DEFINITION

Distal radius fractures are defined by their involvement of the metaphysis of the distal radius. They are assessed on the basis of fracture pattern, alignment, and stability:

Articular versus nonarticular Reducible versus irreducible Stable versus unstable

Irreducible or unstable fractures require surgical reduction and stable fixation.

Volar plating historically has been the method of choice for volar shear-type fractures.

Fixed-angle plates have become the preferred method of fixation for most types of distal radius fractures.

 

 

ANATOMY

 

The distal radius serves as a buttress for the proximal carpus, transmitting 75% to 80% of its forces into the forearm.

 

 

The remaining 20% to 25% of force is transmitted through the distal ulna and the triangular fibrocartilage complex (TFCC).

 

 

 

Thickness of distal radius articular cartilage is 1 mm or less.16 Dorsally

 

The distal radius is the origin for the dorsal radiocarpal ligament.

 

It is the floor of the fibro-osseous extensor tendon compartments and includes Lister tubercle, assisting in extensor pollicis longus function (FIG 1A).

 

The extensor tendons are in immediate contact with the dorsal surface of the distal radius.

 

Volarly

 

 

The distal radius is the origin for volar extrinsic ligaments of the wrist, including the radioscaphocapitate ligament and long and short radiolunate ligaments.

 

It also is the origin of the pronator quadratus.

 

The flexor tendons are separated from the distal radius by the pronator quadratus.

 

Ulnarly

 

 

The distal radius is the origin for the triangular fibrocartilage (see FIG 1A).

 

It also contains the sigmoid notch, which articulates with the head of the distal ulna, allowing forearm rotation.

 

Distally

 

 

The surface is divided into a triangular scaphoid fossa and a square lunate fossa articulating with each respective carpal bone (FIG 1B).

 

The distal articular surface is inclined approximately 22 degrees ulnarly in the coronal plane and 11 degrees volarly in the sagittal plane (FIG 1C,D).

 

The metaphysis is defined by the distal radius within a length of the articular surface that is equivalent to the widest portion of the entire wrist.

 

The dorsal cortical bone is less substantial than the volar cortical bone, contributing to the characteristic dorsal bending fracture pattern of distal radius fractures.

 

PATHOGENESIS

 

The mechanism of injury in a distal radius fracture is an axial force across the wrist, with the pattern of injury determined by bone density, the position of the wrist, and the magnitude and direction of force.

 

Most distal radius fractures result from falls with the wrist extended and pronated, which places a dorsal bending moment across the distal radius.

 

 

Relatively weaker, thinner dorsal bone collapses under compression, whereas stronger volar bone fails under tension, resulting in a characteristic “triangle” of bone comminution with the apex volar and greater comminution dorsal.

 

Other possible mechanisms form a basis for some fracture classifications such as the one proposed by Jupiter and Fernandez.6

 

Bending

 

 

Axial compression Shear

 

 

Avulsion Combinations

 

Articular involvement and its severity are the basis of some fracture classifications, such as the AO Orthopaedic Trauma Association (AO/OTA)10 and Melone12 classifications.

 

Articular involvement splits the distal radius into distinct fragments separate from the radius shaft (FIG 2):

 

 

Scaphoid fossa fragment

 

Lunate fossa fragment. With comminution of this fragment may be separated into two impacted articular fragments, involving the dorsal ulnar corner and the volar rim.11

NATURAL HISTORY

 

Clinical outcome usually, but not always, correlates with deformity.

 

 

Variable residual deformity can be tolerated best by individuals with fewer functional demands.

 

As wrist deformity increases, physiologic function is progressively altered.

 

 

Intra-articular displacement of 1 to 2 mm results in an increased risk of osteoarthritis.3, 7

 

 

Radial shortening of 3 to 5 mm or more results in increased loading of the ulnar complex.1, 15

 

P.54

 

 

 

 

FIG 1 • A. Axial magnetic resonance (MR) image of the wrist at the level of the distal radius. Lister tubercle is marked with an asterisk. Dotted lines represent dorsal and volar borders of the triangular fibrocartilage that helps stabilize the distal radioulnar joint. The dorsal distal radius acts as an attachment for dorsal extensor compartment sheaths. B. The distal articular surface of the radius is divided into a triangularly shaped scaphoid fossa (SF) and a square-shaped lunate fossa (LF). The distal ulna and the TFCC act as ulnar buttresses for the wrist. C. MR coronal cut of the distal radius. The articular surface of the distal radius is inclined about 22 degrees relative to the forearm axis (dotted lines). The ulnar aspect of the distal radius (ie, the lunate fossa) usually is distal to the end of the distal ulna (ie, negative ulnar variance). Note the solid lines marking ulnar variance. D. MR sagittal cut of the distal radius. The articular surface of the distal radius is inclined approximately 11-degree palmar relative to the forearm axis (dotted lines). Proximally, there exists relatively thinner dorsal cortical bone versus the thicker volar bone.

