Franklin Chen and David M. Kalainov

Indications

1. Fractures that cannot be adequately reduced by closed means

2. Displaced dorsal and volar shear fractures (i.e., dorsal Barton’s and volar Barton’s fractures)

3. Fractures involving the lunate fossa with separation of the dorsal and palmar components

4. In combination with external fixation for radio-carpal fracture-dislocations and complex, high-energy fractures with greater than 2 mm of articular displacement

Contraindications

1. Stable nondisplaced fractures

2. Fractures amenable to treatment by closed means

3. Severe coexisting medical illness or patient noncompliance

4. Active local infection

5. Significant soft-tissue or bone loss

Preoperative Preparation

1. AP/lateral/oblique plain radiographs; comparative views of the contralateral wrist may be helpful.

2. Determine the fracture pattern: extra-articular, intra-articular, articular gap/step-off, direction of displacement, amount of displacement, comminution, ulnar styloid involvement.

3. The classification scheme used to describe the fracture is less important than a general understanding of the fracture pattern.

4. Consider CT scanning if the complexity of the fracture is not clearly evident on plain radiographs. CT has been shown to be more reliable than plain radiography in quantifying articular surface incongruencies.

5. Evaluate the entire extremity for associated injuries (e.g., scaphoid fracture, scapholunate dissociation, distal radioulnar joint instability, compartment syndrome).

6. Document the neurovascular status; median nerve symptoms are not uncommon. Worsening signs and symptoms of median nerve compression should be addressed by carpal tunnel release.

Special Instruments, Position, and Anesthesia

1. Supine position with a hand table extension

2. Upper extremity pneumatic tourniquet

3. Basic hand tray and routine orthopedic instruments

4. Standard or mini-fluoroscopy unit

5. Familiarize yourself with the available plating system. Plates and screws ranging in size from 2 to 3.5 mm are recommended.

6. Intra-operative traction is sometimes necessary and can be achieved with temporary external fixation or finger-trap traction.

Tips and Pearls

1. A clear understanding of the fracture pattern is critical for planning the surgical approach and method of fracture stabilization.

2. Autogenous bone grafting may be necessary in the setting of significant comminution and/or bone loss. A trephine can be used to harvest cancellous graft from the anterior iliac crest through a small incision.

3. Complex fractures may require open reduction with both internal and external fixation to adequately stabilize the distal radius. The external fixator should be applied first to assist with intra-operative fragment reduction. In rare instances of extensive dorsal and volar comminution, both surfaces of the distal radius may require plating in addition to temporary external fixation.

4. It is not necessary to place a screw through every hole in a plate.

5. Provisional fixation with K-wires can be helpful (0.045 to 0.062 in).

6. For small, but critical bone fragments consider augmenting the fixation with screws and washers.

7. When placing screws in the distal radius, remember to accommodate for normal radial inclination and volar angulation to avoid inadvertent penetration into the joint.

8. Opening the extensor retinaculum in a step-cut fashion will facilitate subsequent closure by allowing the retinaculum to be reapproximated in a lengthened state.

9. Intravenous antibiotics should be given prior to tourniquet inflation.

10. Discuss with the patient the common potential complications associated with operative treatment of distal radius fractures.

What To Avoid

1. Avoid excessive retraction of the neurovascular structures.

2. Do not violate the volar capsule as injury to the volar radio-carpal ligaments may lead to carpal instability.

3. Avoid leaving the tendons in direct contact with the plate, which may cause tendon irritation and eventual rupture. In a volar approach, reattach the remaining pronator quadratus as a buffer over the plate. In a dorsal approach, elevate the fourth extensor compartment in a subperiosteal fashion, preserving both the periosteum and tendon sheath. A strip of the extensor retinaculum can be used as an interpositional material between the radial wrist extensors and dorsal plate.

4. Do not be overly aggressive in the elderly patient population. Internal fixation of osteoporotic bone can be difficult and the fixation tenuous. Low-demand elderly individuals often tolerate deformity better than younger patients.

Postoperative Care Issues