Table of Contents
Fractures of the distal radius are common injuries, with an annual incidence of 27 per 10,000 per year. As many as two-thirds of these fractures are displaced, necessitating reduction to restore wrist function and avoid neurovascular compromise. When adequate reduction cannot be achieved by closed reduction alone, closed reduction and percutaneous pinning versus open reduction and internal fixation are considered. Here we present the case of a middle-aged female presenting with a dorsally displaced and angulated fracture of the distal radius after a fall on the outstretched hand. The fracture was treated by open reduction and internal fixation with a volar locking plate. We outline the natural history, preoperative care, intraoperative technique, and postoperative considerations of distal radial fractures.
Fractures of the distal radius represent 17% of all orthopedic complaints seen in the emergency department.1 As two-thirds of these fractures are displaced on presentation, reduction of the fracture will be necessary in the majority of cases.2
Surgical options for treating fractures in which satisfactory alignment cannot be achieved by closed manipulation include closed reduction and percutaneous pinning, closed reduction and external fixation, as well as open reduction and internal fixation (ORIF). In comparing these two methods, ORIF has been shown to carry a decreased risk of infection, complications, and malunion vs. external fixation, though ORIF may carry an increased risk of tendon rupture.3, 4, 5
Obtain a history including mechanism of trauma, timeline and progression of the present injury, and any previous injury to the affected area.
- Was it a low- or high-energy injury?
- Is it an isolated injury or not?
- Is the patient an independent ambulator or one who requires assistive devices?
- Is the patient experiencing signs of neuropathy (pain, tingling, loss of sensation, etc.)?
- Inspection: Assess for deformity, swelling, ecchymosis, bleeding, and open wounds.
- Palpation: Assess for pain, crepitans, and range of motion.
- Neuro: Perform a targeted neurological exam focusing on the median nerve, including sensation to the radial three and a half digits and thenar strength by way of thumb abduction strength.
- Vascular: Assess radial and ulnar pulses at the wrist, and assess capillary refill to screen for vascular compromise.
Standard assessment of suspected fractures of the distal radius includes at least two radiographs: a posteroanterior (PA) view and a lateral view.6 A CT is also reasonable for preoperative planning purposes to determine greater fracture characterization.
The natural history of distal radius fracture depends on the degree of displacement. Potential complications of displaced distal radius fracture include malunion, stiffness, weakness, tendon rupture (most commonly of the flexor pollicis longus), carpal tunnel syndrome or median neuropathy, complex regional pain syndrome, compartment syndrome, and post-traumatic arthritis.7 However, fractures of the distal radius that go on to heal within acceptable alignment, either with operative or non-operative treatment, can be expected to have a full recovery.
Non-displaced or minimally-displaced fractures can readily be treated non-surgically with cast or brace treatment. Displaced or unstable fractures are often treated operatively with either closed reduction and percutaneous fixation, external fixation, and ORIF.
The primary goal of ORIF for distal radius fractures is the restoration of anatomical position and function of the wrist. Internal fixation of displaced or non-reducible fracture decreases the likelihood of long-term fracture complications including post-traumatic osteoarthritis, diminished range of motion, malunion, and persistent functional impairment.8 Moreover, the distal radius acts as a fulcrum for extensor tendon function so dorsally angulated fractures as seen in this case can decrease tendon mechanical advantage and lead to long-term tendinopathy and hand extensor weakness.9
There are few absolute contraindications for ORIF of radius fractures. Relative contraindications include severe osteoporosis, elderly individuals with low functional status, general anesthesia intolerance, and patient preference.
There are two classic approaches to distal radius fractures in order to perform an ORIF with locking plate fixation; palmar and dorsal. Depending on the fracture characteristics, surgeons may prefer one approach to another. The patient in this case had a minimally-displaced dorsally angulated fracture, which was approached palmar using the modified Henry approach.10, 11In this technique, an incision is made sharply over the flexor carpi radialis (FCR) tendon, ulnar to the radial artery but radial to the median nerve. The plane between the FCR tendon and the radial artery is developed and the flexor tendons are mobilized ulnarly with the radial-most flexor tendon being that of the flexor pollicis longus. The floor of the FCR tendon sheath is incised to provide access to the deep volar compartment and the pronator quadratus is sharply elevated using an L-shaped incision, first along the radial surface, then distally just proximal to the joint line. This provides adequate access to the fracture site.
The patient in this case received a volar locking plate for internal fixation. Options for plating include both dorsal, radial, bridge, and volar plates. Classically, volar plating was used primarily for palmar angulated fractures. However, reports of high rates of complications with dorsal plating, including extensor tendon rupture and joint stiffness caused many surgeons to prefer volar plating as the preferred form of management of most distal radius fractures.12 With that being said, the superiority of volar plating to dorsal plating is still being investigated.