 

 

Dorsal angulation greater than 10 degrees shifts contact forces to the dorsal scaphoid fossa and the ulnar complex, causing increased disability.17, 20

 

The incidence of associated intracarpal injuries increases with fracture severity. Such injuries can account for poor outcomes. These injuries often are not recognized at first, leading to delayed treatment.4, 18

 

TFCC tears

 

 

 

Scapholunate and lunotriquetral ligament tears Chondral injuries involving the carpal surfaces Distal radioulnar joint injury

 

Distal ulnar fractures

 

 

 

FIG 2 • The arrowhead points to the articular split. Articular displacement of the scaphoid fossa fragment radially and the lunate fossa fragment ulnarly is apparent, as is significant shortening (ulnar positive variance) as outlined by the lines.

 

 

By predicting the stability of a distal radius fracture, deformity and its complications can be minimized. Several

risk factors have been suggested by LaFontaine et al8 and others. The presence of three or more indicates instability:

 

 

 

Dorsal (or volar apex) angulation greater than 20 degrees Dorsal comminution

 

 

 

Intra-articular extension Associated ulnar fracture Patient age older than 60 years

PATIENT HISTORY AND PHYSICAL FINDINGS

 

 

The mechanism of injury should be sought to assist in assessing the energy and level of trauma. Associated injuries are not uncommon and should be carefully ruled out.

 

 

Injuries to the hand, carpus, and proximal arm, including other fractures or dislocations Injuries to other extremities or the head, neck, and torso

 

Establish the patient's functional and occupational demands.

 

 

Document coexisting medical conditions that may affect healing such as smoking or diabetes. Determine possible risk factors for anesthesia and surgery, such as cardiac disease.

 

The physical examination should document the following:

 

 

Condition of surrounding soft tissues (ie, skin and subcutaneous tissues)

 

 

Quality of vascular perfusion and pulses Integrity of nerve function

 

Sensory two-point discrimination or threshold sensory testing

 

Motor function of intrinsic muscles, including thenar and hypothenar muscles, of the hand

 

 

P.55

 

Examination of the distal ulna, TFCC, and distal radioulnar joint should rule out disruption and instability.

 

 

Reliable physical examination of the carpus often is difficult, making radiographic review even more critical and followup examinations important.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Imaging establishes fracture severity, helps determine stability, and guides the operative approach and choice of fixation.

 

Plain radiographs should be obtained before and after reduction: posteroanterior (PA) (with the forearm in neutral rotation), lateral, and two separate oblique views.

 

 

Oblique views, in particular, help evaluate articular involvement, particularly the lunate fossa fragment (FIG 3A,B).

 

The lateral view should be modified with the forearm inclined 15 to 20 degrees to best visualize the articular surface (FIG 3C; see TECH FIG 5B,C).

 

Fluoroscopic evaluation can be useful because it gives a complete circumferential view of the wrist and, with traction applied, can help evaluate injuries of the carpus.

 

 

 

FIG 3 • A. This pronated view accentuates the dorsal articular surface irregularity (arrowhead) and the displaced fragment. B. This supinated view accentuates the displaced radial styloid fragment. C. On this lateral radiograph, the arrowhead points to the articular split and the displacement of the lunate fossa fragment. Note the dorsal angulation and collapse (dotted line). Observe the significantly thicker volar cortical bone in comparison to the dorsal bone. D,E. AP and lateral cuts taken from CT images of a distal radius fracture revealing the extent of comminution and central impaction, which are not easily appreciated on plain radiographs.

 

 

Computed tomography (CT) helps define intra-articular involvement and helps detect small or impacted fragments, which may not be apparent on plain radiographs, particularly those involving the central portion of the distal radius (FIG 3D,E).

 

DIFFERENTIAL DIAGNOSIS

Diagnosis is directly confirmed by radiographs.

Associated and contributory injuries should always be considered.

Pathologic fracture (eg, related to tumor, infection)

 

Associated injuries to the carpus (eg, scaphoid fracture, scapholunate ligament injury)

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative treatment is reserved for distal radius fractures that are reducible and stable based on the criteria previously discussed.

