Abstract:
A system for assisting a surgeon in implanting hook plate-type bone plates includes a cannulated multiple barreled drill guide, a cannulated inserter/impactor, and a cannulated fastener coupling the inserter/impactor to a bone plate. The multiple barreled drill guide facilitates the drilling of at least two parallel holes at the distal end of a bone at the correct position and angle of entry, and includes a body and two drill guide channels coupled to the body in substantially parallel orientation relative to each other, with a guide pin aperture disposed between and substantially parallel to the drill guide tubes. The inserter/impactor likewise includes a central channel accommodating the same guide pin employed to place and align the multiple barreled drill guide.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application claims the benefit of U.S. provisional patent application No. 61/901,964, filed Nov. 8, 2013, the entirety of which is hereby incorporated by reference. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    1. Field of the Invention 
         [0003]    The present invention relates, in general, to the fixation of bone fractures and, more particularly, to the fixation of bone fractures having small fragments proximate a terminal end of a bone. 
         [0004]    2. Description of Related Art 
         [0005]    Plates and screws are well accepted techniques for fixation of fractures. The standard bone plate is a planar bar of material, usually metal, having circular and/or slotted holes through which bone screws are placed. The bone plate is used to span a fracture and fixation screws are placed through holes in the bone plate positioned on either side of the fracture to secure the bone fragments the plate. 
         [0006]    One example of a fracture occurring relatively close to the end of a bone is a fracture of the lateral malleolus, the terminal portion of the fibula that is present on the outside of the ankle, occurring close to its tip. In such situations, only a very small distal fragment may be present, providing inadequate room for more than one or two screws to be placed. Moreover, since the deep portion of this bone is a part of the overall ankle joint, screws cannot be placed through both cortices, as is commonly practice with plate/screw techniques. 
         [0007]    Distal radius fractures (what is often meant when using the term ‘wrist fracture’) are common injuries. These fractures are often comminuted and unstable. It is of importance in addressing such fractures to restore a smooth, anatomic and congruent articular surface with enough stability so that it does not displace during healing. In other locations in the body one objective of internal fixation is to produce compression between stable and unstable fragments in order to promote healing. However, in the case of the distal radius fractures, fixation that would produce this type of compressive loads between the articular fragments and the shaft may result in migration of the fragments, loss of length, malunions and failure. For this reason, the tenets of internal fixation for distal radius fractures are different, aimed at achieving a stable anatomic reduction while maintaining the joint surface in space supported out to length. 
         [0008]    Generally volar fixation plates need to be thick in cross-section in order to provide sufficient material to allow enough internal threads in the holes in order to securely lock the cooperatively threaded peg to the plate (whether at a fixed or variable angle). Since it is known that thick implants close to the rim of the distal radius may often cause irritation and even rupture of important tendons and other vital structures nearby, existing volar generally plates do not extend to the distal rim. As a result, small fractures of the distal volar rim are often not secured by these plate designs, which can result in the fragment flipping over the edge of the plate, potentially causing catastrophic loss of reduction and dislocation of the carpal bones of the wrist. 
         [0009]    Hook plates are implants that have been used at other locations to address fixation of a small terminal fragment with little available osseous bone area to accommodate fixation screws. Although early designs such as the LCP Hook Plate manufactured by Synthes, Inc. wrap around the end of the bone, these types of implants do not achieve any internal purchase of the fragment to be secured, and may have very limited to no purchase overall, resulting in poor rotational stability and limited resistance to sideways drift of the terminal fragment. 
         [0010]    The hook plates disclosed within U.S. Pat. No. 8,177,822 to Medoff, the entirety of which is hereby incorporated by reference, are configured for application to the lateral malleolus or the olecranon, and achieve fixation of terminal fragments with two intra-osseous ‘teeth’, or “hook members”, that provide rigid internal purchase of the fragment. These hook plates provide for rigid fixation of the terminal fragment and angular or translational movement under the plate. In addition, this type of plate promotes compressive load across the fracture which is intended for treatment at these locations. 
