and women. These patterns, in addition to other, nonkinematic influences, especially in the female population, may contribute to the pathomechanics of the osteoarthritic joint.

Biomechanical comparison of parallel versus 90-90 plating of bicolumn distal humerus fractures with intra-articular comminution.

PURPOSE: To compare the biomechanical properties of 90-90 versus mediolateral parallel plating of C-3 bicolumn distal humerus fractures. METHODS: We created intra-articular AO/Orthopaedic Trauma Association C-3 bicolumn fractures in 10 fresh-frozen matched pairs of cadaveric elbows. We determined bone mineral density of the metaphyseal region with dual-energy x-ray absorptiometry. The matched pairs of elbows were randomly assigned to either 90-90 or parallel plate fixation. We tested anteroposterior displacement at a rate of 0.5 mm/s to a maximum load of ± 100 N for both the articular and entire distal humerus segments. We tested torsional stability at a displacement rate of 0.1 Hz to a maximum torque of ± 2.5 Nm. After cyclical testing, we loaded the specimens in torsion to failure. RESULTS: There was no significant difference in the bone density of the paired specimens. Compared with parallel fixation, 90-90 plate fixation had significantly greater torque to failure load. Both plating constructs were equally sensitive to bone density. Both techniques had the same mode of failure in torsion, a spiral fracture extending from the medial plate at the metaphyseal-diaphyseal junction. There was no significant difference in the stiffness of fixation of the articular fragment or the entire distal segment in anteroposterior loading. CONCLUSIONS: This study demonstrated that 90-90 and parallel plating had comparable biomechanical properties for fixation of comminuted intra-articular distal humerus fractures, and that 90-90 plating had greater resistance to torsional loading.

Traumatic Fibular Loss Managed with a Free Vascularized Fibular Graft: A Case Report.

CASE: A 25-year-old man involved in a jet skiing accident experienced a traumatic excision of his distal fibula in conjunction with other lower extremity injuries. He subsequently underwent a reconstruction of his lateral malleolus using an ipsilateral free vascularized fibular graft (FVFG) from his proximal fibular shaft, resulting in a preserved and stabilized ankle joint at 1 year. CONCLUSION: Traumatic distal fibular excision is a rare injury that can be successfully managed using an FVFG, with fusion of the distal syndesmosis and a symmetric ankle mortise observed at the 1-year follow-up.

Excessive Derotational K-Wire Angulation Decreases Compression by Headless Compression Screw.

Background Scaphoid fracture is the most common carpal bone fracture. Open reduction internal fixation of scaphoid fractures typically undergo stabilization by a single headless compression screw (HCS). During screw insertion, a derotational Kirschner wire (K-wire) is often placed for rotational control of the near and far fragment. Questions/Purposes The aim of this study was to determine if there is an angle of derotational K-wire placement in relation to the axis of a HCS that compromises the amount of compression generated at a fracture site by the HCS. We hypothesize that increased off-axis angle will lead to decreased compression across the fracture site. Methods A Cellular Block 20 rigid polyurethane foam (Sawbones, Vashon, WA) scaphoid model was created to eliminate variability in bone mineral density in cadaveric bone. MiniAcutrak HCS screws (Acumed, Hillsboro, OR) were used for testing. Three conditions were tested: (1) HCS with derotational wire inserted parallel to the HCS (zero degrees off-axis); (2) HCS with derotational wire inserted 10 degrees off-axis; and (3) HCS with derotational wire inserted 20 degrees off-axis. Results A statistically significant difference in the mean compression of the control group (56.9 N) was found between the mean compression with the derotational K-wire placed 20 degrees off-axis (15.2 N) ( p = 0.001). Conclusions Compression at the fracture site could be impeded by placing an excessively angulated off-axis derotation wire prior to insertion of the HCS. Clinical Relevance Our study adds a new detail to the optimal technique of HCS placement in scaphoid fractures to improve compression and fracture union.

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609).

BACKGROUND: Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost. METHODS: In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations. RESULTS: Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types. CONCLUSION: Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

Fracture of the distal radius: risk factors for complications after locked volar plate fixation.

