Management of Complications Following Open Reduction and Plate Fixation of Distal Radius Fractures

11 Management of Complications Following Open Reduction and Plate Fixation of Distal Radius Fractures

Niels W.L. Schep

Abstract

Most guidelines advise nonoperative treatment in the form of plaster cast immobilization for patients with adequately reduced distal radius fractures.1^,² However, open reduction and plate fixation has become more popular, as it improves quality of reduction and fracture stability allowing for early postoperative mobilization and quicker return to work.³^,⁴

Nevertheless, most of the radiological parameters correlate poorly with functional outcome.⁵^,⁶ Patient-reported outcome measures (PROMs) have gained importance in studies concerning fracture treatment, and clinical decision- making is more often based on studies that use these outcomes.⁷ The patient-rated wrist evaluation (PRWE) and disabilities of the arm, shoulder, and hand (DASH) are two specific PROMs related to wrist function, and are valid and reliable outcome measures in patients with distal radius fractures.⁸ A meta-analysis by Vannabouathong et al concluded that open reduction and plate fixation offers the best results for adult patients with a DRF, in terms of radiological-functional outcome and fracture healing.⁹

Yet, open reduction and plate fixation comes with a trade-off of complications. The complication percentage following plate fixations of DRFs ranges between 10 and 50%, depending whether implant removal is considered as a complication. In 2014 Bentohami et al published a systematic review showing 9% minor and 8% major complications.¹⁰^,¹¹^,¹²

Complications can be categorized into tendon-, nerve-, reduction or hardware-related, and general complications such as deep and superficial infections. The aim of this chapter is to share our experience in preventing or treating these complications.

Keywords: distal radius fracture, complications, surgical approach, neuromas, reduction, malunion, infection

11.1 Complications Related to the Surgical Approach

11.1.1 Neuromas due to the Volar Approach

A modified Henry approach is our working horse to approach the volar side of the distal radius. The surgeon sits at the head of the patients, which enables a good view on the ulnar part of the radius. Dissection is performed radially from the FCR (flexor carpi radialis) leaving the tendon-sheath intact. This may help avoid adhesions of the FCR to the skin. Moreover, this may also evade accidental damage to the palmar cutaneous branch of the median nerve (PCBMN). The PCBMN originates from the medial side of the median nerve 3 to 8 cm proximal to the wrist palmar crease. It follows a path parallel and medial of the FCR tendon and the palmaris longus. However, it may also run inside the FCR sheath or perforate the sheath. A painful neuroma may be formed postoperatively following retraction of the FCR, opening the FCR sheath or because of aggressive dissection. By dissecting on the radial side of the FCR instead of going next to the tendon sheath, injury of the PCBMN may be avoided.

Subsequently, the pronator quadratus (PQ) is L-shaped incised along the radial radius border and below the watershed line. Avoid damaging the volar ligaments while exposing the distal radius. The brachioradialis insertion is released from the distal radial fracture fragment until we encounter the first extensor compartment. This will aid reducing the distal radial fragment, especially if there is a long delay between trauma and surgery. The fracture is reduced, dictated by the fracture pattern and temporarily fixed with K-wires. If fracture reduction is problematic, Orbay’s maneuver is performed; the proximal radius shaft is pronated with a reduction clamp while the patient’s hand is fixated with your other hand. This exposes the dorsal side of the distal radius and lifting off the extensor tendons subperiosteally and enables fracture debridement and therefore reduction. Once adequate reduction is reached, the plate is positioned. During closure, the PQ is not reinserted because there is no functional advantage in repairing this muscle and may even lead to less pronation strength.¹³^,¹⁴ (Only the skin is closed using absorbable monofilament.) Pressure bandage is applied (making sure MCP joints are free) for 48 hours. The patient will start non-weightbearing wrist motion exercises the same day to avoid stiffness and swelling. Weightbearing is allowed 6 weeks postoperatively.