         [0011]    For fixation of the distal radius, however, the configuration of these types of hook plates is not optimal, especially for fractures involving the volar or dorsal rim. Since hook plates such as those disclosed in U.S. Pat. No. 8,177,822, configured for application to the lateral malleolus or the olecranon, promote compression against the stable fragment, in the case of distal radius fixation this would cause shortening of the fragment into the metaphyseal bone, and thus loss of articular reduction. For fractures of the distal radius, radial hook plates, such as those disclosed in U.S. Pat. No. 8,821,508 to Medoff and Shin, the entirety of which are hereby incorporated by reference, are preferred. Moreover, hook plates of a differing design may alternatively be employed to address fractures proximate the terminal ends of the fifth metatarsal bone, the hip, shoulder/clavicle, or other bones. 
         [0012]    U.S. Pat. No. 8,177,822 discloses a multi-barreled drill guide for drilling pilot holes for placement of hook plates, including hook plates configured for addressing fractures of the lateral malleolus; and U.S. Pat. No. 8,821,508 discloses holders/impactors for the affixation of hook plates, including hook plates configured for addressing fractures of the distal radius. While these drill guides and holders/impactors are useful, there is a need for an overall system enabling surgeons to more easily and accurately place hook plates for optimal securement of small terminal end bone fragments. 
         [0013]    Accordingly, it is an object of the present invention to provide an overall system for the placement of hook plates, that employs the placement of a guide pin, such as a Kirschner, or K-wire, prior to the drilling of pilot holes and the impacting of the hook plate into the bone, as a common basis for the positioning of both associated drill guides and associated inserters/impactors. 
         [0014]    It is another object of the present invention to provide a hook plate drill guide and an associated holder/impactor that permit the drilling of pilot holes and the impacting of the hook plate into the bone prior to the removal of the common guide pin that was initially placed through the fracture site. 
         [0015]    It is a further object of the present invention to provide an overall system for the placement of hook plates that reduces or eliminates the risk of placing pilot holes, and the hook plates themselves, at an improper position or an improper angle, making the implantation procedure more precise while, at the same time, permitting the procedure to be performed in a minimal amount of time, while requiring the surgeon to perform a minimal amount of steps. 
         [0016]    These and other objects and features of the present invention will become apparent in view of the present specification, drawing and claims. 
       BRIEF SUMMARY OF THE INVENTION 
       [0017]    The present invention comprises a system for assisting the surgeon in implanting hook plate-type bone plates, including a cannulated multiple barreled drill guide and a cannulated inserter/impactor. The multiple barreled drill guide facilitates the drilling of at least two parallel holes at the distal end of a bone at the correct position and at the correct angle. In one embodiment, an additional third hole may be provided for a distal cross-locking peg to be placed through the bone. This optional cross-locking peg may be at a position between two hook members of a bone plate. In one embodiment, the multiple barreled drill guide has a body, and two drill tubes extending through the body in substantially parallel orientation relative to each other, with a guide pin aperture disposed either between our outside of and substantially parallel to the drill tubes. The longitudinal axes of the drill tubes and guide pin aperture are angled relative to the longitudinal body of the drill guide in a manner that substantially coincides with the angle between the intra-osseous tines and elongated body of an associated bone plate to be implanted. The multiple barreled drill guide may further include a threaded aperture, threadedly receiving an associated fastener. In one embodiment, the fastener is cannulated and serves to both temporarily attach the inserter/impactor to the hook plate, and to facilitate the drilling of a locking peg pilot hole through the fastener for enhanced subchondral fixation. Like the multiple barreled drill guide, the inserter/impactor includes a channel accommodating the same guide pin employed to place and align the multiple barreled drill guide. The inserter/impactor has a bottom surface contour that substantially corresponds to the top distal surface contour of an adjacent portion of the hook plate upon attachment of the inserter/impactor to the hook plate. 