PURPOSE: To identify risk factors for complications after volar locking plate fixation of distal radius fractures. METHODS: We assessed early postoperative complications in 594 patients with fracture of the distal radius repaired with a volar locking plate and a minimum 1-month evaluation in the medical record. Later complications were assessed among 321 patients as a subset of the original cohort with a minimum 6 months' evaluation. We compared patient demographics, fracture characteristics, and aspects of management between patients with and without complications in bivariate analysis. Multivariable logistic regression analysis was applied to identify the factors independently associated with complications. RESULTS: A total of 47 complications were documented in the medical record. Early complications occurred in 24 of 594, including 8 intra-articular screws and 7 patients with loss of fixation. Late complications occurred in 23 of 321, including 14 patients diagnosed with tendon irritation (one rupture of the flexor pollicis longus tendon) and 5 patients who had subsequent surgery to address dysfunction of the distal radioulnar joint (malunion, synostosis, and arthrofibrosis). Of the 47 complications, 26 were attributed to the plate, of which 9 were considered major (intra-articular screws and tendon rupture; 1.3% (8 out of 594) and less than 1% (1 out of 321) of the early and late groups, respectively). In the logistic regression models, fall from a height and an ipsilateral elbow injury were positive independent predictors of early complications, whereas high-volume surgeons and plates other than the most commonly used plate were positive independent predictors of later complications. CONCLUSIONS: Volar locking plate fixation of distal radius fractures was associated with relatively few plate-related complications in our institutions. Factors indicating higher energy or complexity predicted early complications. The most common late complication was tendon irritation, which is less discrete and perhaps variably diagnosed. Further study is warranted regarding plate design and familiarity, which may help reduce complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures.

BACKGROUND: Closed reduction and casting for type-2 supracondylar fractures is a viable treatment option, but studies have shown that some patients will fail to maintain the initial reduction in a cast. This study sought to identify predictors of failed treatment of closed reduction and casting for these fractures. METHODS: We performed a retrospective case-control study of type-2 supracondylar fractures treated by closed reduction and casting. Using radiographic failure of reduction as our primary outcome measure, we examined injury, postreduction, and follow-up films evaluating the anterior humeral line, cast flexion angle, and degree of cast padding in an attempt to identify predictors of failure. RESULTS: We reviewed 645 fractures. Of 126 type-2 fractures, 61 fractures were included in the study. There were 49 (80%) nonoperative treatment successes and 12 failures (20%) with an average follow-up of 41 days (range, 20 to 161 d). We found that (1) the degree of fracture extension using an index based on the anterior humeral line on the injury film was significantly related to failure of cast treatment (P=<0.01), and (2) the width of the soft tissue shadow of the upper arm on the postreduction film was of borderline significance (P=0.02). Cast flexion angle and cast padding were not predictive of radiographic loss of reduction (P=0.94 and 0.70). CONCLUSIONS: Despite adequate reduction and casting of type-2 supracondylar fractures, some fractures will lose reduction and require delayed pinning. The degree of extension of the distal fragment at the time of injury may help to predict the likelihood of failure of nonoperative treatment.

Nuances of Radiographic Assessment of Distal Radius Fractures to Avoid Missed Fragments.

Distal radius fractures, like many articular and periarticular fractures, can make it difficult to determine the true number, location, and orientation of fracture fragments. This article should help the reader work through imaging interpretation starting from the initial, often displaced radiographs to postreduction imaging and determination if further 3-dimensional imaging is necessary.

Ring and little finger metacarpal fractures: mechanisms, locations, and radiographic parameters.

