Key Points

Myriad treatment options exist for complex distal radius fractures, with various surgical approaches, reduction techniques, fixation options, and reconstructive procedures available. However, there are important core principles upon which to guide treatment. This article reviews an approach that involves structured evaluation, aggressive soft tissue management, early reduction and skeletal stabilization, and a columnar approach to definitive care of the osseous and ligamentous injuries.

Evaluation and initial management

The assessment of complex distal radius fractures requires an organized approach to assess injury severity and identify associated injuries. The location and severity of pain, and history of neurologic or vascular symptoms help identify arterial injury, nerve injury, or compartment syndrome. The timing of neurologic symptoms may indicate whether there is ongoing or progressive nerve compression ( Box 1 ).

Physical examination is the mainstay of assessment of complex distal radius injuries. The entire limb is closely examined to evaluate soft tissue integrity, degree of deformity, instability, tenderness, and neurovascular status. Pain and tenderness will limit some aspects of evaluation. Perfusion is assessed with color, warmth, pulse oximetry, and/or Doppler ultrasound as needed. Neurologic examination is documented with graded motor strength and objective sensation measures such as 2-point discrimination, monofilament threshold, or vibration testing. Progressive deterioration requires urgent intervention.

Tourniquets are avoided before hospitalization and emergency management to maintain perfusion to surrounding muscle and other soft tissues. Open wounds are irrigated and dressed, with pressure dressings applied to actively bleeding wounds. Extremities are realigned and splinted with adequate analgesia and sedation. Tetanus and antibiotic prophylaxis is given at the time of initial evaluation. First-generation cephalosporin coverage is sufficient for Gustilo-Anderson grade 1 and 2 injuries, and infectious complication rates are more similar to those of closed injuries. For grade 3 injuries, gram-negative coverage with gentamicin is recommended. Soil contamination may be an indication for penicillin prophylaxis against clostridia species, and other antibiotics may be recommended for specific scenarios such as aquatic injuries.

Plain film radiographs of the wrist and forearm are obtained, including posteroanterior, lateral, and oblique views. A detailed description of the radiolographical evaluation of distal radius fractures is beyond the scope of this article, but an excellent discussion of this is available elsewhere. Radiographs of the elbow and shoulder are obtained when there is suspicion of proximal injury. Traction and/or stress radiographs may be helpful in identifying fracture fragments and patterns of instability. CT clarifies fracture pattern and position in suspected die punch fractures, volar rim fractures, and carpal fractures or dislocations, but can be difficult to interpret prior to realignment of the injury.

The patient may then be brought to the operating room for surgical debridement, skeletal stabilization, and possible definitive fixation of the fracture and/or soft tissue reconstruction as needed. Physical examination and imaging that were limited by pain and other factors in the emergency department can be better assessed under anesthesia.

Soft tissue management—Lister’s tumor debridement

The outcome of open distal radius fractures with significant soft tissue injury is dominated by factors related to the wounds. The ability to prevent contamination from becoming sepsis correlates best with functional outcome, and is influenced by the extent and adequacy of debridement and the restoration of the soft tissue envelope. Historically, tissues were debrided every 48 to 72 hours to allow tissues to declare themselves, until all nonviable tissues were removed. This technique is well established, but associated with bacterial wound colonization and delays in definitive reconstruction. The authors avoid this wait-and-see approach and perform early aggressive debridement ( Box 2 ).

Lister asserted that upon completion of a single aggressive debridement, the wound should resemble a tumor resection. This is done under tourniquet control, so the viability or ischemia of tissues is not obscured by blood in the field. If the investing tissue of nerves, arteries, and tendons is visibly contaminated, debridement is limited to removal of adventitia, epineurium, and epitenon; excision of intact nerves, arteries, or tendons is avoided. Tissues are left in place to declare themselves only in the setting of a broad crush injury, where the extent of muscle damage cannot be defined, and this requires repeat debridement every 48 hours.

Free tissue transfer can significantly improve potential for limb salvage over amputation when needed. In cases where immediate soft tissue coverage is not feasible due to available resources or fatigue of the operative team, wet-to-moist gauze can be changed regularly, or polymethylmethacrylate (PMMA) antibiotic bead pouches or negative pressure wound therapy can be applied. Generally, the authors aim for complete coverage within 1 week of injury.

The authors often use negative-pressure wound therapy (NPWT) when soft tissue reconstruction is not immediately feasible. Animal data suggest that the negative pressure leads to decreased edema, improved blood flow, increased granulation tissue, and improved bacterial clearance. A recent comparative study of NPWT and wet-to-moist gauze for complex open fracture wounds also showed decreased rates of infection (5.4% vs 28%). On the other hand, NPWT has not been shown to shorten the time to closure or influence the choice of closure. Size, grade of soft tissue injury, and degree of contamination remain the primary determinants of time to achievement of a clean stable wound for closure, not the dressing.

Prolonged duration of antibiotic coverage has not been shown to improve outcome in regard to infectious complications. A short course of antibiotics (12 hours) has been shown to be equally effective to a prolonged course of antibiotics (14 days). The authors typically limit antibiotic prophylaxis to 24 hours after soft tissue coverage is achieved.