     
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS 
         [0018]      FIG. 1  is a top perspective view of an embodiment of a cannulated, guide wire-accommodating, double barreled drill guide, configured for volar application in the fixation of certain fractures of the distal radius; 
           [0019]      FIG. 2  is a left side view of the drill guide of  FIG. 1 ; 
           [0020]      FIG. 3  is a top plan view of the drill guide of  FIG. 1 ; 
           [0021]      FIG. 4  is a bottom view of the drill guide of  FIG. 1 ; 
           [0022]      FIG. 5  is a front view of drill guide of  FIG. 1 ; 
           [0023]      FIG. 6  is a rear view of the drill guide of  FIG. 1 ; 
           [0024]      FIG. 7  is an exploded perspective view of an embodiment of a cannulated, guide wire accommodating inserter/impactor and associated cannulated fastener, configured for volar application in the fixation of certain fractures of the distal radius; 
           [0025]      FIG. 8  is a right side view of the inserter/impactor of  FIG. 7 ; 
           [0026]      FIG. 9  is a top plan view of the inserter/impactor of  FIG. 7 ; 
           [0027]      FIG. 10  is a bottom view of the inserter/impactor of  FIG. 7 ; 
           [0028]      FIG. 11  is a rear view of the inserter/impactor of  FIG. 7 ; 
           [0029]      FIG. 12A  is top perspective view of a prior art 4-hole, neutral offset fracture fixation plate, configured for volar application in the fixation of certain fractures of the distal radius; 
           [0030]      FIG. 12B  is a bottom perspective view of the prior art fracture fixation plate of  FIG. 12A ; 
           [0031]      FIG. 13A  is top perspective view of a prior art 4-hole, neutral offset fracture fixation plate, configured for dorsal application in the fixation of certain fractures of the distal radius; 
           [0032]      FIG. 13B  is a bottom perspective view of the prior art fracture fixation plate of  FIG. 13A ; 
           [0033]      FIG. 14  is a top perspective view of another embodiment of a cannulated, guide wire-accommodating, double barreled drill guide, configured for dorsal application in the fixation of certain fractures of the distal radius, and shown having been slid along an exposed length of a distal guide pin and adjacent a fracture of the distal dorsal rim; 
           [0034]      FIG. 15  is a top perspective view of a portion of another embodiment of a cannulated, guide wire accommodating inserter/impactor and associated cannulated fastener, configured for dorsal application in the fixation of certain fractures of the distal radius, shown attached to a fracture fixation plate of  FIGS. 13A-13B  and after having been slid along an exposed length of a distal guide pin during placement adjacent a fracture of the distal dorsal rim; 
           [0035]      FIG. 16  is a top perspective view of the inserter/impactor, cannulated fastener, and fracture fixation plate of  FIG. 15 , shown following placement of the intra-osseous tines of the plate through the pilot holes and removal of the guide pins; and 
           [0036]      FIG. 17  is a top perspective view of the fracture fixation plate of  FIGS. 15 and 16 , showing complete fixation of a fracture of the distal dorsal rim. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0037]    While several different embodiments of certain components of the present invention are described herein and shown in the various figures, the use of the prime symbol in conjunction with common reference numerals in the figures denote similar or analogous elements or structure to those of a previously described embodiment. 
         [0038]    A four-hole, neutral offset bone plate  220 , configured for volar application in conjunction with fractures of the distal radius and for which the drill guide and inserter/impactor of  FIGS. 1-11  of the present invention may be employed for placement and affixation, is shown in  FIGS. 12A and 12B  as comprising elongated body  221 , having a first end  222  proximate first hook member, or intra-osseous tine  224  and second hook member, or intra-osseous tine  225 . Elongated body  221  includes a first region  228  proximate first end  222 , a second region  226  proximate a second end  223 , and an intermediate, angled, or “flared” region disposed between first region  228  and second region  226 . This angled region is generally defined and created by the presence of an angle of curvature relative to the bottom surface of bone plate  220  substantially matching the inclination of the flare of the associated bone requiring fracture fixation. 
         [0039]    Elongated body  221  further includes a plurality of apertures extending therethrough for use in conjunction with conventional locking or non-locking bone screws, with three circular holes, including female threaded locking peg hole  230 , and one slotted hole. The use of a locking peg placed through locking peg hole  230  and into adjacent bone provides enhanced subchondral fixation directed at an angle that extends between the axes of hook members  224  and  225 . This allows a third point of subchondral support in addition to the two hook members, acting like a cup behind the articular surface. The female threads of locking peg hole  230  permit a cannulated set screw to be employed to attach hook plate  220  to a cannulated inserter/impactor. 
         [0040]    Another four-hole, neutral offset bone plate  300 , configured for dorsal application in conjunction with fractures of distal radius and for which the drill guide and inserter/impactor of  FIGS. 14-16  of the present invention may be employed for placement and affixation, is shown in  FIGS. 13A and 13B  as comprising elongated body  301 , having a first end  302  proximate first hook member, or tooth member  304  and second hook member, or tooth member  305 . Elongated body  301  includes a curved apex proximate first end  302 , a second region  306  proximate a second end  303 , and an intermediate, angled, or “flared” region  307  disposed between the curved apex and second region  306 . 