 

 

The goal of nonoperative treatment is to immobilize the wrist while maintaining acceptable alignment until the fracture is healed.

 

 

Goals for treatment9

P.56

 

 

 

Radial inclination greater than 10 degrees Ulnar variance less than 3-mm positive

 

 

Palmar tilt less than 10 degrees dorsal or 20 degrees volar Articular congruity with less than a 2-mm gap or step-off

 

Patients are immobilized in a short-arm cast for 6 weeks. Radiographic follow-up is performed on a weekly basis for the first 2 to 3 weeks to identify fracture displacement that may warrant reduction.

 

SURGICAL MANAGEMENT

 

The goal of operative treatment is to achieve acceptable alignment and stable fixation.

 

Various methods of fixation are available: pins, external fixators, intramedullary devices, and plates (volar, dorsal, fragment specific).

 

Preoperative Planning

 

Preoperative medical and anesthesia evaluation are performed as required.

 

Discontinue blood-thinning medications (anticoagulants and nonsteroidal anti-inflammatory drugs, especially acetylsalicylic acid).

 

Request necessary equipment, including fluoroscopic and power equipment.

 

Confirm the plate fixation system to be used, and check the equipment before beginning surgery for completeness (ie, all appropriate drills, plates, and screws).

 

 

Have a contingency plan or additional fixation (external fixator, bone graft, or bone graft substitute). Review and have previous radiographic studies available.

 

Consider use of a regional anesthetic for postoperative pain control.

 

Positioning

 

 

Place the patient in the supine position with the affected extremity on an arm table. Apply an upper arm tourniquet, preferably within the sterile field.

 

Incorporate weights or a traction system to apply distraction across the fracture (FIG 4).

 

The surgeon is seated so that the elbow is pointing toward the patient's torso and the dominant hand works toward the fingers of the patients.

 

The assistant is seated opposite the surgeon.

 

The fluoroscopy unit is brought in from the end or corner of the table.

 

Approach

 

Dorsal exposure allows for direct visualization of the articular surface when necessary.

 

 

 

FIG 4 • Traction is applied over the arm table with finger traps and hanging weights. The surgeon sits on the volar side and the assistant on the dorsal side. Fluoroscopy can be brought in from any direction but preferably from the side adjacent or the opposite surgeon.

 

 

Fracture comminution is more severe dorsally, making overall alignment more difficult to judge.

 

The thicker volar cortex is less comminuted, allowing for more precise reduction and buttressing of bone fragments.

 

Sometimes, both dorsal and volar exposures may be necessary to achieve articular congruency and volar reduction and fixation, respectively.

 

An extended volar ulnar exposure may be necessary to manage isolated volar fractures of the lunate facet or to perform a simultaneous carpal tunnel release if indicated.

 

The techniques described in this chapter use the volar approach to distal radius, as described by Henry (FIG 5).

 

 

 

FIG 5 • The volar incision is represented by the dotted line just proximal to the wrist flexion creases and radial to the flexor carpi radialis longus. Care is exercised to avoid dissection from ulnar to the flexor carpi radialis because the palmar cutaneous nerve branch of the median nerve (arrow) is at risk.

 

 

 

P.57

 

TECHNIQUES

• Volar Fixed-Angle Plate Fixation of the Distal Radius

Incision and Dissection

Make a 4- to 8-cm longitudinal incision from the proximal wrist flexion crease proximally, along the radial border of the flexor carpi radialis tendon.

Use a zigzag incision to cross the wrist flexion creases if required.

Carefully avoid the palmar cutaneous branch of the median nerve which arises within 10 cm of the wrist flexion crease and travels along the ulnar side of the flexor carpi radialis tendon.

Branches of the dorsal radial sensory nerve and lateral antebrachial cutaneous nerve may appear along the path of the incision and also need to be protected.

At the distal end of the incision, protect the palmar branch of the radial artery to the deep palmar arch.

It usually is not necessary to dissect out the radial artery (TECH FIG 1A).

Incise the anterior sheath of the flexor carpi radialis tendon and retract the tendon ulnarly to help protect the median nerve (TECH FIG 1B).

