Open Reduction and Internal Fixation of the Distal Radius With a Volar Locking Plate

Jesse B. Jupiter, MD

David Ring, MD, PhD

Dr. Jupiter or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy, A Johnson & Johnson Company; serves as a paid consultant to or is an employee of Aptis Co. and OHK; serves as an unpaid consultant to SynthesTrimed; has stock or stock options held in OHK; has received research or institutional support from the AO Foundation; serves as a board member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons and the American Society for Surgery of the Hand. Dr. Ring or an immediate family member has received royalties from Skeletal Dynamics and Wright Medical Technology, Inc.; serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

PATIENT SELECTION

Healthy, active patients with an unstable fracture of the distal radius are considered for open reduction and internal fixation (ORIF) with a volar locking plate. Instability is defined as inadequate alignment after manipulative reduction, loss of adequate alignment after manipulative reduction, or a high likelihood of healing with inadequate alignment with cast immobilization alone. The likelihood of losing alignment has been related to several factors, including initial fracture displacement, comminution, and age and functional level (both likely related to osteoporosis).¹^,² Adequate alignment is variably and somewhat arbitrarily defined as more than 10° to 20° of dorsal tilt of the articular surface on a lateral view, more than 3 to 5 mm of ulnar positive variance, and a 2 mm or greater articular step or gap.²

FIGURE 1 Lateral (A) and PA (B) image-intensifier views show a fracture of the distal radius.

PREOPERATIVE IMAGING

AP and lateral radiographs of the wrist before and after manipulative reduction are usually sufficient to characterize a fracture of the distal radius and inform management decisions. Radiographs with traction applied to the wrist can be helpful, particularly for identifying associated intercarpal ligament injuries. CT can provide additional detail about the number, size, location, and displacement of articular fractures. There is some evidence that three-dimensional reconstructions are easier and more reliable for surgeons to interpret.³

PROCEDURE

In this chapter, we describe a patient with a nascent malunion of a volar shearing fracture to illustrate the surgical technique (Figure 1).

FIGURE 2 Photograph shows the skin incision for open reduction and internal fixation of a distal radius fracture using a volar locking plate. The incision lies directly over the flexor carpi radialis tendon and zigzags across the transverse wrist creases to limit scar thickness.

Surgical Technique

A longitudinal skin incision is planned over the flexor carpi radialis (FCR). The incision can either end at the transverse wrist creases or cross them obliquely for a thinner scar (Figure 2).

The sheath of the FCR is incised (both volar and dorsal) to access the deeper structures (Figure 3). The radial artery is left undissected in the soft tissues directly radial to the FCR sheath. If the incision is more ulnar than intended, care should be taken to protect the palmar cutaneous branch of the median nerve, which runs between the palmaris longus and FCR tendons.

After sweeping the fat from the space of Parona, the pronator quadratus and the flexor pollicis longus are exposed. The attachment of the flexor pollicis longus to the radial side of the wrist should be mobilized ulnarward. In younger, more active patients, there is often a relatively large vessel to be cauterized in this area (Figure 4).

The pronator quadratus is incised on its radial and distal aspects and elevated subperiosteally from radial to ulnar off the volar surface of the radius. If the surgeon goes to the radial limit of the pronator quadratus, the entire muscle can be elevated, which can facilitate repair back to the brachioradialis tendon at the time of closure although the value of closure of this muscle is debated (Figure 5). The fracture lines are then identified and cleared of muscle, hematoma, and incipient callus (Figure 6).

FIGURE 3 Intraoperative photograph shows the flexor carpi radialis tendon sheath incised to gain deeper exposure.

The volar cortex—particularly the volar ulnar corner— is the thickest bone in the metaphysis of the distal radius. In dorsally displaced fractures, there is usually little or no volar comminution. Therefore, it is usually straightforward to realign and stabilize the volar cortex. To reduce the fracture fragments, it can be useful to lever the distal fragments out from under the proximal shaft using an osteotome (Figure 7). To limit the possibility of fracturing the proximal fragment during this maneuver, particularly in osteoporotic individuals, the surgeon’s thumb can be used as a counterpressure over this bone during the levering maneuver.

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