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The Effect of Plate Design on the Flexor Pollicis Longus Tendon After Volar Locked Plating of Distal Radial Fractures

Stepan, Jeffrey G. MD, MSc1; Marshall, Danielle C. MD2; Wessel, Lauren E. MD1; Endo, Yoshimi MD1; Miller, Theodore T. MD1; Sacks, Hayley A. MD3; Weiland, Andrew J. MD1; Fufa, Duretti T. MD1,3

doi: 10.2106/JBJS.18.01087
Scientific Articles
Supplementary Content

Background: Injury to and rupture of the flexor pollicis longus (FPL) tendon are known complications after volar locking plate fixation for distal radial fractures. Recent investigations have demonstrated that plate positioning contributes to the risk of tendon rupture; however, the impact of plate design has yet to be established. The purpose of this study was to compare FPL tendon-to-plate distance, FPL tendon-plate contact, and sonographic changes in the FPL tendon for 2 volar locking plate designs (ADAPTIVE compared with FPL) using ultrasound examination.

Methods: We identified patients who underwent distal radial fracture fixation by 2 fellowship-trained hand surgeons with either standard (ADAPTIVE) or FPL plates. Patients were matched by age, sex, and Soong grade. Enrolled patients returned for a research-related office visit for a clinical examination and bilateral wrist ultrasound. We measured plate-tendon distance, plate-tendon contact, sonographic changes in the FPL tendon, and postoperative radiographic parameters in the operatively treated wrist and the uninjured wrist.

Results: Forty patients with Soong grade-1 or 2 plate prominence underwent bilateral wrist ultrasound examination; all of the patients had distal radial fracture fixation, 20 with the standard volar locking plate and 20 with the FPL volar locking plate. Similar proportions of patients with the FPL plate (65%) and those with the standard plate (79%) had plate-tendon contact (p = 0.48); however, the FPL volar locking plate group had significantly less of the FPL tendon in contact with the volar plate than the standard volar locking plate group at wrist extension at both 0° (p < 0.001) and 45° (p < 0.001). There was no difference (p = 0.5) in the proportion of patients with sonographic changes in the FPL tendon between the FPL volar locking plate group (25%) and the standard volar locking plate group (21%). The postoperative volar tilt was significantly lower in patients with FPL plate-tendon contact (p = 0.01) and correlated moderately with the percentage of FPL tendon-plate contact at 0° (r = −0.51; p < 0.001) and 45° (r = −0.53; p < 0.001). There were no cases of tendon rupture in the cohort.

Conclusions: We found that the FPL volar locking plate and decreased volar tilt significantly reduced the plate-tendon contact area compared with the standard volar locking plate. In our asymptomatic cohort, we were unable to find a difference in sonographic changes in the FPL tendon. Further studies are needed to determine the clinical importance of decreased tendon-plate contact area seen in modified volar locking plate designs.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

1Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY

2Case Western Reserve University School of Medicine, Cleveland, Ohio

3Weill Cornell Medical College, New York, NY

E-mail address for J.G. Stepan:

Investigation performed at the Hospital for Special Surgery, New York, NY

Disclosure: Medartis, the manufacturer of both the Adaptive II plates and FPL volar locking plates used in the study, provided financial support to fund bilateral ultrasound examinations, patient remuneration, and research supplies. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (including consultant work for Medartis by A.J.W. and D.T.F.) and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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