Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

254. Volar Plating of Distal Radius Fractures

John J. Fernandez

DEFINITION

images Distal radius fractures are defined by their involvement of the metaphysis of the distal radius.

images They are assessed on the basis of fracture pattern, alignment, and stability:

images Articular versus nonarticular

images Reducible versus irreducible

images Stable versus unstable

images Irreducible or unstable fractures require surgical reduction and stable fixation.

images Volar plating historically has been the method of choice for volar shear-type fractures.

images Recently developed fixed-angle plates have now made it a preferred method of fixation for most types of distal radius fractures.

ANATOMY

images The distal radius serves as a buttress for the proximal carpus, transmitting 75% to 80% of its forces into the forearm.

images The remaining 20% to 25% of force is transmitted through the distal ulna and the triangular fibrocartilage complex (TFCC).

images Dorsally

images The distal radius is the origin for the dorsal radiocarpal ligament.

images It is the floor of the fibro-osseous extensor tendon compartments and includes Lister's tubercle, assisting in extensor pollicis longus function (FIG 1A).

images The extensor tendons are in immediate contact with the dorsal surface of the distal radius.

images Volarly

imagesThe distal radius is the origin for the extrinsic ligaments of the carpus, including the radioscaphocapitate ligament.

images It also is the origin of the pronator quadratus.

images The flexor tendons are separated from the distal radius by the pronator quadratus.

images Ulnarly

images The distal radius is the origin for the radial triangular fibrocartilage (FIG 1A).

images It also contains the sigmoid notch, which articulates with the head of the distal ulna, contributing to forearm rotation.

images Distally

images The surface is divided into a triangular, radioscaphoid fossa and a square, radiolunate fossa articulating with the respective carpal bones (FIG 1B).

images The distal articular surface is inclined approximately 22 degrees ulnarly in the coronal plane and 11 degrees volarly in the sagittal plane (FIG 1C,D).

images The metaphysis is defined by the distal radius within a length of the articular surface that is equivalent to the widest portion of the entire wrist.

images

FIG 1  A. Axial MR image of the wrist at the level of the distal radius. Lister's tubercle is marked with an asterisk. Dotted lines represent dorsal and volar borders of the triangular fibrocartilage that helps stabilize the distal radioulnar joint. The dorsal distal radius acts as an attachment for dorsal extensor compartment sheaths. B. The distal articular surface of the radius is divided into a triangularly shaped scaphoid fossa (SF) and a square-shaped lunate fossa (LF). The distal ulna and the triangular fibrocartilage complex (TFCC) act as ulnar buttresses for the wrist. C. MR coronal cut of the distal radius. The articular surface of the distal radius is inclined about 22 degrees relative to the forearm axis (dotted lines). The ulnar aspect of the distal radius (ie, the lunate fossa) usually is distal to the end of the distal ulna (ie, negative ulnar variance). Note the solid lines marking ulnar variance. D. MR sagittal cut of the distal radius. The articular surface of the distal radius is inclined approximately 11 degrees palmar relative to the forearm axis (dotted lines). Proximally, there exists relatively thinner dorsal cortical bone versus the thicker volar bone.

images The dorsal cortical bone is less substantial than the volar cortical bone, contributing to the characteristic dorsal-bending fracture pattern of distal radius fractures.

PATHOGENESIS

images The mechanism of injury in a distal radius fracture is an axial force across the wrist, with the pattern of injury determined by bone density, the position of the wrist, and the magnitude and direction of force.

images Most distal radius fractures result from falls with the wrist extended and pronated, which places a dorsal bending moment across the distal radius.

images Relatively weaker, thinner dorsal bone collapses under compression, whereas stronger volar bone fails under tension, resulting in a characteristic “triangle” of bone comminution with the apex volar and greater comminution dorsal.

images Other possible mechanisms form a basis for some fracture classifications such as the one proposed by Jupiter and Fernandez.5

images Bending

images Compression

images Shear

images Avulsion

images Combinations

images Articular involvement and its severity are the basis of some fracture classifications, such as the AO9 and Melone8 classifications.

images Articular involvement splits the distal radius into distinct fragments separate from the radius shaft (FIG 2):

images Scaphoid fossa fragment

images Lunate fossa fragment. Further comminution can split the lunate fossa fragment into dorsal and volar segments, creating the so-called four-part fracture.