Volar plating was thought historically to have a lower risk of tendon complications, as the plate is placed farther from the flexor tendons and may be covered by the pronator quadratus intraoperatively. However, there are reports that volar plating may still be susceptible to extensor tendon rupture.13 Additionally, volar plating has also been associated with other common complications, such as carpal tunnel syndrome, median nerve injury, neuropraxia, and complex regional pain syndrome.13 Which plating method, then, should be used in the majority of patients? To answer this question, Wei et al. conducted a meta-analysis examining complication rates between dorsal and volar plating in 2013.14 Interestingly, this group found no difference overall in complication rates between dorsal and volar plating. However, on sub-group analysis, volar plating was found to have a significantly increased risk of neuropathy and carpal tunnel syndrome, whereas dorsal plating was found to carry an increased risk of tendonitis. This group also found that overall, the risk of complex regional pain syndrome and tendon rupture did not differ significantly between the two groups. Subsequently, Disseldorp et al. found, in comparing volar plating with next-generation lower profile dorsal plates, that again there was no difference in complication rates between each method, though volar plating demonstrated slightly increased range of motion when compared with the patient’s uninjured wrist.13 The authors advocated, therefore, that the surgical approach should be guided by surgeon preference and experience, rather than by consideration of various complication rates.
Following surgery, wounds are cleaned and dressed until the postoperative visit 10 to 14 days postoperatively. During that time, patients are advised to use their hand for activities of daily living but to avoid strenuous activity. After office assessment, a splint is typically applied and rehabilitation is begun. Rehabilitation for distal radius fractures can be divided into three phases: early splinting, mobilization, and strengthening. The ultimate goals of surgical treatment of most intra- and peri-articular fractures are the restoration of articular surfaces, stable internal fixation of the fracture, and early joint mobility.15 However, at this point, no consensus has been reached on the optimal postoperative treatment regimen for fractures of the distal radius. A 2017 paper by Quadlbauer et al. compared early mobilization of the injured wrist with casted immobilization in patients treated with a volar locking plate for distal radius fractures. They found that patients rehabilitated with early mobilization showed significantly improved range of motion in the sagittal and frontal planes, improved 6-week forearm rotation, increased grip strength at 6-month follow-up, and improved functional scores when compared with patients with immobilized wrists.15 Early mobilization also resulted in no change in pain, duration of physical therapy, and loss of reduction, providing evidence that early mobilization programs may be superior to prolonged casting in some patients.15 So while the optimal rehabilitation protocol is still being explored, early referral to physiotherapy will likely play a key role moving forward.
The implant used in this procedure was the Globus Medical ANTHEM™ 7 Volar Plate (Audubon, Pennsylvania, USA).
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. The Journal of hand surgery. 2001;26(5):908-915. https://doi.org/10.1053/jhsu.2001.26322
- Brogren E, Petranek M, Atroshi I. Incidence and characteristics of distal radius fractures in a southern Swedish region. BMC Musculoskelet Disord. 2007;8:48. https://doi.org/10.1186/1471-2474-8-48.
- Yuan ZZ, Yang Z, Liu Q, Liu YM. Complications following open reduction and internal fixation versus external fixation in treating unstable distal radius fractures: Grading the evidence through a meta-analysis. Orthopaedics & traumatology, surgery & research : OTSR. 2018;104(1):95-103. https://doi.org/10.1016/j.otsr.2017.08.020
- Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. The Journal of hand surgery. 2005;30(6):1185-1199. https://doi.org/10.1016/j.jhsa.2005.08.009
- Alter TH, Sandrowski K, Gallant G, Kwok M, Ilyas AM. Complications of Volar Plating of Distal Radius Fractures: A Systematic Review. J Wrist Surg. 2019 Jun;8(3):255-262. https://doi.org/10.1055/s-0038-1667304
- Meena S, Sharma P, Sambharia AK, Dawar A. Fractures of distal radius: an overview. Journal of family medicine and primary care. 2014;3(4):325-332. https://doi.org/10.4103/2249-4863.148101
- Lee DS, Weikert DR. Complications of Distal Radius Fixation. The Orthopedic clinics of North America. 2016;47(2):415-424. https://doi.org/10.1016/j.ocl.2015.09.014
- Gouk C, Ng SK, Knight M, Bindra R, Thomas M. Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: A meta-analysis. Orthopedic reviews. 2019;11(3):7809. https://doi.org/10.4081/or.2019.7809
- He JJ, Blazar P. Management of High Energy Distal Radius Injuries. Current reviews in musculoskeletal medicine. 2019;12(3):379-385. https://doi.org/10.1007/s12178-019-09555-5