         [0041]    Elongated body  301  further includes a plurality of apertures extending therethrough for use in conjunction with conventional locking or non-locking bone screws, including three circular holes, and one slotted hole. The use of a locking peg through locking peg hole  330  and into adjacent bone provides enhanced subchondral fixation directed at an angle that extends between the axes of hook members  304  and  305 . This allows a third point of subchondral support in addition to the two hook members, acting like a cup behind the articular surface. 
         [0042]    Angled or flared region  307  is generally defined and created by the presence of an angle of curvature relative to the bottom surface of bone plate  300  proximate the juncture of substantially linear first region  301  and substantially linear angled, or flared region  307 . The length of the linear angled region  307  and the inclination defined by the angle of curvature substantially match the length and inclination of the flare of the associated bone requiring fracture fixation, in this case the radius, with dorsal application proximate the dorsal rim at the distal radial epiphyseal plate. As a result, the bottom surface of elongated body  301  of bone plate  300  is given an overall longitudinal contour which substantially corresponds to the flared profile of the distal end of the human radius proximate the dorsal rim. 
         [0043]    A cannulated, central guide wire-accommodating, double barreled drill guide  100 , configured for use in addressing fractures of the volar rim of the distal radius in conjunction with the hook plates of  FIGS. 12A and 12B , and in conjunction with the cannulated inserter/impactor of  FIGS. 7 through 11 , is shown in  FIGS. 1 through 6  as comprising elongated body  110 , quick connect hub  120 , and head region  130 . Elongated body  110  comprises proximate end  111 , and distal end  112  terminating in head region  130 . With cross-reference to  FIGS. 12A and 12B , and with the exception of bosses  118  and associated guide pin tubes  117 , body  110  has substantially the same configuration and dimensions as elongated body  221  of hook plate  220 , with substantially linear region  114  of body  110  being configured substantially similarly to substantially linear region  226  of hook plate  220 , with flared region  115  of body  110  being configured substantially similarly to the flared region of hook plate  220 , and with bottom surface  116  of body  110  having a curvilinear, contoured shape substantially similar to the curvilinear, contoured bottom surface of elongated body  221  of hook plate  220 . 
         [0044]    Body  110  further comprises two opposing bosses  118  proximate first end  111 , each having a guide pin tube  117  sized to accommodate passage of a guide pin therethrough. Upon removal of double barreled drill guide  100  following the drilling of pilot holes for the intra-osseous tines, or hook members of a hook plate, guide pins placed through one or both of guide pin tubes  117  may be left in place, serving as temporary buttresses or locating members to facilitate accurate placement proximally of the hook plate as it is impacted into place and as it is further secured to the bone with suitable fasteners. Additional guide pin tubes may optionally disposed along body  110 , likewise sized to permit further guide pins to be placed therethrough, enabling further temporary securement of drill guide  100  in a desired position prior to the drilling of pilot holes for the intra-osseous tines of the hook plate. 
         [0045]    Quick connect hub  120  is coupled to body  110  and facilitates the optional connection of a quick release handle  160  to drill guide  100  to further facilitate manual placement of drill guide  100  across a fracture site, if desired. Quick connect hub  120  is generally cube-shaped, with two opposing planar sides  121  and two opposing arcuate sides  122 , yielding a horizontal cross-section that is substantially stadium-shaped. Planar sides  121  each have an associated dimpled indent  122  which, in conjunction with the stadium-shaped cross-section of quick connect hub  120 , facilitates the attachment of a quick release handle to quick connect hub  120 . Quick connect hub  120  further comprises central vertical channel  124 , extending through both quick connect hub  120  and body  110 , and having an associated countersunk aperture  125  extending through a top surface of quick connect hub  120 . Central vertical channel  124  is oriented, relative to body  110 , at an angle corresponding to the angle at which a distal locking peg is disposed through locking peg hole  230  of hook plate  220 , permitting a K-wire to be initially placed through vertical channel  124  in order to confirm the final position through which a distal locking peg will be placed between the axes of hook members  224  and  225 . 