NATURAL HISTORY

images Clinical outcome usually, but not always, correlates with deformity.

images Variable residual deformity can be tolerated best by individuals with fewer functional demands.

images As wrist deformity increases, physiologic function is progressively altered.

images Intra-articular displacement of 1 to 2 mm results in an increased risk of osteoarthritis.3,6

images Radial shortening of 3 to 5 mm or more results in increased loading of the ulnar complex.1,12

images Dorsal angulation greater than 10 degrees shifts contact forces to the dorsal scaphoid fossa and the ulnar complex, causing increased disability.13,16

images The incidence of associated intracarpal injuries increases with fracture severity. Such injuries can account for poor outcomes. These injuries often are not recognized at first, with the result that treatment is delayed.4,14

images Triangular fibrocartilage (TFC) tears

images Scapholunate and lunotriquetral ligament tears

images Chondral injuries involving the carpal surfaces

images Distal radioulnar joint injury

images Distal ulna fractures

images By predicting the stability of a distal radius fracture, deformity and its complications can be minimized. Several risk factors have been suggested by LaFontaine et al7 and others. The presence of three or more indicates instability:

images Dorsal angulation greater than 20 degrees

images Dorsal comminution

images Intra-articular extension

images Associated ulna fracture

images Patient age over 60 years

images

FIG 2  The arrowhead points to the articular split. Articular displacement of the scaphoid fossa fragment radially and the lunate fossa fragment ulnarly is apparent, as is significant shortening (ulnar positive variance) as outlined by the lines.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The mechanism of injury should be sought, to assist in assessing the energy and level of destruction.

images Associated injuries are not uncommon and should be carefully ruled out.

images Injuries to the hand, carpus, and proximal arm, including other fractures or dislocations

images Injuries to other extremities or the head, neck, and torso

images Establish the patient's functional and occupational demands.

images Document co-existing medical conditions that may affect healing, such as osteoporosis or diabetes.

images Determine possible risk factors for anesthesia and surgery, such as cardiac disease.

images The physical examination should document the following:

images Condition of surrounding soft tissues (ie, skin and subcutaneous tissues)

images Quality of vascular perfusion and pulses

images Integrity of nerve function

images Sensory two-point discrimination or threshold sensory testing

images Motor function of intrinsic, thenar, and hypothenar muscles of the hand

images Examination of the distal ulna, TFCC, and distal radioulnar joint should rule out disruption and instability.

images Reliable physical examination of the carpus often is difficult, making radiographic review even more critical and follow-up examinations important.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Imaging establishes fracture severity, helps determine stability, and guides the operative approach and choice of fixation.

images

FIG 3  A. This pronated view accentuates the dorsal articular surface irregularity (arrowhead) and the displaced fragment. B. This supinated view accentuates the displaced radial styloid fragment. C. On this lateral radiograph, the arrowhead points to the articular split and the displacement of the lunate fossa fragment. Note the dorsal angulation and collapse (dotted line). Observe the significantly thicker volar cortical bone in comparison to the dorsal bone. D,E. AP and lateral cuts taken from CT images of a distal radius fracture revealing the extent of comminution and central impaction, which are not easily appreciated on plain radiographs.

images Plain radiographs should be obtained before and after reduction: PA, lateral, and two separate oblique views.

images Oblique views, in particular, help evaluate articular involvement, particularly the lunate fossa fragment (FIG 3A,B).

images The lateral view should be modified with the forearm inclined 15 to 20 degrees to best visualize the articular surface (FIG 3C; see Tech Fig 5BC).

images Fluoroscopic evaluation can be useful, because it gives a complete circumferential view of the wrist and, with traction applied, can help evaluate injuries of the carpus.

images CT helps define intra-articular involvement and helps detect small or impacted fragments, which may not be apparent on plain radiographs, particularly those involving the central portion of the distal radius (FIG 3D,E).