PURPOSE: To describe a series of ring and little finger metacarpal fractures with regard to mechanism, location, midshaft diameter, and isthmus diameter, to better define injury patterns and assist the surgeon in selection of appropriately sized implants. METHODS: We reviewed all metacarpal fractures in skeletally mature patients who presented to a single surgeon over a 2-year period. Fractures of the ring and little finger metacarpals were analyzed with regard to mechanism and fracture location. Metacarpal midshaft and minimum isthmus diameters were measured on posteroanterior radiographs. RESULTS: A total of 101 fractures involved the ring and little finger metacarpals. Punching-type injuries accounted for most fractures in the little finger metacarpal (49 of 67) and ring finger metacarpal (26 of 34). Among these punching-related ring and little finger metacarpal fractures, the most common fracture location was the little finger metacarpal neck (34 of 75), followed by the ring finger metacarpal shaft (21 of 75). Among men in this series, the metacarpal midshaft and minimum isthmus diameters were significantly narrower in the ring finger metacarpal than in the little finger (7.4 vs 8.7 mm, p < .001; and 2.2 vs 3.8 mm, p < .001). CONCLUSIONS: Whereas punching injuries tended to cause neck fractures in little finger metacarpals in this series, they caused shaft fractures in ring finger metacarpals, which may thus be considered a variant boxer's fracture. Furthermore, in men with fractures, the ring finger metacarpal is significantly narrower than the little finger, both in midshaft diameter and isthmus diameter, which surgeons should consider when planning internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Delayed presentation of a brachial artery pseudoaneurysm after a supracondylar humerus fracture in a 6-year-old boy: a case report.

Supracondylar fractures of the humerus are the most common elbow fractures in children, accounting for 60% to 70% of all pediatric elbow fractures. These fractures often have neurovascular complications because of deformity and the sharp nature of the fracture fragments. The management of patients who present with diminished or absent pulses, but a well-perfused extremity is a topic of debate. Between 3% and 14% of patients present with an altered vascular examination and a consistent treatment logarithm has not been proposed in the literature. To our knowledge, a brachial artery pseudoaneurysm presenting in a delayed fashion in the setting of a normal vascular examination has not been reported. We report a 6-year-old boy who had a delayed presentation of a brachial artery pseudoaneurysm after a supracondylar humerus fracture, which was repaired with a saphenous vein graft. This is to emphasize close neurological and vascular monitoring even in the setting of a well-perfused hand. In addition, this would suggest that closer postoperative evaluation in significantly displaced fractures should be performed, even beyond the fracture healing stage.

Evaluation, Management, and Outcomes of Lunate and Perilunate Dislocations.

Lunate and perilunate dislocations are potentially devastating injuries that are often unrecognized at initial evaluation. Prompt recognition and treatment is necessary to prevent adverse sequelae, including median nerve dysfunction, carpal instability, posttraumatic arthritis, reduced functionality, and avascular necrosis. In patients who are surgical candidates, operative intervention is warranted to restore carpal kinematics and provide optimal outcomes. [Orthopedics. 2019; 42(1):e1-e6.].

Fluoroscopic evaluation of intra-articular screw placement during locked volar plating of the distal radius: a cadaveric study.

PURPOSE: To evaluate specific fluoroscopic views for assessment of intra-articular screw placement during locked volar plating of the distal radius. METHODS: The distal radius of a cadaver forearm was plated with a fixed-angle volar plate according to the surgical technique guide of the manufacturer. A goniometer was used to place the specimen at various described angles in the fluoroscope including standard posteroanterior (PA), tilt PA (11 degrees ), standard lateral, and tilt lateral (15 degrees , 23 degrees , 30 degrees ) views. Radiographic images of each screw individually and in various combinations were digitally captured. RESULTS: Only the tilt PA view correctly showed all 4 screws to be extra-articular. On the standard PA view, the 2 ulnar screws appeared intra-articular. Lower angle tilt lateral views (15 degrees and 23 degrees ) correctly visualized the ulnar screws but not the styloid screw. The highest angle lateral view (30 degrees ) correctly visualized the radial screws but not the sigmoid (most ulnar) screw. The styloid screw appeared to be intra-articular on every lateral view except at 30 degrees and was correctly visualized on both the PA and tilt PA views. CONCLUSIONS: Multiple oblique views are required for evaluation of intra-articular screw placement during locked volar plating of the distal radius. Lower angle tilt lateral views are more specific for the ulnar screws, and higher angle views are more specific for the radial screws. We suggest first placing the ulnar screws whenever possible, using lower angle tilt lateral views (15 degrees to 23 degrees ) to evaluate for intra-articular placement. The styloid screw may be placed last and can then be evaluated on the PA and tilt PA views.