         [0046]    Head region  130  of drill guide  100 , coupled to body  110  at distal end  112 , comprises two substantially parallel drill tubes  131  and  132 , with guide pin channel  133  disclosed between and parallel to drill tubes  131  and  132 . In a preferred embodiment, drill tubes  131  and  132  are both sized to closely accommodate the passage of a 1.75 millimeter drill bit in order to pre-drill pilot holes to accommodate the intra-osseous tines of hook plate  220 , and are spaced apart from each other by a distance substantially corresponding to the distance between intra-osseous tines  224  and  225  of the hook plate to be impacted into a distal bone fragment. The predominantly longitudinal axes of the drill guides are also oriented relative to a predominantly longitudinal axis of body  114  at an angle that substantially corresponds to the angle between the predominantly longitudinal axis of hooks  224  and  225  to the predominantly longitudinal axis of linear portion  226  of plate  220 . Alternatively, drill tubes  131  and  132  may of different diameter to accommodate other sizes of drills or pins, or enlarged to permit them to serve as outer sleeves that can accommodate a variety of tubular insert sleeves, each differently sized to accommodate a surgical drill bit having a specific desired diameter. 
         [0047]    Guide pin channel  133  is sized to closely accommodate the passage of a guide pin, such as a 1.1 millimeter Kirschner wire, or K-wire, therethrough. As discussed in further detail below, guide pin channel  133  permits a guide pin to initially be placed into the bone at a desired location of the fracture site, with the accuracy of the placement optionally verified by C-arm. The free, proximal end of the guide pin is then advanced through guide pin channel  133  from its bottom opening, by sliding drill guide  100  along the exposed length of the guide pin until arcuate bottom surface  116  of drill guide  100  rests against the surface of the bone proximate the fracture site, and the bottom openings of drill tubes  131  and  132  rest against the distal bone fragment(s) proximate the fracture site. Alternatively, the drill guide may be initially placed in position adjacent the bone, and a K-wire placed through guide pin channel  133  and into the bone, with subsequent optional verification of position using a C-arm. 
         [0048]    As discussed above, body  110  of drill guide  100  has substantially the same configuration, contour and dimensions as elongated body  221  of hook plate  220 . Moreover, as best seen in  FIGS. 2 ,  12 A and  12 B, the parallel longitudinal axes  134  extending through drill tubes  131  and  132  and guide pin channel  133  are disposed at an angle  135 , relative to longitudinal axis  136  of flared region  115  of body  110 , that substantially corresponds to the angle between the longitudinal axes of hook members  224  and  225  and the adjacent, flared region of hook plate  220 . In this manner, pilot holes drilled through drill tubes  131  and  132  following the positioning of drill guide  100  adjacent the bone, are disposed at an angle, or attitude, that permits body  221  of hook plate  220  to rest flush against the bone upon impacting the intra-osseous tines  224  and  225  of hook plate  220  into the pilot holes. 
         [0049]    A first embodiment of a cannulated inserter/impactor  140  of the present invention, configured for use in addressing fractures of the volar rim of the distal radius in association with the drill guide shown in  FIGS. 1 through 6  and the hook plate shown in  FIGS. 12A and 12B , is shown in  FIGS. 7 through 11  as comprising cannulated handle  150 , cannulated base  160  and cannulated set screw  170 . Although inserter/impactor  140  is show in  FIGS. 7 and 8  as being constructed of separate components  150  and  160 , in other embodiments these may be combined as a single structure. However, there are certain advantages to the two-piece construction of  FIGS. 7 through 11 . Specifically, it is desirably for the inserter/impactor to have a handle of sufficient length to provide a gripping region of sufficient size to provide ergonomic use and operation of the inserter/impactor. This desired length is significantly longer than the approximately three centimeters of exposed guide pin length that is to be left after cutting the guide pin following placement of the drill guide, as explained in detail below. Accordingly, a unitary inserter/impactor of having sufficient handle length will not leave an exposed guide pin extending through a top opening. The modular, two-piece construction of the inserter/impactor provides a handle of sufficient ergonomic length while, at the same time, upon separation of the handle, providing sufficient access and clearance to the guide pin to enable a drill to be employed for its removal. 