- Conti Mica MA, Bindra R, Moran SL. Anatomic considerations when performing the modified Henry approach for exposure of distal radius fractures. Journal of orthopaedics. 2017;14(1):104-107. https://doi.org/10.1016/j.jor.2016.10.015
- Ilyas AM. Surgical approaches to the distal radius. Hand (N Y). 2011 Mar;6(1):8-17. https://doi.org/10.1007/s11552-010-9281-9
- Martineau PA, Berry GK, Harvey EJ. Plating for distal radius fractures. The Orthopedic clinics of North America. 2007;38(2):193-201, vi. https://doi.org/10.1016/j.ocl.2007.01.001
- Disseldorp DJ, Hannemann PF, Poeze M, Brink PR. Dorsal or Volar Plate Fixation of the Distal Radius: Does the Complication Rate Help Us to Choose? Journal of wrist surgery. 2016;5(3):202-210. https://doi.org/10.1055/s-0036-1571842
- Wei J, Yang TB, Luo W, Qin JB, Kong FJ. Complications following dorsal versus volar plate fixation of distal radius fracture: a meta-analysis. The Journal of international medical research. 2013;41(2):265-275. https://doi.org/10.1177/0300060513476438
- Quadlbauer S, Pezzei C, Jurkowitsch J, et al. Early Rehabilitation of Distal Radius Fractures Stabilized by Volar Locking Plate: A Prospective Randomized Pilot Study. Journal of wrist surgery. 2017;6(2):102-112. https://doi.org/10.1055/s-0036-1587317
Cite this articleBradley Richey, MSc, Asif M. Ilyas, MD, FACS. Distal radius open reduction and internal fixation. J Med Insight. 2022;2022(301). https://doi.org/10.24296/jomi/301
Table of Contents
- 1. Surgical Approach
- 2. Incision
- 3. Dissection to FCR Tendon Sheath
- 4. Open and Release FCR Tendon Sheath
- 5. Access to Deep Volar Compartment
- 6. Radius Exposure
- 7. Elevation and Reflection of Pronator Quadratus to Expose Fracture Site
- 8. Brachioradialis Tendon Release
- 9. Assess Alignment Under Fluoroscopy
- 10. Fracture Mobilization
- 11. Provisional Reduction Under Fluoroscopy
- 12. Placement of Variable Angle Volar Plate and Confirmation of Fit and Position
- 13. Proximal-First Reduction and Fixation
- 14. Closure
- 15. Dressings
- Apply Proximal Plate
- Reduce Fracture and Hold with K-Wires
- Apply Distal Plate
- Assessment Under Fluoroscopy
With the operative limb draped across the hand table, a tourniquet applied, and the limb prepped and draped, the incision is marked out directly over the FCR tendon sheath. The incision is then pre-injected with a local anesthetic. My preference is 0.5% Bupivacaine with epinephrine. After injection, the limb is exsanguinated, and the tourniquet is inflated to 250 mmHg.
An incision is made with a 15 blade scalpel directly over the FCR tendon. Occasionally, branches of the palmar cutaneous nerve can be found crossing the FCR tendon sheath and must be identified and protected.
Blunt dissection is then performed down to the FCR tendon sheath.
With the FCR tendon exposed, the tendon sheath is then opened sharply with a blade and then extended proximally and distally with scissors. Retractors are then placed to expose the floor of the FCR tendon sheath. The release of the floor of the FCR tendon sheath is done with care and is a thin layer and should be done directly under the tendon. If you go too far radial, you can injure the radial artery. If you go too far ulnar, you can inadvertently injure the median nerve or the palmar cutaneous branch of the median nerve. It is helpful to take the release of the floor as far distal and proximal as possible in order to maximize exposure of the deep volar compartment. Here you'll see that the FCR tendon is retracted, and the floor is released as far as possible under direct visualization. Similarly, the floor is released proximal in a similar fashion.
Once the floor is opened, the deep volar compartment is entered and can be readily accessed with blunt dissection. You'll notice that the radial artery is kept radial and in the field at all times, and blunt dissection only is used to mobilize the flexor tendons and they're all taken ulnarly. The radial-most flexor tendon should be the flexor pollicis longus tendon.
Hohmann retractors are then placed next around the radial shaft both medially and laterally. Alternatively, a Weitlaner retractor can be utilized in order to expose the radius.
With the pronator quadratus exposed overlying the radius, it is elevated sharply along the radial border and reflected medially. This is best performed sharply in order to maximize subperiosteal elevation for later closure if desired. Prior to releasing the transverse distal limb of the pronator quadratus, the radial part is released first, and a sharp elevator is then used to elevate the pronator quadratus. This elevator is off of the distal radius set, and the system being used is by Globus. The distal release is not performed yet as it is easy to inadvertently release the pronator quadratus over the joint line and inadvertently transect the volar radiocarpal ligaments. Once the fracture site and the joint line is identified and confirmed, the distal aspect of the pronator quadratus can be released. Notice it is being released with the knife being directed away from the flexor tendons and the median nerve. Once released, the elevator is brought back in, and the rest of the distal pronator quadratus is elevated, thereby exposing the fracture site.