DIFFERENTIAL DIAGNOSIS

images Diagnosis is directly confirmed by radiographs.

images Associated and contributory injuries should always be considered.

images Pathologic fracture (eg, related to tumor, infection)

images Associated injuries to the carpus (eg, scaphoid fracture, scapholunate ligament injury)

NONOPERATIVE MANAGEMENT

images Nonoperative treatment is reserved for distal radius fractures that are reducible and stable based on the criteria previously discussed.

images The goal of nonoperative treatment is to immobilize the wrist using a method that will maintain acceptable alignment until the fracture is healed.

images Radial inclination greater than 10 degrees

images Ulnar variance less than 4 mm positive

images Palmar tilt less than 15 degrees dorsal or 20 degrees volar

images Articular congruity less than 2-mm gap or step-off

SURGICAL MANAGEMENT

images The goal of operative treatment is to achieve acceptable alignment and stable fixation.

images Various methods of fixation are available: pins, external fixators, dorsal plates, intramedullary devices, and volar plates.

Preoperative Planning

images The standard preoperative medical and anesthesia evaluation for concurrent medical problems is done.

images Discontinue blood thinning medications (anticoagulants and nonsteroidal anti-inflammatory drugs).

images Request necessary equipment, including fluoroscopic and power equipment.

images Confirm the plate fixation system to be used and check the equipment before beginning surgery for completeness (ie, all appropriate drills, plates, and screws).

images Have a contingency plan or additional fixation (external fixator, bone graft, or bone graft substitute).

images Review previous radiographic studies.

images Consider use of a regional anesthetic for postoperative pain control.

Positioning

images Place the patient in the supine position with the affected extremity on an arm table.

images Apply an upper arm tourniquet, preferably within the sterile field.

images Incorporate weights or a traction system to apply distraction across the fracture (FIG 4).

images The surgeon is seated on the side, toward the patient's head, particularly if he or she is right-hand dominant.

images The assistant is seated opposite the surgeon.

images The fluoroscopy unit is brought in from the end or corner of the table.

images

FIG 4  Traction is applied over the arm table with finger traps and hanging weights. The surgeon sits on the volar side, and the assistant on the dorsal side. Fluoroscopy can be brought in from any direction, but preferably from the side adjacent or the opposite surgeon.

Approach

images Dorsal exposure allows for direct visualization of the articular surface when necessary.

images Fracture comminution is more severe dorsally, making overall alignment more difficult to judge.

images The thicker volar cortex is less comminuted, allowing for more precise reduction and buttressing of bone fragments.

images Sometimes both dorsal and volar exposures may be necessary to achieve articular congruency and volar reduction and fixation, respectively.

images An extended volar–ulnar exposure may be necessary to perform a carpal tunnel release if indicated.

images The techniques described in this chapter use the volar approach to distal radius, as described by Henry (FIG 5).

images

FIG 5  The volar incision is represented by the dotted line just proximal to the wrist flexion creases and radial to the flexor carpi radialis longus. Care is exercised to avoid dissection ulnar to the flexor carpi radialis, because the palmar cutaneous nerve branch of the median nerve (arrow) is at risk.

TECHNIQUES

VOLAR FIXED-ANGLE PLATE FIXATION OF THE DISTAL RADIUS

Incision and Dissection

images  Palpate the flexor carpi radialis tendon and make a 4 to 8-cm longitudinal incision from the proximal wrist flexion crease, extending proximally along the radial border of the flexor carpi radialis tendon.

images If the incision must cross the wrist flexion creases, use a zigzag incision in that area.

images  Carefully avoid the palmar cutaneous branch of the median nerve along the ulnar side of the flexor carpi radialis within 10 cm of the wrist flexion crease.

images Branches of the dorsal radial sensory nerve and lateral antebrachial cutaneous nerve sometimes appear along the path of the incision and also need to be protected.

images  At the distal end of the incision, protect the palmar branch of the radial artery to the deep arch.

images It usually is not necessary to dissect out the radial artery (TECH FIG 1A).

images  Incise the anterior sheath of the flexor carpi radialis tendon and retract the tendon ulnarly to help protect the median nerve (TECH FIG 1B).

images  Incise the posterior sheath of the flexor carpi radialis tendon.

images The deep tissues likely will bulge out from the pressure of swelling and fracture hematoma.

images The median nerve lies within the subcutaneous tissues along the ulnar portion of the wound (TECH FIG 1C,D).

images The flexor pollicis longus tendon sits along the radial margin of the wound.