         [0050]    Handle  150  is generally cylindrical and hollow tubular in construction, and includes elongated body  151 , having a top striking surface  153 , bottom end  155 , and ribbed or knurled gripping region  152 . Channel  154  extends through body  151  from an opening through top surface  153  to an opening through bottom end  155 . Top surface  153  of handle  150  serves as a striking surface enabling a hammer to be employed to drive the hook members of a volar bone plate engaged by inserter/impactor  140  into associated pre-drilled pilot holes. A portion of the interior surface of channel  154  adjacent bottom end  155  is internally female threaded and threadedly engages a cooperating, male threaded portion  163  of base  160  for removable attachment of handle  150  to base  160 . 
         [0051]    Base  160  includes curvilinear bottom surface  164  and flange  168  having set screw aperture  169 . Set screw aperture  169  is internally female threaded to threadedly and axially receive male threads  172  of set screw  170  for removable attachment of set screw  170  to base  160 , and for overall removable attachment of inserter/impactor  140  to a hook plate such as volar plate  220  of  FIGS. 12A and 12B . A cannula, or longitudinal central channel  165 , sized in diameter to permit close passage of a guide pin to be extended therethrough, extends longitudinally through the entire length of base  160 , from the top surface to bottom surface  164 . Upon threaded attachment of handle  150  to base  160 , central channel  165  of base  160  communicates with channel or interior region  154  of handle  150 . 
         [0052]    Set screw  170  includes a cannula, or longitudinal channel extending therethrough, top opening  171 , and a shaft region terminating in male external threads  172 . The longitudinal channel includes an interior serrated or fluted region adjacent top opening  171  configured for mating engagement with a hexalobular-type or other suitable screwdriver. The shaft of set screw  170  is long enough to permit, upon full threaded advancement of set screw  170  through screw aperture  169  of base  160  until the head of set screw  170  contacts flange  168 , for at least a portion of threads  172  to extend through bottom surface  164  of base  160 , thereby permitting threads  172  to further threadedly engage locking peg hole  230  of hook plate  220 , thereby securing base  160  to hook plate  220 . 
         [0053]    Upon such securement of base  160  of inserter/impactor  140  to hook plate  220 , the predominantly longitudinal axis of the longitudinal channel extending through set screw  170  is positioned at an angle, relative to a predominantly longitudinal axis of the body of hook plate  220  at locking peg hole  230 , that is the same as the relative position and angle at which a predominantly longitudinal axis of central vertical channel  124  is positioned relative to a predominantly longitudinal axis of elongated body  110  of drill guide  100 . In this manner, and as will be discussed in further detail below, a K-wire or guide pin placed through central vertical channel  124  following placement of drill guide  100  adjacent a fracture site may be used as a guide for reference purposes as an indicator of the position at which a pilot hole for a cross-locking fastener to be placed through locking peg hole  230  may subsequently be drilled through set screw  170  upon the subsequent placement of hook plate  220  at the fracture site. 
         [0054]    Upon attachment of inserter/impactor  140  to a hook plate  220  via the threaded engagement of set screw  170  with locking peg hole  230 , the contour of curvilinear bottom surface  164  of inserter/impactor base  160  is configured to substantially match the adjacent top surface contours of, and to rest directly atop, a distal portion of hook plate  220 , with the apex of hook members  224  and  225  adjacent an arcuate portion of bottom surface  164 , and with a longitudinal axis of inserter/impactor  140  being parallel to and proximate to the longitudinal axes of hook members  224  and  225 . This, in turn, transfers a striking force applied to top striking surface  153  of inserter/impactor  140  in a direction substantially along the length of both hook members  224  and  225  of attached hook plate  220 , to facilitate impacting the hook members into previously drilled pilot holes into one or more bone fragments proximate a fracture site. 
         [0055]    Moreover, with reference to  FIG. 8 , the longitudinal axis of flange  168  is disposed at an angle  191  relative to the longitudinal axis of elongated body  151  that substantially coincides with the angle between the flared region and hook members  224  and  225  of bone plate  220 . Furthermore, with reference to  FIG. 2 , angle  191  also substantially coincides with angle  135  between longitudinal axis  134  of, collectively, drill tubes  131  and  132  and guide pin channel  133 , and longitudinal axis  136  of flared region  115  of drill guide  100 . This, in turn, further enables the parallel alignment of a longitudinal axis of body  151  of inserter/impactor  140  with the longitudinal axes of hook members  224  and  225  of bone plate  220  as well as with the longitudinal axes of the pilot holes that are drilled to accept the hook members using drill guide  100 . 