Soft tissue management—Lister’s tumor debridement

The outcome of open distal radius fractures with significant soft tissue injury is dominated by factors related to the wounds. The ability to prevent contamination from becoming sepsis correlates best with functional outcome, and is influenced by the extent and adequacy of debridement and the restoration of the soft tissue envelope. Historically, tissues were debrided every 48 to 72 hours to allow tissues to declare themselves, until all nonviable tissues were removed. This technique is well established, but associated with bacterial wound colonization and delays in definitive reconstruction. The authors avoid this wait-and-see approach and perform early aggressive debridement ( Box 2 ).

Lister asserted that upon completion of a single aggressive debridement, the wound should resemble a tumor resection. This is done under tourniquet control, so the viability or ischemia of tissues is not obscured by blood in the field. If the investing tissue of nerves, arteries, and tendons is visibly contaminated, debridement is limited to removal of adventitia, epineurium, and epitenon; excision of intact nerves, arteries, or tendons is avoided. Tissues are left in place to declare themselves only in the setting of a broad crush injury, where the extent of muscle damage cannot be defined, and this requires repeat debridement every 48 hours.

Free tissue transfer can significantly improve potential for limb salvage over amputation when needed. In cases where immediate soft tissue coverage is not feasible due to available resources or fatigue of the operative team, wet-to-moist gauze can be changed regularly, or polymethylmethacrylate (PMMA) antibiotic bead pouches or negative pressure wound therapy can be applied. Generally, the authors aim for complete coverage within 1 week of injury.

The authors often use negative-pressure wound therapy (NPWT) when soft tissue reconstruction is not immediately feasible. Animal data suggest that the negative pressure leads to decreased edema, improved blood flow, increased granulation tissue, and improved bacterial clearance. A recent comparative study of NPWT and wet-to-moist gauze for complex open fracture wounds also showed decreased rates of infection (5.4% vs 28%). On the other hand, NPWT has not been shown to shorten the time to closure or influence the choice of closure. Size, grade of soft tissue injury, and degree of contamination remain the primary determinants of time to achievement of a clean stable wound for closure, not the dressing.

Prolonged duration of antibiotic coverage has not been shown to improve outcome in regard to infectious complications. A short course of antibiotics (12 hours) has been shown to be equally effective to a prolonged course of antibiotics (14 days). The authors typically limit antibiotic prophylaxis to 24 hours after soft tissue coverage is achieved.

Indirect reduction and skeletal stabilization

Realignment of the fracture and skeletal stabilization is a critical component of soft tissue management. This can be achieved with external, percutaneous, or internal plate fixation as needed. The authors use a reduction method based on multiplanar ligamentotaxis, as described by Agee, which involves sequential manual traction, palmar translation, and pronation of the hand relative to the forearm. Wrist flexion and forearm pronation are avoided. Five to 10 pounds of axial traction through finger traps aid intraoperative reduction maintenance. Excessive traction is associated with persistent pain, stiffness, and nerve dysfunction.

Fluoroscopic imaging during reduction allows assessment of mechanical alignment, articular congruity, and patterns of instability. Detailed assessment can be obtained when images are taken in multiple planes. In a normal wrist, the lunate facet is inclined approximately 10°, so elevating the forearm 10° from the plane of the receiver plate for the lateral view aids in visualizing the articular surface. The authors center much of their operative decision making on the findings at the time of this closed reduction, and this has largely obviated the need for a preoperative CT scan.

Although the current trend is to prefer open reduction and internal fixation to percutaneous and external fixation for distal radius fractures, bridging external fixation remains well suited for complex injuries. External fixators can retain length, allow soft tissue management, and temporarily stabilize fractures when immediate definitive care is not feasible. Complications include superficial radial nerve injury, pin tract infection, and loss of reduction, but these can be prevented with open incisions and blunt dissection, loose pin site closure, and additional percutaneous pin fixation to prevent loss of articular reduction.

The authors’ preferred variation on the concept of external fixation is the spanning internal fixator or distal radius bridge plate. The concept was first described by Burke and Singer, and has since been modified by Ruch and Hanel. A locking plate is passed under the extensor retinaculum using limited incisions proximally and distally, and is fixed to the radial and metacarpal diaphyses. The authors use a 2.4/2.7 mm stainless steel plate specifically designed for use as a distal radius bridge plate (DRB plate, Synthes, Paoli, Pennsylvania), passed through the second dorsal compartment.

Compared with external fixation, the dorsal bridge plate technique avoids pin tract infection, reduces nursing care, and provides strong fixation immediately adjacent to bone. It can be combined with a limited open articular fixation approach as needed. If reduction is satisfactory and well maintained, the plate is removed following adequate fracture healing. This usually takes about 4 months (especially for open injuries), and is followed by wrist rehabilitation. The plate can also be used like a temporary external fixator, with removal at the time of definitive osteosynthesis or soft tissue reconstruction. Wrist range-of-motion and upper limb functional scores are not significantly related to duration of plate fixation at 1 year postoperatively for patients treated with the dorsal bridge plate.