 

 

 

 

TECH FIG 1 • A. The interval between the radial artery (arrow) and the flexor carpi radialis tendon (asterisk) is seen. B. The posterior sheath (asterisk) of the flexor carpi radialis is visible after retracting the flexor carpi radialis ulnarly (arrow). Be careful during deeper dissection because swelling and hematoma may distort the position of the median nerve beneath the sheath. C. Following incision in the flexor carpi radialis posterior sheath, the deep tendons are visible, including the flexor pollicis longus (FPL) and the flexor digitorum superficialis (FDS) of the index finger. The median nerve also is visible (asterisk). D. The palmar cutaneous nerve branches of the median nerve (arrowhead) and median nerve (asterisk) are both at risk for injury during this approach. Be careful regarding placement of retractors and during dissection and plate placement. (continued)

 

 

Incise the posterior sheath of the flexor carpi radialis tendon.

 

The deep tissues likely will bulge out from the pressure of swelling and fracture hematoma.

 

The median nerve is at risk lying within the subcutaneous tissues along the ulnar portion of the wound (TECH FIG 1C,D).

 

The flexor pollicis longus tendon sits along the radial margin of the wound.

 

Using blunt dissection with a gauze-covered finger, sweep the tendons and the nerve ulnarly.

 

A self-retaining retractor is carefully placed just deep to the radial artery radially and the tendons and median nerve ulnarly.

 

The pronator quadratus is now visualized on the floor of the wound.

 

Incise the pronator quadratus at its radial insertion, leaving fascial tissue on either side to aid in closure. Also, determine the proximal and distal extent of the muscle, and make horizontal incisions at both of those points (TECH FIG 1E).

 

The distal margin of the pronator quadratus attaches along the distal volar lip of the distal radius, along

the “teardrop” and the watershed line.

 

The radial margin is in proximity to the tendons of the first dorsal compartment and the brachioradialis.

 

 

P.58

 

 

 

TECH FIG 1 • (continued) E. The pronator quadratus (PQ) is incised distally, radially, and proximally and then reflected ulnarly after dissection off the volar distal radius. F. The brachioradialis (arrow) can be a deforming force, especially in comminuted fractures and in those for which treatment has been delayed. This tendon can be released if necessary.

 

 

Subperiosteally, dissect the pronator quadratus off the volar surface of the distal radius as an ulnarly based flap with a knife or elevator.

 

Retract the pronator ulnarly with the flexor tendons and median nerve.

 

Particularly, if significant shortening of radial-sided fracture fragments has occurred, incise the broad insertion of the brachioradialis to eliminate the deforming force (TECH FIG 1F).

 

 

Release the first dorsal compartment and retract the tendons before releasing the brachioradialis. Alternatively, Z-lengthen the brachioradialis tendon to allow for repair at the completion of the case.

Fracture Reduction and Provisional Fixation

 

Apply a lobster claw clamp around the radius shaft at a perpendicular angle to the volar surface at the most proximal portion of the wound (TECH FIG 2A).

 

This allows for excellent control of the proximal shaft for rotation and translation, providing an excellent counterforce when correcting the dorsal angulation collapse.

 

It also aids in soft tissue retraction.

 

With the fracture now exposed, apply traction distally to distract and disimpact the fragments.

 

Carefully clean the fracture of any interposed muscle, fascia, hematoma, or callus while maintaining the bony contours.

 

In the case of significant volar comminution, reduce and provisionally stabilize the fragments with K-wires.

 

Take plate positioning into account when placing these K-wires.

 

The articular surface is first reduced, if necessary.

 

Under fluoroscopic guidance, manipulate the articular fragments through the fracture with a periosteal elevator, osteotome, or K-wires (TECH FIG 2B,C).

 

Longitudinal traction is important during this reduction phase. It can be performed by an assistant or using crosstable weights and finger traps.

 

A dorsal exposure is performed at this stage if there is significant articular impaction, particularly

centrally, that cannot be corrected using the extra-articular technique described here.

 

Place K-wires from the radial styloid fragment into the lunate fossa fragment to maintain the articular reduction (TECH FIG 2D).

 

The K-wires should be placed as close as possible to subchondral bone (TECH FIG 2E,F).

 

Once the distal articular reduction is complete, reduce the distal radius as a single unit to the radius shaft.

 

Insert K-wires as required to maintain the provisional reduction between the distal fragments and the proximal shaft fragment.

 

If radial collapse and translation are prominent, a large K-wire can be introduced into the radial portion of the fracture. By advancing it proximally and ulnarly, it behaves like an intrafocal pin, providing a radial buttress by pushing the distal fragment ulnarly.

 

A similar technique can be applied through the dorsal fracture to assist in maintaining palmar tilt correction.