         [0056]    Notably, inserter/impactor  140 , unlike certain prior art inserters, does not require the placement of any portion of the inserter/impactor beneath the bottom surface of an attached bone plate in order to securely hold the bone plate, which requires removal of the inserter/impactor prior to final impaction of the bone plate adjacent the surface of the bone so as to avoid interference caused by intervening structure of the inserter/impactor. 
         [0057]    The use of an overall surgical system employing a cannulated drill guide and a cannulated inserter/impactor of the present invention will now be described with reference to  FIGS. 14 through 17  using variations of the components previously described, that are instead configured for use in addressing fractures of the dorsal rim of the distal radius in conjunction with the dorsal hook plate of  FIGS. 13A and 13B . 
         [0058]    First, a skin incision is made ulnar to Lister&#39;s tubercle. The dorsal retinacular sheath is excised, followed by dissection of either the 3 rd  and 4 th  or 4 th  and 5 th  extensor compartments. The extensor pollicis longus is transposed, if necessary, and the fracture is reduced, and temporarily fixed with one or more K-wires, as needed. 
         [0059]    Next, cannulated dorsal drill guide  100 ′ is placed in the desired position, as shown in  FIG. 14 . With cross-reference to  FIGS. 13A and 13B , and with the exception of bosses  118 ′ and associated guide pin tubes  117 ′, body  110 ′ of drill guide  100 ′ has substantially the same configuration and dimensions as elongated body  301  of hook plate  300 , with a substantially linear region of body  110 ′ being configured substantially similarly to a substantially linear region of hook plate  300 , with a flared region of body  110 ′ being configured substantially similarly to the flared region of hook plate  300 , and with a bottom surface of body  110 ′ having a surface contour substantially similar to the bottom surface contour of elongated body  301  of hook plate  300 . 
         [0060]    A quick release handle may optionally be attached to quick connect hub  120 ′ of drill guide  100 ′ to assist in the initial placement of drill guide  100 ′. Following initial placement of the drill guide, a 1.1 millimeter K-wire  10  is advanced through guide pin channel  133 ′ and into a terminal bone fragment in order to verify the positions on opposing sides of K-wire  10  in which the hook members of a dorsal hook plate are to be impacted. As shown in  FIGS. 14 and 15 , each K-wire  10  may include alternating stripes of a predetermined length, such as five millimeters, so that, among other things, the depth at which a K-wire is inserted into a bone may be readily gauged, and the length at which a K-wire is to be cut may be readily determined. A C-arm or other medical imaging apparatus is preferably employed to confirm that the position of K-wire  10  is subchondral to the joint and is properly positioned, both distally and angularly. 
         [0061]    A second K-wire may optionally be placed through central vertical channel  124 ′ of quick connect hub  120 ′ and advanced into the bone to verify the position where a cross locking peg will subsequently be placed through locking peg hole  330  of dorsal hook plate  300  and into the bone at a position between the hook plate&#39;s intra-osseous tines. The proper placement of this second K-wire may likewise be verified by C-arm, if desired. As shown in  FIG. 14 , additional K-wires  10  may further be placed through one or both of guide pin tubes  117 ′ extending from bosses  118 ′to function, upon subsequent removal of drill guide  100 ′ over K-wires  10 , as guides to facilitate the placement of a dorsal hook plate, proximally. 
         [0062]    Next, the distal K-wire  10  extending above vertical channel  124 ′ is cut to extend no more than approximately thirty millimeters, to provide clearance for drill bits to be advanced through drill tubes  131 ′ and  132 ′. If a K-wire  10  was previously placed through central vertical channel  124 ′ of quick connect hub  120 ′ as described above, this K-wire is removed. A 1.75 millimeter drill bit is then employed to drill holes at a desired depth through drill tubes  131 ′ and  132 ′ as pilot holes for the hook members of a dorsal hook plate, at the position and angle determined by the positioning of head region  130 ′ of drill guide  100 ′, further determined by the positioning and parallel angle of the initially placed K-wire  10 . Drill guide  100 ′ is then removed by sliding the drill guide along the previously placed K-wires and away from the surface of the bone. 