images  Using blunt dissection with a gauze-covered finger, sweep the tendons and the nerve ulnarly.

images A self-retaining retractor is carefully placed between the radial artery radially and the tendons and median nerve ulnarly.

images

TECH FIG 1  A. The interval between the radial artery (arrow) and the flexor carpi radialis tendon (*) is seen. B. The posterior sheath (*) of the flexor carpi radialis is visible after retracting the flexor carpi radialis ulnarly (arrow). Be careful during deeper dissection, because swelling and hematoma may distort the position of the median nerve beneath the sheath. C. Following incision in the flexor carpi radialis posterior sheath, the deep tendons are visible, including the flexor pollicis longus (FPL) and the flexor digitorum superficialis of the index finger (FDS). The median nerve also is visible (*). D. The palmar cutaneous nerve branches of the median nerve (arrow) and median nerve (asterisk) are both at risk for injury during this approach. Be careful regarding placement of retractors and during dissection and plate placement. E. The pronator quadratus (PQ) is incised distally, radially, and proximally and then reflected ulnarly after dissection off the volar distal radius. F. The brachioradialis (arrow) can be a deforming force, especially in comminuted fractures and in those for which treatment has been delayed. This tendon can be released if necessary.

images The pronator quadratus is now visualized at the floor of the wound.

images  Incise the pronator quadratus at its radial insertion, leaving fascial tissue on either side to aid in closure. Also, determine the proximal and distal extent of the muscle, and make horizontal incisions at both of those points (TECH FIG 1E).

images The distal margin of the pronator quadratus attaches along the distal volar lip of the distal radius, along the “teardrop.”

images The radial margin is in proximity to the tendons of the first dorsal compartment and the brachioradialis.

images  Subperiosteally dissect the pronator quadratus off the volar surface of the distal radius as an ulnarly based flap with a knife or elevator.

images  Retract the pronator ulnarly with the flexor tendons and median nerve.

images  Particularly if significant shortening of radial-sided fracture fragments has occurred, incise the broad insertion of the brachioradialis to eliminate the deforming force (TECH FIG 1F).

images  Release the first dorsal compartment and retract the tendons before releasing the brachioradialis.

images  Alternatively, Z-lengthen the brachioradialis tendon to allow for repair at the completion of the case.

Fracture Reduction and Provisional Fixation

images  Apply a lobster-claw clamp around the radius shaft at a perpendicular angle to the volar surface at the most proximal portion of the wound (TECH FIG 2A).

images This allows for excellent control of the proximal shaft for rotation and translation.

images It also provides an excellent counterforce when correcting the dorsal angulation collapse.

images  With the fracture now exposed, apply traction distally to distract and disimpact the fragments.

images  Carefully clean the fracture of any interposed muscle, fascia, hematoma, or callus while maintaining the bony contours.

images  In the case of significant volar comminution, reduce and provisionally stabilize the fragments with K-wires.

images Take plate positioning into account when placing these K-wires.

images  The articular surface is first reduced, if necessary.

images  Under fluoroscopic guidance, manipulate the articular fragments through the fracture with a periosteal elevator, osteotome, or K-wires (TECH FIG 2B,C).

images Longitudinal traction is important during this reduction phase. It can be performed by an assistant or using cross-table weights and finger-traps.

images A dorsal exposure is performed at this stage if there is significant impaction, particularly centrally, that cannot be corrected using the extra-articular technique described here.

images

TECH FIG 2  A. A lobster-claw clamp (double arrow) is applied to the radius shaft well proximal to the fracture. This instrument helps the surgeon control the radius during reduction and define the lateral margins of the radius. A Freer elevator is inserted into the fracture to help disimpact the fragments and assist in their reduction. B. The brachioradialis (white arrow) is released, and the first compartment extensor tendons are visible in the background (black arrow). An instrument can now be placed to assist in the reduction (arrow). C. The Freer elevator is used to reduce the fragments. In this case, the intra-articular step-off is being corrected, and the radial length and inclination are being restored. D. K-wires are placed across the radial styloid into the reduced ulna fossa fragment. An assistant usually applies traction, and the lobster-claw clamp can be used for powerful leverage. If there is no articular involvement, this K-wire can be placed into the radius metaphysis or diaphysis proximally. E. The K-wire should be placed as close as possible to the subchondral bone, avoiding areas of comminution. F. The K-wire should maintain the articular reduction without any support.