During K-wires fixation, the sensory branch of the radial nerve (RSN) should be protected as neuromas can result from a (blind) percutaneous approach (Fig. 11‑1). Treatment of RSN neuroma includes resection. The proximal RSN is dissected free of the surrounding tissues in such a way that it allows relocation of the nerve. Subsequently, an opening is made in the proximal mobile wad and the nerve is buried without tension. A single absorbable suture between the epineurium and the muscle fascia is used to hold the nerve in place. The nerve may also be relocated in the radius; therefore, a cortical hole is drilled obliquely to a size larger than the nerve. The nerve is held in place with a absorbable suture between the epineurium and periosteum.

Fig. 11.1 A painful neuroma due to transection of a branch of the superficial radial nerve (RSN) at the level of the styloid process of the radius following temporary K-wire fixation.

11.1.2 Posterior Interosseous Nerve and Tendon Problems due to the Dorsal Approach

For the dorsal approach we make an incision just ulnar of Lister’s tubercle. When this anatomic structure is difficult to palpate due to edema or fracture anatomy, a longitudinal line just radial of the third finger is chosen to mark the incision. Next, the extensor retinaculum is incised at the level of the third extensor compartment and the tendon of the extensor pollicis longus (EPL) is elevated to the radial side.

On the bottom of compartment four, the terminal branch of the posterior interosseous nerve is found and excised for 2 cm. We do not bother its proprioceptive properties because nerve division does not appear to be associated with decreased proprioception of the wrist.15 Moreover, we encountered multiple patients with a painful dorsal wrist following dorsal plate fixation in which the nerve was trapped under the plate or where a symptomatic neuroma had formed just at the wrist capsule.

Next, subperiosteal dissection is performed under compartment four to release the common extensor tendons. The dissection is continued until the distal radioulnar joint (DRUJ) but be careful not to open the DRUJ. We try to leave the dorsal capsule closed; however, when deemed necessary the dorsal capsule may be opened to inspect the intra-articular anatomy by a mini-Berger flap.

When the dorsal plate is positioned on the dorsal part of the lunate facet, the plate is covered with a flap of the extensor retinaculum to protect the extensor tendons. The EPL is left out of its compartment and sits dorsally to the extensor retinaculum. The skin is closed using absorbable monofilament.

11.2 Complications Related to the Quality of Reduction

The AAOS guidelines advise operative treatment for fractures with postreduction radial shortening >3 mm, dorsal tilt of >10 degrees or intra-articular step off of more than 2 mm. On the contrary, the Dutch guidelines are more liberate: more than 10 degrees tilt in any direction, more than 5 mm radial shortening or intra-articular step off of more than 2 mm.

As stated in the introduction the commonly used radiographic parameters seem not to perfectly correlate with patient-related outcome measures. However, most surgeons will agree that when an open reduction and plate fixation is chosen as treatment modality we should aim for a perfect anatomic reduction.

Therefore, accurate assessment of intraoperative fluoroscopic images is essential. First, the surgeon should assess the posterior anterior fluoroscopic view instead of the anterior posterior view. Otherwise, the position of the ulnar styloid and the length of the radius may not be judged accurately.

11.2.1 Posterior Anterior View

●Radial inclination: Measures from the tip of radial styloid process (PSR) to the center point of the ulnar side of the distal radius. This center point (CRP) is located between the volar and dorsal rim which can easily be identified on the PA fluoroscopic image. Radial inclination is normally 20 to 25 degrees.

●Ulnar variance: The distance between the CRP and distal articular surface of the ulna. Normally +0.9 mm (range −4.2 to 2.3 mm).

●Radial length: It is defined by the length measured between the tip of the radial styloid and the distal articular surface of the ulna. Normally 10 to 13 mm.

Next we will address the coronal plane translation, which we consider a significant parameter. This term is used to describe radial displacement of the distal fragment. Radial translation of the distal fragment might be associated with DRUJ instability due to lack of tension on the distal oblique bundle (the most distal part of the distal interosseous membrane) and the PQ. As we noted earlier, the surgeon sits at the head of the patient because the ulnar side of the radius can be accurately assessed from that side. To avoid coronal plane translation fracture reduction should be perfect at the ulnar side of the radius (Fig. 11‑2).

Fig. 11.2 (a–c) Coronal plane translation can be measured by drawing a line on the ulnar side of the radius which intersects the lunate. This line should bisect the lunate in an anatomic situation.

Only gold members can continue reading. Log In or Register to continue