         [0063]    Next, as shown in  FIG. 15 , a cannulated inserter/impactor  140 ′, configured for use in addressing fractures of the dorsal rim of the distal radius, is secured to dorsal hook plate  300 . Specifically, a hexalobular or other suitable driver is employed to rotate cannulated set screw  170  clockwise, advancing the set screw through flange  168 ′ of base  160 ′, causing the set screw&#39;s threads to engage cooperating threads of peg hole  330  of bone plate  300 . This affixation may be simplified by providing a caddy having an assembly slot within an overall tray of hook plates, cannulated drill guides, cannulated inserters/impactors, cannulated set screws, K-wires, fasteners, and other implements, supplied as an overall kit for performing the present surgical procedure. 
         [0064]    Upon attachment of inserter/impactor  140 ′ to a hook plate  300  via the threaded engagement of set screw  170  with locking peg hole  330 , curvilinear bottom surface  164 ′ of inserter/impactor base  160 ′ is configured to substantially match the adjacent top surface contours of, and to rest directly atop, a distal portion of hook plate  300 , with the apex of hook members  304  and  305  adjacent an arcuate portion of bottom surface  164 ′, and with a longitudinal axis of inserter/impactor  140 ′ being parallel to and proximate to the longitudinal axes of hook members  304  and  305 . This, in turn, transfers a striking force applied to the top surface of inserter/impactor  140 ′ in a direction substantially along the length of both hook members  304  and  305  of attached hook plate  300 , to facilitate impacting the hook members into previously drilled pilot holes into one or more bone fragments proximate the fracture site. Moreover, with reference to  FIG. 15 , the longitudinal axis of flange  168 ′ is disposed at an angle relative to the longitudinal axis of handle  150 ′ that substantially coincides with the angle between the flared region and hook members  304  and  305  of bone plate  300 . This, in turn, further enables the parallel alignment of a longitudinal axis of handle  150  with the longitudinal axes of hook members  304  and  305  of bone plate  300 . 
         [0065]    As shown in  FIG. 15 , the cannula, or longitudinal central channel of base  160 ′ of inserter/impactor  140 ′ is positioned to engage and is then advanced along distal K-wire  10 , with hook members  304  and  305  of dorsal hook plate  300  being guided into the associated pilot holes, and with the additional K-wires  10 , if present, further guiding the edge of the hook plate, proximally, until hook plate  300  is fully seated, with a bottom surface of hook plate  300  positioned adjacent the bone and across the fracture site. A hammer may be applied to the striking surface of handle  150 ′ to fully seat dorsal hook plate  300 , as shown in  FIG. 16 . 
         [0066]    Next, a 2.3 millimeter screw  20  is placed through the proximal slotted hole of hook plate  300  and into the adjacent bone to secure hook plate  300  proximally. Handle  150 ′ is then unscrewed and removed from base  160 ′ of inserter/impactor  140 ′, and the distal K-wire is likewise removed. A hole is then drilled for a distal subchondral locking peg by advancing a suitably sized drill bit through the cannula, or longitudinal channel, of set screw  170  and into the adjacent bone, between the intra-osseous tines of hook plate  300 . Base  160 ′ is then removed by rotating cannulated set screw  170  counterclockwise to disengage the threads of set screw  170  from peg hole  330  of bone plate  300 . As shown in  FIG. 17 , proximal fixation is then completed using additional 2.3 millimeter cortical screws  20  or 2.3 millimeter threaded locking pegs. Depending upon the type and severity of the fracture, additional dorsal and/or volar hook plates may be applied in a similar manner, as needed. 
         [0067]    Each of cannulated double barreled drill guides  100  and  100 ′ and cannulated inserter/impactors  140  and  140 ′ may be constructed of a surgical stainless steel material, such as, for example, type 17-4 precipitation hardened surgical stainless steel, condition H-900. Cannulated set screw  170  may likewise be constructed of a surgical stainless steel material, such as, for example, type 455/465 precipitation hardened surgical stainless steel, condition H-900. The implants, guides, and inserter components may be alternatively manufactured from other suitable surgical grade materials 
         [0068]    The preceding description and drawings merely explain the invention and the invention is not limited thereto, as those of ordinary skill in the art who have the present disclosure before them will be able to make changes and variations thereto without departing from the scope of the present invention.