The Watershed Line of the Distal Radius: Cadaveric and Imaging Study of Anatomical Landmarks

Minke Bergsma; Job N. Doornberg; Annelise Borghorst; W.A. Kernkamp; R. L. Jaarsma; Gregory I. Bain

doi:10.1055/s-0039-1698452

Journal of Wrist Surgery, Table of Contents

J Wrist Surg 2020; 09(01): 044-051
DOI: 10.1055/s-0039-1698452

Scientific Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Watershed Line of the Distal Radius: Cadaveric and Imaging Study of Anatomical Landmarks

Authors

Minke Bergsma

¹Department of Orthopaedic Surgery, Flinders Medical Centre/Department of Orthopaedic Trauma Surgery and the Biomechanics & Implants Research Group, Flinders University, Adelaide, Australia

²Department of Orthopaedic Surgery, Amsterdam University Medical Center/University of Amsterdam, Amsterdam, the Netherlands

³Department of Radiology, Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands
Job N. Doornberg

¹Department of Orthopaedic Surgery, Flinders Medical Centre/Department of Orthopaedic Trauma Surgery and the Biomechanics & Implants Research Group, Flinders University, Adelaide, Australia

²Department of Orthopaedic Surgery, Amsterdam University Medical Center/University of Amsterdam, Amsterdam, the Netherlands
Annelise Borghorst

¹Department of Orthopaedic Surgery, Flinders Medical Centre/Department of Orthopaedic Trauma Surgery and the Biomechanics & Implants Research Group, Flinders University, Adelaide, Australia
W.A. Kernkamp

⁴Department of General Surgery, Albert Schweizer Hospital, Dordrecht, the Netherlands

⁵Postdoctoral Research Fellowship, Shanghai Jiao Tong University, Shanghai, People's Republic of China
R. L. Jaarsma

¹Department of Orthopaedic Surgery, Flinders Medical Centre/Department of Orthopaedic Trauma Surgery and the Biomechanics & Implants Research Group, Flinders University, Adelaide, Australia
Gregory I. Bain

¹Department of Orthopaedic Surgery, Flinders Medical Centre/Department of Orthopaedic Trauma Surgery and the Biomechanics & Implants Research Group, Flinders University, Adelaide, Australia

Abstract

Background Placement of volar plates remains a challenge as the watershed line may not be an easy-identifiable distinct line intraoperatively.

Objectives The main objective of this article is to define how anatomical landmarks identifiable upon the volar surgical approach to the distal radius relate to the watershed line.

Methods We identified anatomical landmarks macroscopically upon standard volar approach to the distal radius in 10 cadaveric forearms and marked these with radiostereometric analysis (RSA) beads in cadaveric wrists. The RSA beads were then referenced against the volar osseous structures using quantification of three-dimensional computed tomography and advanced imaging software.

Results The mean measurements were the radial and ulnar prominences 11.1 mm and 2.1 mm proximal to the joint line of the distal radius, respectively. The interfossa sulcus was 0.3 mm proximal and 3 mm dorsal to the ulnar prominence. The watershed line was between 3.5 (minimal) and 7.6 (maximal) mm distal to the distal line of insertion of the pronator quadratus.

Conclusion The watershed line is situated distal to the pronator quadratus, but with a wide variability making it an impractical landmark for plate position. The osseous ulnar prominence is a good anatomical reference for safe plate positioning, as it is located on the watershed line and easily palpated at surgery. One should keep in mind the sulcus—the point on the watershed line where the flexor pollicis longus runs—can be situated just proximal to the ulnar prominence.

Clinical Relevance To provide anatomical landmarks that are easy to identify upon surgical approach without the direct need for intraoperative imaging.

Keywords

distal radius fracture - watershed line - volar approach - anatomy - Q3DCT imaging - volar plating

