Limited-Open Reduction and Percutaneous Pin Fixation with External Fixation of Distal Radius Fractures

2 Limited-Open Reduction and Percutaneous Pin Fixation with External Fixation of Distal Radius Fractures

Indications

Displaced, intra-articular fracture of the distal radius without palmer comminution

Technique

Expose the dorsoradial aspect of the index metacarpal identifying and protecting radial sensory nerves.

Predrill and place two external fixation pins at a 45 degree angle from the dorsum of the hand. Place the proximal pin at the proximal metaphyseal flare (Fig. 2-1).
Expose the dorsoradial aspect of the radius just proximal to the strap muscles. Identify the radial sensory nerve as it emerges from between the brachioradialis and extensor carpi radialis longus. Develop the interval between the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). Predrill and place two pins in the radial shaft. Check pin placement in the metacarpal and radial shaft with fluoroscopy.
Assemble fixator. As a temporary measure, distract the wrist to help reduce the fracture and tighten the fixator. It may be necessary to supinate, flex, and place the wrist in ulnar deviation to effect a good reduction. Check the reduction with fluoroscopy.
Make a 2 to 3 cm incision on the dorsal aspect of the distal radius (Fig. 2-2).
Release extensor pollicis longus (EPL) tendon from third compartment and retract radially. Elevate tendons of fourth extensor compartment to expose only the comminuted portion of the radius fracture (Fig. 2-3).
Make a 2 cm incision just radial to the radial styloid. Expose tip of styloid dorsal to the first extensor compartment. Protect sensory nerves.
Elevate and pin articular components of the fracture. Then pin reassembled articular surface to the intact proximal radius (Fig. 2-4).
Check fracture and pin position with fluoroscopy. Place bone graft in the metaphyseal defect.
Relieve the distraction on the wrist. Place the wrist in neutral position with only slight distraction and retighten the fixator (Fig. 2-5). Check wrist position with fluoroscopy.
Before wound closure check the stability of the distal radoulnar joint (DRUJ) with the forearm in neutral, supination, and pronation. An unstable DRUJ should be managed with either closed pinning, repair of the triangular fibrocartilage complex (TFCC), or open reduction internal fixation (ORIF) of an associated ulnar styloid fracture.