Plate Application

 

Apply a fixed-angle volar plate to the volar surface of the distal radius and shaft. Position the plate to accommodate for the unique design characteristics of the plating system as well as the location of the fracture fragments.

 

Each plating system has unique characteristics that determine its optimal placement.

 

Ideally, the plate should be placed as close to the articular margin as possible without the distal locking pegs or screws penetrating the joint.

 

If the fracture has not yet been fully reduced, this must be taken into account when placing the device.

 

Plate placement distal to the watershed line should be avoided as this increases the risk for flexor tendon rupture.

 

Clamp the previously applied lobster claw to the proximal portion of the plate to keep the plate centralized on the radius shaft.

 

Place provisional K-wires through the plate to maintain position (TECH FIG 3). Then fluoroscopically confirm proper plate position in both the distal proximal and radioulnar directions.

 

Proper alignment of the plate can be determined only using a true anteroposterior (AP) image in which the distal radioulnar joint is well visualized.

 

The K-wires allow for fine adjustment in plate position before committing to insertion of a screw.

 

 

P.59

 

 

TECH FIG 2 • A. A lobster claw clamp (double arrow) is applied to the radius shaft well proximal to the fracture. This instrument helps the surgeon control the radius during reduction and define the lateral margins of the radius. A Freer elevator is inserted into the fracture to help disimpact the fragments and assist in their reduction. B. The brachioradialis (white arrow) is released, and the first compartment extensor tendons are visible in the background (black arrow). An instrument can now be placed to assist in the reduction (arrow). C. The Freer elevator is used to reduce the fragments. In this case, the intra-articular step-off is being corrected, and the radial length and inclination are being restored. D. K-wires are placed across the radial styloid into the reduced ulna fossa fragment. An assistant usually applies traction, and the lobster claw clamp can be used for powerful leverage. If there is no articular involvement, this K-wire can be placed into the radius metaphysis or diaphysis proximally. E. The K-wire should be placed as close as possible to the subchondral bone, avoiding areas of comminution. F. The K-wire should maintain the articular reduction without any support.

 

 

 

TECH FIG 3 • Keep the plate centered on the radius and as distal as possible. The lobster claw clamp helps keep the plate centered. K-wires (arrowheads) are helpful as provision fixation until alignment can be confirmed radiographically and screws placed.

 

 

Drill and insert a provisional screw in the oblong hole in the plate.

 

If the bone is osteopenic, a screw longer than the initial measurement should be placed to ensure that both cortices are engaged. Otherwise, the plate may not be held securely, and reduction will be compromised. After the remaining screws have been secured, this screw can be replaced with one of appropriate length.

 

Insert at least one additional proximal screw and remove the provisional K-wires holding the plate in place.

Distal Fragment Reduction

 

Once the plate has been secured proximally, execute any additionally needed reduction.

 

A well-designed plate serves as an excellent buttress for correction of palmar tilt (TECH FIG 4A).

 

 

P.60

 

Apply counterforce through the lobster claw clamp in a dorsal direction while the distal hand and wrist are translated palmarly and flexed (TECH FIG 4B).

 

This maneuver reduces the distal radius to the plate, effectively restoring volar tilt by pushing the lunate against the volar lip of the distal radius (TECH FIG 4C,D).

 

Additional distraction and ulnar deviation correct radial collapse and loss of radial inclination.

Plate Fixation

 

While the reduction is held, drill the holes in the distal plate segment (TECH FIG 5A).

 

Some plate systems allow for provisional fixation using K-wires placed through the distal plate segment.

 

Do not penetrate the dorsal distal radius with the drill, thereby avoiding injury to the dorsal extensor tendons.

 

Drill and place the distal ulnar screws first and then proceed radially and proximally.

 

Accurate screw placement using the same inclination of the drill is required to avoid cross-threading into the plate and lessening stability.

 

Judge the placement of all distal screws or pegs precisely using fluoroscopic imaging in multiple planes.

 

In order to confirm extra-articular placement of distal screws, perform a “true” lateral view of the wrist with the x-ray beam at a 20-degree angle to the radius shaft (TECH FIG 5B,C). This is facilitated by lifting the wrist off the table with the elbow maintained on the table and the forearm at a 20-degree angle to the table (TECH FIG 5D,E).

 

The extensor pollicis longus is at greatest risk of injury from a protruding screw.

 

Because of the prominence of Lister tubercle and the triangular configuration of the distal radius, the lateral view of the wrist may not accurately rule out dorsal screw protrusion.

