Distal Radius Fixation

Planning

  • Identify fracture configuration
    • Pattern – colles/smiths/bartons/die-punch
    • Consider location of comminution
    • Intra-articular extension
    • May need CT for operative planning
    • Consider contralateral wrist radiograph to assess normal patient anatomy
  • Approach
    • Volar +/- dorsal
    • Can extend volar incision radially
  • Equipment
    • Volar locking plate
    • K wires
    • Fluoroscopy

Positioning

  • Supine with arm on radiolucent arm table
  • Surgeon can sit on either side of arm table, depending on preference
  • Fluoroscopy from opposite side
  • Tourniquet
  • Rolled up small drape under wrist to raise hand off table and allow for reduction manoeuvres

Approach/Technique

  • FCR (flexor carpi radialis) approach to volar wrist
    • Internervous plane — flexor carpi radialis (median nerve) and flexor policis longus (anterior interosseous nerve)
    • Incise skin overlying palpable FCR tendon — from volar wrist crease, proximally as far as required based on fracture
    • Incise FCR tendon sheath to mobilise tendon and retract ulnarly to reveal fascia overlying FPL
      • Can retract radially if need to access carpal tunnel
    • Incise fascia overlying FPL and retract FPL ulnarly — care of palmar cutaneous branch of median nerve
    • Reveal pronator quadratus underlying FPL
    • Feel radial border of radius and sharply dissect PQ off radius — can be easier to do distally to proximally
      • Use periosteal elevator to strip — easier with broad elevator, stick to bone
      • Care for branches of radial artery
    • Can release brachioradialis to allow for mobilisation of styloid fragment and restore radial height
      • Care for 1st extensor compartment tendons (APL/EPB) and superficial branch of radial nerve
  • Fracture reduction
    • Remove fracture haematoma/soft callus/interposed periosteum from fracture site and fragment ends
    • Depends on fracture configuration
      • Most fractures can be reduced with traction and manipulation of hand
      • May need to manipulate individual fragments to reduce — ulnar column fragment, radial styloid etc.
        • Can use radial styloid K-wire (1.6mm) from tip of styloid to ulnar border radius to stabilise unstable fracture fragments
      • Die-punch fractures often need cortical window to elevate fragment to reduce
  • Fixation
    • Can start with proximal or distal fixation
    • Reduce fracture
    • Assess size/length/position of plate on radius
    • Distal fixation first
      • Position plate distally then hold with plate specific K-wires
      • Distal enough to get subchondral screws but not past watershed line (distal volar ridge of radius)
      • Can use K-wires to assess position/angle of distal locking screws
      • Place howarth/hohmann/raytec sponge under proximal plate to hold off bone
      • Insert distal locking screws
      • Check AP/radial inclination view
      • Remove K-wires and bring plate down to shaft and affix (locking screws not routinely required for shaft fixation – Lutsky et al. 2015)
    • Proximal fixation first
      • Position plate and place cortical screw in oval shaft hole
      • Check position under fluoroscopy and reposition plate as required
      • Insert distal screws, ensure capturing all fragments
      • Check screw length and position on fluoroscopy – ensure no intra-articular screws
      • Affix remaining shaft screws
    • Care with styloid and shaft screw length to avoid EPL rupture
  • Closure
    • Irrigation
    • Deflate tourniquet and achieve haemostasis
    • Lay PQ over plate – no benefit to repair
    • Subcutaneous layer – 2-0 absorbable braided suture
    • Skin – 3-0 subcuticular absorbable monofilament suture
    • Dressing
    • Volar slab vs bulky bandage (see Post-operative Care)
  • Dorsal approach to distal radius (useful for die-punch fractures with intact volar cortex)
    • No internervous/intermuscular plane
    • Dissection between 3rd and 4th extensor compartments
    • Technique
      • Incision (approx 8cm) halfway between radial/ulna styloids
      • Dissect to and incise extensor retinaculum longitudinally overlying EIP/EDC
      • Mobilise tendons either side to visualise distal radius and capsule
      • Can incise capsule and dorsal radiocarpal ligaments to visualise intra-articular bony reduction
    • Repair capsule, dorsal ligamentous structures and extensor retinaculum when closing
    • Care of superficial radial nerve/cutaneous branches, radial artery, carpal interosseous ligaments and scaphoid capsular attachments

Post-operative Care

  • Can utilise volar slab for immobilisation until wound healed or start range of motion in bulky bandage immediately if satisfactory fixation, good quality bone and reliable patient
    • No functional outcome difference if using immobilising slab for 2 weeks as opposed to early range of motion starting D2-3 (Clementson et al. 2019)
    • Can utilise removable velcro wrist splint for up to 6 weeks post-op
  • Vitamin C 500-1000mg for 50-90 days not associated with lower rates of complex regional pain syndrome or improved functional outcome (Evaniew et al. 2015)
  • Limited weight bearing for 6 weeks
  • 2 week wound review
  • 6 week review to advance weight bearing status and remove any splint

Operative Risks/Complications

  • Palmar cutaneous branch of median nerve
    • Arises 5cm proximal to wrist joint, immediately ulnar to FCR
  • Median nerve neuropathy (carpal tunnel syndrome) – 1-30%
  • Superficial branches of radial nerve
    • Underlying brachioradialis
    • Can be caught with K-wires in radial styloid
  • Superficial/deep infection – 1-2%, higher in diabetics (up to 20%)
  • Radial artery injury
  • FPL rupture from plate positioning
  • Radiocarpal instability from release of volar wrist capsule/ligaments
  • Chondrolysis from intra-articular screw penetration
  • Post-traumatic radoiocarpal arthritis
  • Malunion/non-union
  • Screw cutout – especially osteoporotic bone
  • Complex regional pain syndrome

References

  1. Lutsky K, Hoffler CE, Kim N, Matzon JL. Routine use of locking shaft screws is not necessary in volar plate fixation of distal radius fractures. Hand. 2015 Sep 10;(3):489-91
  2. Clementson SO, Hammer OL, Saltyte Benth J, Jakobsen RB, Randsborg PH. Early mobilization and physiotherapy vs. late mobilization and home exercises after ORIF of distal radial fractures: A randomized controlled trial. JB JS Open Access. 2019 Aug 28;4(3)
  3. Evaniew N, McCarthy C, Kleinlugtenbelt YV, Ghert M, Bhandari M. Vitamin C to prevent complex regional pain syndrome in patients with distal radius fractures: A meta-analysis of randomized controlled trials. J Orthop Trauma. Aug; 29(8):e235-41

Contributions

Page written by Dr James Drummond (orthopaedic registrar) 2020