Re: “Intraoperative Detection of Screw Penetration Following Volar Plating of the Distal Radius: A Cadaveric Study Comparing Fluoroscopic Imaging and Ultrasound”

Dear Editor,

We read with interest the article by Persitz et al,[1] comparing the carpal shoot-through view (CSV forearm supination, wrist extension), the dorsal horizon/skyline view (forearm pronation, wrist flexion), and intraoperative ultrasound (US) for detecting dorsal cortical and distal radioulnar joint (DRUJ) screw penetration after volar plating of distal radius fractures. They found higher overall sensitivity for the supination/extension view to detect dorsal penetration, superior performance of the pronation/flexion view for DRUJ involvement, and lower diagnostic utility for surgeon-performed US. Notably, they affirm to be the first to evaluate both dorsal and DRUJ penetration after volar plating with direct verification of screw length by gross dissection, unfeasible in clinical studies, also showing comparable CSV sensitivity across observer experience levels.

These observations have clear clinical implications. Screw length is difficult to assess on standard lateral views, and dorsal cortical overlength can cause attritional extensor tendon ruptures after volar plating.[1] [2]

These implications were investigated in a clinical study on 75 patients; the supination/flexion view changed intraoperative screw decisions in approximately 15% of cases when findings were occult on the lateral view, with a modest additional radiation burden relative to conventional wrist series.[2]

When the US was directly compared with the supination/flexion view, the detection rate of long epiphyseal screws was 43.33% with US versus 96.67% with fluoroscopy (p = 0.01). Interobserver agreement was poor for US (κ = 0.0129; p = 0.912) and excellent for fluoroscopy (κ = 0.91; p < 0.001), leading the authors to conclude that US cannot replace the skyline view for this indication.[3]

A study compared two fluoroscopic views (supination/extension vs. supination/flexion) in assessing anatomic landmark recognition. Recognition of four key landmarks (radial styloid, dorsal cortex, Lister's tubercle, DRUJ) was 78% in supination/extension versus 66% in supination/flexion (p < 0.001); the authors concluded that wrist extension and supination are optimal to evaluate reduction, the DRUJ, and screw length during volar plating.[4]

Integrating these data with the cadaveric findings of Persitz et al,[1] intraoperative US should not be considered a substitute for fluoroscopy in detecting dorsal or DRUJ screw penetration. In practice, the supination/extension projection should be routinely employed to screen for dorsal screw prominence at all levels of surgical experience, with an additional pronation/flexion view when DRUJ violation is suspected. Importantly, we underline that terms such as “skyline view” have been used inconsistently in the literature to describe different arm–wrist configurations. For clarity, we advocate reporting the precise forearm (pronation/supination) and wrist (flexion/extension) position rather than relying on ambiguous terminology.

We commend Persitz et al[1] for advancing safe fixation practices and emphasize that systematic use of the supination/extension view, complemented by a pronation/flexion view when appropriate, will contribute to reducing hardware-related extensor tendon complications.

Publication History

Received: 03 October 2025

Accepted: 16 October 2025

Article published online:
11 November 2025

• References

• 1 Persitz J, Essa A, Shor R. et al. Intraoperative detection of screw penetration following volar plating of the distal radius: A cadaveric study comparing fluoroscopic imaging and ultrasound. J Wrist Surg 2024; 14 (05) 471-477
• 2 Vaiss L, Ichihara S, Hendriks S, Taleb C, Liverneaux P, Facca S. The utility of the fluoroscopic skyline view during volar locking plate fixation of distal radius fractures. J Wrist Surg 2014; 3 (04) 245-249
• 3 Vernet P, Durry A, Nicolau X. et al. Detection of penetration of the dorsal cortex by epiphyseal screws of distal radius volar plates: Anatomical study comparing ultrasound and fluoroscopy. Orthop Traumatol Surg Res 2017; 103 (06) 911-913
• 4 El Amiri L, Igeta Y, Pizza C, Facca S, Hidalgo Diaz JJ, Philippe L. Distal radius fluoroscopic skyline view: extension-supination versus flexion-supination. Eur J Orthop Surg Traumatol 2019; 29 (03) 583-590 Erratum in: Eur J Orthop Surg Traumatol. 2019 Jul;29(5):1161. Doi: 10.1007/s00590-018-02361-8. Philippe L [corrected to Liverneaux P]. PMID: 30374641