 

The dorsal horizon view can aid in assessing adequate screw length dorsally. It is obtained by wrist hyperflexion and aiming the beam of the image intensifier along the long axis of the radius.5

 

Sequentially insert the remaining distal screws or pegs, followed by the remaining proximal plate screws (TECH FIG 5F).

 

If necessary, add bone graft or bone graft substitute around the plate into the fracture site or through a small dorsal incision.

 

Precisely assess the stability of the construct after the plate has been applied. If appropriate, remove the provisional K-wires.

 

If the K-wires are deemed critical for fracture stability, they can be left in place and removed 4 to 8 weeks later.

 

If residual instability exists, add additional fixation with K-wires, an external fixator, a dorsal plate, or a combination.

 

 

 

TECH FIG 4 • A. The final reduction is performed with traction on the hand and with the radius held proximally with a clamp. Once the reduction is confirmed radiographically, the assistant places the distal screws or K-wires. B. The hand is translated (not appreciably flexed) palmarly while the radius shaft is held with the clamp. Prereduction (C) and postreduction (D) radiographs demonstrating the palmar translation reduction maneuver. The volar plate acts as a strong buttress (arrows), allowing the translated lunate to push on the volar radius (asterisk) and correct the dorsal angulation deformity.

 

 

P.61

 

 

 

TECH FIG 5 • A. The remaining holes can now be drilled and screws placed where needed. B. This screw (arrowhead) looks as though it has penetrated the joint, when in reality, it is simply the angle of the radiographic beam that throws its projection into the joint. C. A true lateral view of the distal radius is necessary to judge placement of the radial screws. D. A radiograph is being taken with the wrist perpendicular to the x-ray beam (arrow). This is not a true lateral image because the distal surface of the radius is inclined 20 degrees radially. E. By lifting the hand and wrist 20 degrees off the table, a true lateral image can be achieved. The x-ray beam is now perpendicular to the joint (arrow). F. The remaining screws have been placed.

Closure

 

Repair the pronator quadratus to its insertion site with a series of 3-0 absorbable horizontal mattress sutures (TECH FIG 6A).

 

In many cases, it is impossible to repair the pronator quadratus because the muscle and fascia are extremely thin or the muscle is damaged. In this situation, the muscle can be débrided or simply left in place.

 

Before skin closure, obtain final radiographs (TECH FIG 6B,C) and assess the stability of the distal radioulnar joint.

 

 

Place a drain only if excessive bleeding is anticipated. Consider methods to minimize postoperative pain.

 

 

Percutaneous placement of a pain pump catheter Injection of a long-acting local anesthetic

 

Close the subcutaneous tissues with a 4-0 braided absorbable suture and reapproximate the skin with interrupted 4-0 or 5-0 nylon sutures or a running subcuticular stitch.

 

Place two layers of gauze and a nonadherent gauze over the wound, wrap the wrist and forearm with thick Webril (Kendall, Mansfield, MA), and apply a below-elbow splint in a neutral wrist position, leaving the metacarpophalangeal joints free for range of motion (ROM) (TECH FIG 6D).

 

If there is injury to the ulnar wrist (eg, ulnar styloid fracture, distal radioulnar joint injury), immobilize the forearm in slight supination with an above-elbow or sugar-tong (Munster) splint.

 

 

P.62

 

 

 

TECH FIG 6 • A. The pronator quadratus (PQ) has been repaired. B. AP radiograph demonstrating correction of the articular surface, radial height (lines), and radial inclination (dotted line). C. Lateral radiograph demonstrating correction of the palmar tilt (dotted line). D. A bulky dressing is applied with a volar splint holding the wrist in a neutral position. A pain pump catheter has been inserted for additional pain control.

• Volar Fixed-Angle Plate Using the Plate as Reduction Tool

 

We do not recommend use of the volar fixed-angle plate as a reduction tool in the acute setting. It is best employed (if at all) for a malunion or perhaps for a fracture with minimal articular comminution.

 

This technique is difficult because the plate must be applied accounting for the coronal, sagittal, and translational deformities associated with the fracture fragments before the reduction has been achieved.

 

Perform the surgical approach as previously described.

 

Address first any distal articular involvement with reduction and K-wire fixation.

 

Affix the plate to the distal fragment, accounting for where the plate will sit on the radius shaft once the

reduction is completed.

 

Place the screws so that they are parallel to the articular surface on the lateral x-ray view (TECH FIG 7A,B).

 

On the AP radiograph, align the plate with the perpendicular of the radial inclination of the distal radius (20 degrees; TECH FIG 7C,D).

