After prepping and draping the arm, the limb is exsanguinated and a tourniquet is inflated. A volar longitudinal incision is made over the distal aspect of the flexor carpi radialis (FCR) tendon and carried through the skin (Figure 32.1, A), cauterizing small veins in the subcutaneous tissue. The FCR tendon sheath is opened, and the palmar cutaneous branch of the median nerve is identified within the sheath and avoided. The floor of the sheath is incised, and the interval just radial to the flexor pollicis longus (FPL) muscle is entered. The pronator quadratus is then identified and released distally and radially. The brachioradialis tendon fibers are elevated off of the radial styloid if needed to help with gaining length and radial inclination during the reduction. The fracture is manually reduced (Figure 32.1, B) and the volar plate is positioned on the distal radius, keeping it proximal to the watershed line distally. We tend to fix the plate with an initial screw through the oblong hole proximal to the fracture in the shaft, allowing adjustment of the plate (Figure 32.1, C), and a provisional Kirschner wire
(K-wire) through a wire hole typically located in the distal aspect of the plate. The fracture reduction and placement of the plate is confirmed with fluoroscopy. The fracture is re-reduced if necessary, and a second and third screw are placed into the radial diaphysis. For all metaphyseal fractures, we place distal screws unicortically to minimize the chance of rupturing extensor tendons. Unless the carpus is subluxating dorsally with intra-articular dorsal fracture fragments, all other dorsal comminution is ignored. After fixation, we again review the distal radius alignment, distal radioulnar joint (DRUJ) stability, and evaluate motion in forearm supination and pronation, as well as wrist flexion and extension. Any crepitus raises concern for intra-articular hardware. The final alignment and appropriate hardware placement are verified with fluoroscopy. We let down the tourniquet before closing the skin to confirm hemostasis. Patients are routinely placed into a short-arm volar splint before leaving the operating room.

After prepping and draping the arm, the limb is exsanguinated and a tourniquet is inflated. A dorsal longitudinal incision is made centered at the distal radius over the dorsal aspect of the wrist. The dissection is carried sharply down from the skin to the extensor retinaculum. The extensor retinaculum is opened
with a step cut in order to allow closure over the dorsal plates. The extensor pollicis longus (EPL) tendon is identified and transposed radially. The second and fourth compartments are raised off the dorsal distal radius subperiosteally and off the wrist capsule distally (Figure 32.2, A). A transverse radiocarpal arthrotomy is made off the distal radius, providing visualization of the cartilage surfaces of the scaphoid and lunate, keeping the remaining capsule distally attached. A longitudinal capsular incision can be made to elevate the capsule off the carpal bones to give more exposure as needed. The scaphoid and lunate are examined to identify associated chondral injury. In addition, the scapholunate ligament is evaluated for associated injury. This exposure provides direct visualization of intra-articular fractures and allows for reduction. Displaced fragments are aligned with minimal step-off and gap, placing provisional K-wires as needed. The reduction is verified with direct visualization and confirmed with fluoroscopy. When reduction is achieved, the dorsal plate is positioned on the distal radius to span the fragments (Figure 32.2, B). We typically first place one screw through an oblique hole proximal to the fracture and into the radial shaft. The position of the plate can be fine-tuned to capture the fragment pieces without entering the DRUJ. Distal screws are placed within the fracture fragments, then additional bicortical proximal screws are placed into the shaft. We then do final visual and fluoroscopic checks of alignment, wrist and forearm motion, DRUJ stability, and for proper hardware placement (nothing excessively prominent). The extensor retinaculum is repaired, leaving the EPL transposed in the subcutaneous tissues. We let down the tourniquet before closing the skin to confirm hemostasis. A short-arm volar splint is the applied before leaving the operating room.

Other surgical options rely on ligamentotaxis to reduce distal radius fractures followed by maintenance of reduction with either K-wires or spanning fixation (external fixation or spanning plate fixation). When performing isolated K-wire fixation, incisions are recommended as there are no true safe zones free of nerves or tendons. Postoperatively, patients are immobilized until healing (4–6 weeks). Spanning fixation also obligates absolute wrist immobility until hardware is removed. External fixators are typically removed at 6 weeks while spanning plates that have less risk of infection can be maintained for up to 3 months. During healing, it is imperative to rehabilitate the fingers to prevent digit stiffness.