images  Place K-wires from the radial styloid fragment into the lunate fossa fragment to maintain the articular reduction (TECH FIG 2D).

images The K-wires should be placed as close as possible to the subchondral plate (TECH FIG 2E,F).

images  Once the distal articular reduction is complete, reduce the distal radius as a single unit to the radius shaft.

images  Insert K-wires as required to maintain the provisional reduction between the distal fragments and the proximal shaft fragment.

images If radial collapse and translation are prominent, a large K-wire can be introduced into the radial portion of the fracture and advanced proximally and ulnarly to behave like an intrafocal pin and provide a radial buttress by pushing the distal fragment ulnarly.

images  A similar technique can be applied through the dorsal fracture to assist in maintaining the palmar tilt correction.

Plate Application

images  Apply a fixed-angle volar plate to the volar surface of the distal radius and shaft. Position the plate to accommodate for the unique design characteristics of the plating system as well as the location of the fracture fragments.

images  Each plating system has unique characteristics that determine its optimal placement.

images  Ideally, the plate should be placed as close to the articular margin as possible without the distal locking pegs or screws penetrating the joint.

images  If the fracture has not yet been fully reduced, this must be taken into account when placing the device.

images  Clamp the previously applied lobster claw to the proximal portion of the plate to keep the plate centralized on the radius shaft.

images  Place provisional K-wires through the plate to maintain position (TECH FIG 3). Then fluoroscopically confirm proper plate position in both the distal–proximal and radioulnar directions.

images  Proper alignmentl of the plate can be determined only using a true anteroposterior (AP) image in which the distal radioulnar joint is well visualized.

images

TECH FIG 3  Keep the plate centered on the radius and as distal as possible. The lobster-claw clamp helps keep the plate centered. K-wires (arrows) are helpful as provision fixation until alignment can be confirmed radiographically and screws placed.

images The K-wires allow for fine adjustment in plate position before committing to insertion of a screw.

images  Drill and insert a provisional screw in the oblong hole in the plate.

images If the bone is osteopenic, a screw longer than the initial measurement should be placed to ensure that both cortices are engaged. Otherwise, the plate may not be held securely, and the reduction will be compromised. After the remaining screws have been secured, this screw can be replaced with one of the appropriate length.

images  Insert at least one additional proximal screw and remove the provisional K-wires holding the plate in place.

Distal Fragment Reduction

images  Once the proximal plate has been secured, execute any additional reduction needed.

images A well-designed plate serves as an excellent buttress for correction of the palmar tilt (TECH FIG 4A).

images  Apply counterforce through the lobster-claw clamp in a dorsal direction while the distal hand and wrist are translated palmarly and flexed (TECH FIG 4B).

images This maneuver reduces the distal radius to the plate, effectively restoring volar tilt by pushing the lunate against the volar lip of the distal radius (TECH FIG 4C,D).

images  Additional distraction and ulnar deviation correct radial collapse and loss of radial inclination.

images

TECH FIG 4  A. The final reduction is performed with traction on the hand and with the radius held proximally with a clamp. Once the reduction is confirmed radiographically, the assistant places the distal screws or K-wires. B. The hand is translated (not appreciably flexed) palmarly while the radius shaft is held with the clamp. (continued)

images

TECH FIG 4  (continued) Prereduction (C) and postreduction (D) radiographs demonstrating the palmar translation reduction maneuver. The volar plate acts as a strong buttress (arrow), allowing the translated lunate to push on the volar radius (*) and correct the dorsal angulation deformity.