 

Once distal fixation is complete, secure the proximal plate to the radius shaft, thereby completing the reduction.

 

Close and splint as described previously.

 

 

 

TECH FIG 7 • A. The volar plate is applied with the distal screws placed first (parallel to distal articular surface). (continued)

 

 

P.63

 

TECH FIG 7 • (continued) B. Reducing the plate to the diaphysis proximally accomplishes the reduction. C. The plate is applied at approximately a 20-degree angle relative to the distal articular surface or to the amount of angulation that is estimated. D. By reducing the plate to the diaphysis, the distal angulation is corrected.

 

 

 

PEARLS AND PITFALLS
	Preoperative ▪ Obtain multiple radiographs in different positions (eg, several oblique views), planning especially in the setting of comminution or articular involvement. Obtain a CT scan if assessing the pattern of fracture when radiographs alone are difficult or uncertain.     Surgical ▪ Avoid crossing the distal flexion creases of the wrist. approach ▪ Avoid ulnar exposure to the midline of the flexor carpi radialis. Use extra care with deep dissection in the presence of hematoma or significant swelling.     Fracture ▪ Employ traction across the wrist with a device or weights. reduction ▪ Use a lobster claw clamp on the proximal radius shaft for control of the forearm and as a reference for the lateral margins. Use instruments to disimpact and reduce articular fragments through the fracture itself, either volarly, dorsally, or both. Employ a temporary K-wire to stabilize the reduction before placement of the plate.     Plate ▪ Confirm appropriate radial-ulnar positioning of the proximal plate using a true AP radiograph (ie, forearm in supination with open view of the distal radioulnar joint).

 

	alignment ▪ Confirm proper distal plate position on a true lateral view (ie, forearm 20 degrees off the table). Place the plate as distal as possible, up to the volar teardrop (watershed line) of the distal radius, if possible. Evaluate the screws for possible joint penetration using 360-degree fluoroscopic images.     Plate fixation ▪ Use K-wires to fix the plate provisionally to the proximal radius. The initial “oblong hole” screw should be slightly longer than the measured length to ensure better initial fixation.     Postoperative ▪ Closure of the pronator quadratus is not critical and should be reserved for more substantial muscles with limited trauma. Begin immediate ROM to digits with edema.

 

 

 

P.64

POSTOPERATIVE CARE

 

The wrist is splinted in a neutral position, leaving the digits free.

 

 

If the fracture is particularly tenuous or there is injury to the ulnar wrist, a long-arm or sugar-tong (Munster) splint is applied.

 

Vitamin C 500 to 1500 mg per day for 6 weeks is recommended to reduce the incidence of complex regional pain syndrome.22

 

The patient is instructed to perform active ROM exercises for the digits every hour and to engage in strict elevation for at least 3 days.

 

 

It is critical to emphasize edema prevention and immediate ROM of the digits.

 

At 1 week postoperatively, the splint is removed and the wound is examined.

 

If swelling permits, the therapist fabricates a molded Orthoplast splint (Johnson & Johnson Orthopedics, New Brunswick, NJ) to be worn at all times.

 

 

Active ROM exercises of the wrist are implemented 1 week postoperatively. At 4 to 6 weeks, putty and grip exercises are added.

 

 

At 6 to 8 weeks, the splint is discontinued, and progressive strengthening exercises are advanced. If necessary, progressive passive ROM can begin, including use of dynamic splints.

 

At 10 to 12 weeks, the patient usually can be discharged to all activities as tolerated.

 

Elderly patients with distal radius fractures are at increased risk of sustaining other osteoporosis-related fractures. A referral to an osteoporosis clinic is advised.

 

OUTCOMES

Overall good to excellent results can be expected in over 80% of patients with ROM, strength, and outcomes scoring.13, 14, 19, 21

 

Studies comparing volar fixation to other forms of fixation (eg, external fixators, pins, and dorsal plating) have revealed similar if not superior results.

Results appear to be superior in the early recovery period, with the final outcome yielding equivalent results among all fixation groups.

Some studies suggest better maintenance in overall reduction compared to other forms of fixation.

 

 

 

COMPLICATIONS

Complication rates as high as 27% have been reported.

Complications can be categorized into those involving hardware, fracture, soft tissues, nerves, and tendons.2

Failures of hardware, such as plate or screw breakage, can occur but are rare. Usually, such failures are an indication of other problems, such as nonunion.

The hardware becomes unacceptably prominent in a minority of patients.

