26/12/2025
Case-based learning point:
The attached radiograph demonstrates excessive screw length in the distal row of a volar locking plate, with pe*******on beyond the dorsal cortex. This resulted in mechanical irritation and injury to the extensor tendons, clinically manifesting as severe pain, dorsal swelling, and restricted wrist motion.
The patient was advised to start forceful physiotherapy and aggressive wrist mobilization without reassessment of implant position, which exacerbated tendon irritation and soft-tissue inflammation, increasing the risk of partial or complete extensor tendon rupture.
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Key Technical & Clinical Pearls
1️⃣ Screw length matters
• Distal screws, especially in osteoporotic bone, can silently breach the dorsal cortex.
• Even 1–2 mm of overlength may cause significant extensor tendon morbidity.
2️⃣ Imaging is critical
• Standard lateral views may miss dorsal pe*******on.
• Strongly recommended:
• Dorsal Tangential View (DTV / Skyline view)
• Intraoperative fluoroscopy with wrist in maximal flexion
• Low threshold for postoperative reassessment imaging in patients with disproportionate pain.
Further reading
🔗 1. Extensor tendon complications following volar plate fixation of distal radius fractures
Journal of Hand Surgery (Am. Vol)
https://pubmed.ncbi.nlm.nih.gov/21075305/
🔗 2. Dorsal Tangential (Skyline) View for Detection of Screw Pe*******on
Journal of Hand Surgery (Am. Vol)
https://pubmed.ncbi.nlm.nih.gov/20083384/
🔗 3. Radiographic Assessment of Screw Length in Volar Plate Fixation
Journal of Orthopaedic Trauma
https://pubmed.ncbi.nlm.nih.gov/19587337/
🔗 4. Predictors of Extensor Pollicis Longus Rupture After Distal Radius Fracture Fixation
The Journal of Bone & Joint Surgery
https://pubmed.ncbi.nlm.nih.gov/24590585/
🔗 5. Avoiding Tendon Injury in Volar Plating – Practical Guidelines (Review)
Injury – International Journal of the Care of the Injured
https://pubmed.ncbi.nlm.nih.gov/26482305/