Plate Fixation

images  While the reduction is held, drill the holes in the distal plate (TECH FIG 5A).

images Some plate systems allow for provisional fixation using K-wires placed through the distal plate.

images Do not penetrate the dorsal distal radius with the drill, to protect the dorsal extensor tendons.

images  Drill and place the distal ulnar screws first and then proceed radially and proximally.

images  Judge the placement of all distal screws or pegs precisely using fluoroscopic imaging in multiple planes.

images Perform a “true” lateral view of the wrist with the x-ray beam at a 20-degree angle to the radius shaft

(TECH FIG 5B,C). This is facilitated by lifting the wrist off the table with the elbow maintained on the table and the forearm at a 20-degree angle to the table (TECH FIG 5D,E).

images Lister's tubercle can be mistaken for the dorsal cortex, resulting in screws that are too long.

images The extensor pollicis longus is at greatest risk of injury from a protruding screw.

images  Sequentially insert the remaining distal screws or pegs, followed by the remaining proximal plate screws (TECH FIG 5F).

images  If necessary, add bone graft or bone graft substitute around the plate into the fracture site or through a small dorsal incision.

images

TECH FIG 5  A. The remaining holes can now be drilled and screws placed where needed. B. This screw (arrow) looks as though it has penetrated the joint when in reality it is simply the angle of the radiographic beam that throws its projection into the joint. C. A true lateral view of the distal radius is necessary to judge placement of the radial screws. D. A radiograph is being taken with the wrist perpendicular to the x-ray beam (arrow). This is not a true lateral image, because the distal surface of the radius is inclined 20 degrees radially. (continued)

images

TECH FIG 5  (continued) E. By lifting the hand and wrist 20 degrees off the table, a “true” lateral image can be achieved. The x-ray beam is now perpendicular to the joint (arrow). F. The remaining screws have been placed.

images  Precisely assess the stability of the construct after the plate has been applied. If appropriate, remove the provisional K-wires.

images If the K-wires are deemed critical for fracture stability, they can be left in place and removed 4 to 8 weeks later

images If residual instability exists, add additional fixation with K-wires, an external fixator, a dorsal plate, or a combination.

Closure

images  Repair the pronator quadratus to its insertion site with a series of 3-0 absorbable horizontal mattress sutures (TECH FIG 6A).

images In many cases it is impossible to repair the pronator quadratus because the muscle and fascia are extremely thin or the muscle is damaged. In this situation, the muscle can be debrided or simply left in place.

images  Before skin closure, obtain final radiographs (TECH FIG 6B,C), and assess stability of the distal radioulnar joint.

images  Place a drain only if excessive bleeding is anticipated.

images  Consider methods to minimize postoperative pain:

images Percutaneous placement of a pain pump catheter

images Injection of a long-acting local anesthetic

images  Close the subcutaneous tissues with 4-0 absorbable suture and reapproximate the skin with interrupted 4-0 or 5-0 nylon sutures or a running subcuticular stitch.

images  Place two layers of gauze and a nonadherent gauze over the wound, wrap the wrist and forearm with thick Webril (Kendall, Mansfield, MA), and apply a below-elbow splint in a neutral wrist position (TECH FIG 6D).

images If there is injury to the ulnar wrist (eg, ulna styloid fracture, distal radioulnar joint injury), immobilize the forearm with an above-elbow or Munster splint.

images

TECH FIG 6  A. The pronator quadratus has been repaired. B. AP radiograph demonstrating correction of the articular surface, radial height (lines), and radial inclination (dotted line). C. Lateral radiograph demonstrating correction of the palmar tilt (dotted line). D. A bulky dressing is applied with a volar splint holding the wrist in a neutral position. A pain pump catheter has been inserted for additional pain control.

VOLAR FIXED-ANGLE PLATE USING THE PLATE AS REDUCTION TOOL

images  We do not recommend use of the volar fixed-angle plate as a reduction tool in the acute setting. It is best employed (if at all) for a malunion, or perhaps for a fracture with minimal articular comminution.

images This technique is difficult, because it has to account for the longitudinal and translational alignment of the plate before the reduction has been achieved.

images  Perform the surgical approach previously described.

images  Address first any distal articular involvement with reduction and K-wire fixation.

images  Affix the plate to the distal fragment, accounting for where the plate will sit on the radius shaft once the reduction is completed.

images  Place the screws so that they are parallel to the articular surface on the lateral x-ray view (TECH FIG 7A,B).

images  On the AP radiograph, align the plate with the perpendicular of the radial inclination of the distal radius (20 degrees; TECH FIG 7C,D).

images  Once distal fixation is complete, secure the proximal plate to the radius shaft, thereby completing the reduction.

images  Close and splint as described previously.

