Open Treatment of a Distal Radius Fracture with a Fixed Angle Palmar Plate

5 Open Treatment of a Distal Radius Fracture with a Fixed Angle Palmar Plate

Indications

Any displaced fracture of the distal radius

Pitfall

Intra-articular fractures, particularly those with displaced intra-articular fragments, require experience with this implant.

Pearl

Review technique manuals for specifics regarding the various implants currently available on the market.

Figure 5-1

Technique

Palmar approach via zig-zag incision over flexor carpi radialis (FCR) sheath (Fig. 5-1)
Retract FCR radially.
Incise floor of FCR sheath.
Elevate pronator quadratus off of radius by subperiosteal dissection working from radial to ulnar (Fig. 5-2).
Release brachioradialis tendon from radial styloid.

Figure 5-2

Pitfall

The brachioradialis tendon forms the floor of the first extensor compartment. Take care to avoid injury to the abductor pollicis longus (APL) tendon.

Debride fracture site and attempt provisional reduction.

Pearl

Malposition of a distal radius fracture is usually a combination of malrotation and dorsal angulation of the distal fragment. Malrotation can be corrected by realigning the palmar cortex. Angulation is corrected by tightly securing the distal fragment against an appropriately positioned and anchored palmar plate.

Apply palmar plate by placing one screw in oval hole (proximal fragment) (Fig. 5-3).
Maintain fracture reduction with palmarly directed force over wrist and distal fragment using bump (Fig. 5-3).
Check plate and fracture position with intraoperative radiographs.
Gently screw drill guide into radialmost hole.
Advance a 0.045 in. wire through guide and into styloid; use finger pressure on dorsal cortex to maintain reduction of distal fragment.
Check pin position with an AP, lateral, and “20 degree tilt lateral.”
Remove wire and exchange for a screw directed into the radial styloid (Fig. 5-4).
Adjust reduction as necessary.
Pay careful attention to the reduction of the lunate articular surface and sigmoid notch during fixation into ulnarmost hole (Fig. 5-4).
Fill remaining holes. Place screws where dorsal cortex provides sufficient purchase; use pins with threaded heads where dorsal cortex is comminuted (Fig. 5-5).
Screws without threaded heads can be used to secure fragments that require drilling at an angle other than possible with the fixed-angle holes in the T portion of the plate.
Recheck plate and screw position with intraoperative radiographs.
Place pronator quadratus over plate. Close skin.