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Distal radius fractures are common. Volar plating is a valuable approach for many fractures. There are also difficult fractures that require careful attention to the exposure and technique for successful volar plating. Classic approaches, such as external fixation with additional percutaneous reduction and pinning or bone graft and fragment-specific fixation, remain valuable especially when volar plating is not applicable. The main objectives are to review the intricacies of volar plating and the use of external fixation with distal radius fractures. This also includes an understanding of the associated injuries that are present with these fractures and the expected outcome of these injuries relative to the distal radius fracture. First, the challenges with volar locked plating as well as many tips and tricks to help with reduction and stabilization of these fractures are reviewed. Second, the benefits and tips and tricks of external fixation are discussed. Finally, the management of common combined injuries with distal radius fractures is reviewed.

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RESUMEN

OBJECTIVE: It is common practice to use a new contralateral bur hole for ventriculoperitoneal shunt (VPS) placement in subarachnoid hemorrhage (SAH) patients with an existing ventriculostomy. At Thomas Jefferson University and Jefferson Hospital for Neuroscience, the authors have primarily used the ventriculostomy site for the VPS. The purpose of this study was to compare the safety of the 2 techniques in patients with SAH. METHODS: The rates of VPS-related hemorrhage, infection, and proximal revision were compared between the 2 techniques in 523 patients undergoing VPS placement (same site in 464 and contralateral site in 59 patients). RESULTS: The rate of new VPS-related hemorrhage was significantly higher in the contralateral-site group (1.7%) than in the same-site group (0%; p = 0.006). The rate of VPS infection did not differ between the 2 groups (6.4% for same site vs 5.1% for contralateral site; p = 0.7). In multivariate analysis, higher Hunt and Hess grades (p = 0.05) and open versus endovascular treatment (p = 0.04) predicted shunt infection, but the VPS technique was not a predictive factor (p = 0.9). The rate of proximal shunt revision was 6% in the same-site group versus 8.5% in the contralateralsite group (p = 0.4). In multivariate analysis, open surgery was the only factor predicting proximal VPS revision (p = 0.05). CONCLUSIONS: The results of this study suggest that the use of the ventriculostomy site for VPS placement may be feasible and safe and may not add morbidity (infection or need for revision) compared with the use of a fresh contralateral site. This rapid and simple technique also was associated with a lower risk of shunt-related hemorrhage. While both techniques appear to be feasible and safe, a definitive answer to the question of which technique is superior awaits a higher level of medical evidence.

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