images

TECH FIG 7  A. The volar plate is applied with the distal screws placed first (parallel to distal articular surface). B. Reducing the plate to the diaphysis proximally accomplishes the reduction. C. The plate is applied at approximately a 20-degree angle relative to the distal articular surface or to the amount of angulation that is estimated. D. By reducing the plate to the diaphysis, the distal angulation is corrected.

images

images

POSTOPERATIVE CARE

images The wrist is splinted in a neutral position, leaving the digits free.

images If the fracture is particularly tenuous or there is injury to the ulnar wrist, a long-arm or Munster splint is applied.

images The patient is instructed to perform active ROM exercises for the digits every hour and to engage in strict elevation for at least 3 days.

images It is critical to emphasize edema prevention and immediate ROM of the digits.

images At 1 week postoperatively, the splint is removed and the wound is examined.

images If swelling permits, the therapist fabricates a molded Orthoplast splint (Johnson & Johnson Orthopedics, New Brunswick, NJ) to be worn at all times.

images Active ROM exercises of the wrist are implemented 1 week postoperatively.

images At 4 to 6 weeks, putty and grip exercises are added.

images At 6 to 8 weeks, the splint is discontinued, and progressive strengthening exercises are advanced.

images If necessary, progressive passive ROM can begin, including use of dynamic splints.

images At 10 to 12 weeks, the patient usually can be discharged to all activities as tolerated.

OUTCOMES

images Overall good to excellent results can be expected in over 80% of patients with ROM, strength, and outcomes scoring.10,11,15,17

images Studies comparing volar fixation to other forms of fixation (eg, external fixators, pins, and dorsal plating) have revealed similar if not superior results.

images Results appear to be superior in the early reclovery period, with the final outcome yielding equivalent results among all fixation groups.

images Some studies suggest better maintenance in overall reduction compared to other forms of fixation.

COMPLICATIONS

images Complication rates as high as 27% have been reported.

images Complications can be categorized into those involving hardware, fracture, soft tissues, nerves, and tendons.2

images Failures of hardware, such as plate or screw breakage, can occur but are rare. Usually such failures are an indication of other problems, such as nonunion.

images The hardware becomes unacceptably prominent in a minority of patients.

images This complication may become evident only after some time has elapsed, as swelling of fibrous tissue subsides and bone remodels.

images The most common sites include the dorsal wrist, when screws have been inserted, and the radial wrist, when a plate has been used.

images It can be avoided with careful screw and plate placement and radiographic verification of their position.

images Nonunion and delayed union are unusual. Consider a diagnosis of osteomyelitis or other risk factors such as smoking.

images Loss of fracture reduction and fixation can occur, and is most common in patients with osteopenic bone or comminuted and articular fractures.

images This can be avoided with frequent and early follow-up with repeat radiographs.

images If instability is suspected, the fracture can be casted.

images In the operating room, if instability is suspected, additional fixation should be considered (eg, external fixator, pins, bone graft).

images Soft tissue complications are proportional to the energy of the initial injury.

images Open wounds usually can be addressed with local measures.

images Significant swelling must be addressed with early and aggressive modalities. Swelling can lead to other complications, such as joint stiffness and tendon adhesions.

images Nerve injuries can be the result of initial trauma or subsequent surgical trauma.

images Assess and document neurologic status before sulrgery.

images Avoid further injury to nerves with careful placement of retractors.

images The palmar cutaneous branch of the median nerve can be injured during incision and exposure.

images Postoperative neuromas can cause pain and sensitivity along scar.

images Avoid the nerve with a well-placed incision radial to the flexor carpi radialis and careful deep dissection.

images Postoperative swelling also can lead to median neuropathy. Carpal tunnel release should be performed if there is any suspected compression neuropathy or if this is to be anticipated as a result of postoperative swelling.

images Tendon complications include adhesions and ruptures.

images Most tendon adhesions involve the dorsal extensor tendons resulting in extrinsic extensor tightness.

images Flexor tendon adhesions are uncommon and involve primarily the flexor pollicis longus.

images Tendon ruptures have been described, especially involving the flexor pollicis longus and the extensor pollicis longus, as a result of plate and screw prominence, respectively.

images The distal screws must not be left prominent, and caution must be applied when drilling.

images The sagittal and coronal profiles of the plate being used must be taken into consideration—some plates are very prominent and extend far radially.

REFERENCES

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