Full Text

References

References
1 Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005; 21 (03) 347-354
2 Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res 2006; 445 (445) 58-67
3 Nelson DL, Orbay J, Bindra R. Anatomy of the Volar Distal Radius. 2008 http://eradius.com/AnatomyOfDistalRadius.htm
4 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 (05) 316-322
5 Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am 2011; 93 (04) 328-335
6 Imatani J, Akita K, Yamaguchi K, Shimizu H, Kondou H, Ozaki T. An anatomical study of the watershed line on the volar, distal aspect of the radius: implications for plate placement and avoidance of tendon ruptures. J Hand Surg Am 2012; 37 (08) 1550-1554
7 Obert L, Loisel F, Gasse N, Lepage D. Distal radius anatomy applied to the treatment of wrist fractures by plate: a review of recent literature. SICOT J 2015; 1: 14
8 Agnew SP, Ljungquist KL, Huang JI. Danger zones for flexor tendons in volar plating of distal radius fractures. J Hand Surg Am 2015; 40 (06) 1102-1105
9 Mellema JJ, Doornberg JN, Dyer GS, Ring D. Distribution of coronoid fracture lines by specific patterns of traumatic elbow instability. J Hand Surg Am 2014; 39 (10) 2041-2046
10 de Muinck Keizer RO, Meijer DT, van der Gronde BA. , et al. Articular gap and step-off revisited: 3D quantification of operative reduction for posterior malleolar fragments. J Orthop Trauma 2016; 30 (12) 670-675
11 Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial plateau fracture characteristics: computed tomography mapping of lateral, medial, and bicondylar fractures. J Bone Joint Surg Am 2015; 97 (18) 1512-1520
12 Ahsan ZS, Yao J. The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating. Hand (N Y) 2012; 7 (03) 276-280
13 Goorens CK, Van Royen K, Grijseels S. , et al. Ultrasonographic evaluation of the distance between the flexor pollicis longus tendon and volar prominence of the plate as a function of volar plate positioning and pronator quadratus repair - A cadaver study. Hand Surg Rehabil 2018; 37 (03) 171-174
14 Kara A, Celik H, Bankaoglu M, Oc Y, Bulbul M, Sugun TS. Ultrasonic evaluation of the flexor pollicis longus tendon following volar plate fixation for distal radius fractures. J Hand Surg Am 2016; 41 (03) 374-380
15 Singh TS, Sadagatullah AN, Yusof AH. Morphology of distal radius curvatures: a CT-based study on the Malaysian Malay population. Singapore Med J 2015; 56 (10) 562-566
16 Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000; 5 (02) 103-112
17 Rajeev AS, Sreverthana S, Harrison J. Rupture of flexor pollicis longus tendon: a complication of volar locking plating of the distal radius. Eur J Trauma Emerg Surg 2010; 36 (04) 385-387
18 Valbuena SE, Cogswell LK, Baraziol R, Valenti P. Rupture of flexor tendon following volar plate of distal radius fracture. Report of five cases. Chir Main 2010; 29 (02) 109-113
19 McCann PA, Amirfeyz R, Wakeley C, Bhatia R. The volar anatomy of the distal radius--an MRI study of the FCR approach. Injury 2010; 41 (10) 1012-1014
20 McCann PA, Clarke D, Amirfeyz R, Bhatia R. The cadaveric anatomy of the distal radius: implications for the use of volar plates. Ann R Coll Surg Engl 2012; 94 (02) 116-120
21 Adham MN, Porembski M, Adham C. Flexor tendon problems after volar plate fixation of distal radius fractures. Hand (N Y) 2009; 4 (04) 406-409
22 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 (07) 1144-1152
23 Im JH, Lee JY. Pearls and pitfalls of the volar locking plating for distal radius fractures. J Hand Surg Asian Pac Vol 2016; 21 (02) 125-132
24 Tanaka Y, Aoki M, Izumi T, Fujimiya M, Yamashita T, Imai T. Effect of distal radius volar plate position on contact pressure between the flexor pollicis longus tendon and the distal plate edge. J Hand Surg Am 2011; 36 (11) 1790-1797
25 Wilson J, Viner JJ, Johal KS, Woodruff MJ. Volar locking plate fixations for displaced distal radius fractures: an evaluation of complications and radiographic outcomes. Hand (N Y) 2018; 13 (04) 466-472
26 Oppermann J, Wacker M, Stein G. , et al. Anatomical fit of seven different palmar distal radius plates. Arch Orthop Trauma Surg 2014; 134 (10) 1483-1489
27 Imatani J, Akita K. Volar distal radius anatomy applied to the treatment of distal radius fracture. J Wrist Surg 2017; 6 (03) 174-177
28 Limthongthang R, Bachoura A, Jacoby SM, Osterman AL. Distal radius volar locking plate design and associated vulnerability of the flexor pollicis longus. J Hand Surg Am 2014; 39 (05) 852-860
29 Oura K, Oka K, Kawanishi Y, Sugamoto K, Yoshikawa H, Murase T. Volar morphology of the distal radius in axial planes: a quantitative analysis. J Orthop Res 2015; 33 (04) 496-503
30 Schwarcz Y, Schwarcz Y, Peleg E, Joskowicz L, Wollstein R, Luria S. Three-dimensional analysis of acute scaphoid fracture displacement: proximal extension deformity of the scaphoid. J Bone Joint Surg Am 2017; 99 (02) 141-149
31 Bexkens R, Oosterhoff JH, Tsai TY. , et al. Osteochondritis dissecans of the capitellum: lesion size and pattern analysis using quantitative 3-dimensional computed tomography and mapping technique. J Shoulder Elbow Surg 2017; 26 (09) 1629-1635
32 Armitage BM, Wijdicks CA, Tarkin IS. , et al. Mapping of scapular fractures with three-dimensional computed tomography. J Bone Joint Surg Am 2009; 91 (09) 2222-2228
33 Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma 2013; 27 (07) e152-e156