This complication may become evident only after some time has elapsed, as swelling of fibrous tissue subsides and bone remodels.

The most common sites include the dorsal wrist, when screws have been inserted, and the radial wrist, when a plate has been used.

It can be avoided with careful screw and plate placement and radiographic verification of their position.

Nonunion and delayed union are unusual. Consider a diagnosis of osteomyelitis or other risk factors such as smoking.

Loss of fracture reduction and fixation can occur and is most common in patients with osteopenic bone or comminuted and articular fractures.

This can be avoided with frequent and early follow-up with repeat radiographs. If instability is suspected, the fracture can be casted.

In the operating room, if instability is suspected, additional fixation should be considered (eg, external fixator, pins, bone graft).

Soft tissue complications are proportional to the energy of the initial injury. Open wounds usually can be addressed with local measures.

Significant swelling must be addressed with early and aggressive modalities. Swelling can lead to other complications, such as joint stiffness and tendon adhesions.

Nerve injuries can be the result of initial trauma or subsequent surgical trauma.

Assess and document neurologic status before surgery.

Avoid further injury to nerves with careful placement of retractors.

The palmar cutaneous branch of the median nerve can be injured during incision and exposure. Postoperative neuromas can cause pain and sensitivity along scar.

Avoid the nerve with a well-placed incision radial to the flexor carpi radialis and careful deep dissection.

Postoperative swelling also can lead to median neuropathy. Carpal tunnel release should be performed if there is any suspected compression neuropathy or if this is to be anticipated as a result of postoperative swelling.

Tendon complications include adhesions and ruptures.

Most tendon adhesions involve the dorsal extensor tendons resulting in extrinsic extensor tightness. Flexor tendon adhesions are uncommon and involve primarily the flexor pollicis longus.

Tendon ruptures have been described, especially involving the flexor pollicis longus and the extensor pollicis longus, as a result of plate and screw prominence, respectively.

The distal screws must not be left prominent, and caution must be applied when drilling.

The sagittal and coronal profiles of the plate being used must be taken into consideration—some plates are very prominent and extend far radially.

 

 

REFERENCES

1. Aro HT, Koivunen T. Minor axial shortening of the radius affects outcome of Colles' fracture treatment. J Hand Surg Am 1991;16(3):392-398.

    

    

2. Arora R, Lutz M, Hennerbichler A, et al. Complications following internal fixation of unstable distal radius fracture with a palmar lockingplate. J Orthop Trauma 2007;21(5):316-322.

    

    

3. Fernandez JJ, Gruen GS, Herndon JH. Outcome of distal radius fractures using the short form 36 health survey. Clin Orthop Relat Res 1997;(341):36-41.

    

    

4. Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78(3):357-365.

    

    

5. Joseph SJ, Harvey JN. The dorsal horizon view: detecting screw protrusion at the distal radius. J Hand Surg Am 2011;36(10):1691-1693.

    

    

6. Jupiter JB, Fernandez DL. Comparative classification for fractures of the distal end of the radius. J Hand Surg Am 1997;22(4):563-571.

    

    

   P.65

    

7. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68(5):647-659.

    

    

8. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20(4):208-210.

    

    

9. Lichtman DM, Bindra RR, Boyer MI, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am 2011;93(8):775-778.

    

    

10. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 suppl):S1-S133.

     

     

11. Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005;21(3):279-288.

     

     

12. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am 1984;15(2):217-236.

     

     

13. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg Am 2005;30(4):743-749.

     

     

14. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am 2004;29(1):96-102.

     

     

15. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg Am 1990;15(5):721-727.

     

     

16. Pollock J, O'Toole RV, Nowicki SD, et al. Articular cartilage thickness at the distal radius: a cadaveric study. J Hand Surg Am 2013;38(8):1477-1481.

     

     

17. Porter M, Stockley I. Fractures of the distal radius. Intermediate and end results in relation to radiologic parameters. Clin Orthop Relat Res 1987;(220):241-252.

     

     

18. Richards RS, Bennett JD, Roth JH, et al. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am 1997;22(5):772-776.

     

     

19. Rozental TD, Blazar PE, Franko OI, et al. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am 2009;91(8):1837-1846.

     

     

20. Short WH, Palmer AK, Werner FW, et al. A biomechanical study of distal radial fractures. J Hand Surg Am 1987;12(4):529-534.

     

     

21. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg Am 2005;30(2):289-299.

     

     

22. Zollinger PE, Tuinebreijer WE, Breederveld RS, et al. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am 2007;89(7):1424-1431.