Next, in order to aid in fracture mobilization and increase exposure, the brachioradialis tendon can be released along the radial border. Here, the radial structure identified - this is a radial sensory nerve branch. This is the radial artery. Both these structures are identified and then retracted radially. Deep to that, the relationship between the first dorsal compartment tendons and the brachioradialis is appreciated. The first compartment tendons lie superficial to the brachioradialis tendon. There's a lot of motion and excursion of those first compartment tendons as identified here. They can be readily released and then retracted radially. The brachioradialis tendon will be deep to those tendons and have less motion and excursion as they're inserting along the radial border of the distal radius. They can then be sharply released at the level or slightly proximal to the fracture line and then elevated off the distal fragment.
Now with the fracture exposed, the fracture is examined on fluoroscopy to assess the alignment. As discussed previously, this fracture is primarily dorsally angulated with minimal displacement.
Now with the fracture fully exposed and released, the fracture is now being mobilized. This fracture is nearly 2 weeks old so it's getting a bit sticky so a freer is being used to mobilize the fracture and the distal fragment. If further mobilization and visualization of the distal fragment is necessary, the volar extensile approach can be utilized by mobilizing the proximal fragment and placing a tenaculum retractor around that proximal fragment and then carefully pronating it out of the wound, thereby fully exposing the distal fragment as shown here. Once pronated out of the wound, the distal fragment can be better mobilized and also visualized. Intra-articular fragments can be reduced, dorsal hematoma can be decompressed, dorsal periosteum can be released, and dorsal comminution can also be mobilized and decompressed and/or better reduced. In this case, to better mobilize the distal fragment as it is nearly 2 weeks old, the dorsal periosteum is being released. First it was released with a knife and now being spread with tenotomy scissors.
Now with the fracture fully released and mobilized, it can be more readily reduced. Here a standard traction, ulnar deviation, and volar flexion is being applied with the thumb being placed on the volar cortex as counter-traction, and a nice reduction is achieved.
With provisional reduction confirmed, a variable angle volar plate is selected. This implant is made by Globus Medical. Fluoroscopy confirms good fit and position of the plate.
Broadly speaking, there are 3 standard reduction techniques for distal radius fractures. One is proximal-first. The second is distal-first. And third is the neutralization technique. Proximal-first is what is being done here. Once satisfied, then a reduction can be readily achieved. The plate is applied to the proximal fragment first and then the distal fragment will be brought to that plate. In contrast, the distal-first construct is when the plate is applied to the distal fragment and then the plate and the distal fragment is then applied to the bone. Lastly, the neutralization construct is when the fracture is fully reduced and pinned in place, and then the plate is applied to neutralize the reduction.
Following the proximal-first strategy, here the plate is confirmed reduced on the proximal shaft. The distal fragment is now brought to the plate. A K-wire placed in the distal fragment dorsally is used as a joystick to help manipulate the fracture and to aid in reduction. Once satisfied with the reduction, K-wires are then placed through the plate into the distal fragment to hold it in position as shown here.
With the fracture reduced and held with K-wires, the distal screws are placed. I always drill in oscillation in order to avoid binding up any soft tissue. The first screw that I placed is a cortical screw placed bicortically in order to compress the distal fragment to the plate. This also dials in some additional volar tilt. Then the other, unicortical, subchondral locking screws are placed. Either locking screws or pegs can be placed. Once they're placed, that first bicortical non-locking screw is replaced with a unicortical locking screw. As discussed, once the distal fragment is fixed with additional locking screws, that first bicortical screw is removed and replaced with a unicortical locking screw or peg. In this case, I'm using a peg as shown here.
Final radiographs were taken to assess fracture reduction and hardware position. Typically, 2 or 3 shaft screws is sufficient. Locking screws in the shaft are typically not needed unless very osteopenic or bridging a bony defect. The subchondral distal screw should not be too proud and should not exit past the dorsal limit of the lunate. Radiographs are scrutinized to make sure that the screws are not in the radiocarpal joint or the distal radial ulnar joint. The final construct, shown intraoperatively.
Once satisfied, the wound is washed and closed in layers. The pronator quadratus can be closed over the plate if desired. I typically close with a few subcutaneous sutures with a 3-0 Vicryl and then a running 4-0 Monocryl as shown here.
After the wound is closed, a soft dressing is applied. The patient is asked to leave that soft dressing on and dry until the first postoperative visit in the office. That visit is typically 10 to 14 days after surgery. The patient is allowed to use their hand during that time for activities of daily living, but nothing strenuous or heavy. At that visit, a removable splint is given to be worn for protection and comfort, and formal therapy is prescribed. Thank you for watching.