Journal Logo

Combined Dorsal and Volar Plate Fixation of Complex Fractures of the Distal Part of the Radius

Ring, David, MD1; Prommersberger, Karl, MD2; Jupiter, Jesse B., MD1

doi: 10.2106/JBJS.E.00249
Surgical Techniques
Free

BACKGROUND:

Fractures of the distal part of the radius that are associated with complex comminution of both the articular surface and the metaphysis (subgroup C3.2 according to the Comprehensive Classification of Fractures) are a challenge for surgeons using standard operative techniques.

METHODS:

Twenty-five patients with subgroup-C3.2 fractures that had been treated with combined dorsal and volar plate fixation were evaluated at an average of twenty-six months after the injury. Subsequent procedures included implant removal in twenty-one patients and reconstruction of a ruptured tendon in two patients.

RESULTS:

An average of 54° of extension, 51° of flexion, 79° of pronation, and 74° of supination were achieved. The grip strength in the involved limb was an average of 78% of that in the contralateral limb. The average radiographic measurements were 2° of dorsal angulation, 21° of ulnar inclination, 0.8 mm of positive ulnar variance, and 0.7 mm of articular incongruity. Seven patients had radiographic signs of arthrosis during the follow-up period. A good or excellent functional result was achieved for twenty-four patients (96%) according to the rating system of Gartland and Werley and for ten patients (40%) according to the more stringent modified system of Green and O'Brien.

CONCLUSIONS:

Combined dorsal and volar plate fixation of the distal part of the radius can achieve a stable, mobile wrist in patients with very complex fractures. The results are limited by the severity of the injury and may deteriorate with longer follow-up. A second operation for implant removal is common, and there is a small risk of tendon-related complications.

1 Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkee Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org

2 Klinik fur Handchirurgie, Salzburger Leite 1, D97615 Bad Neustadt, Germany

Back to Top | Article Outline

INTRODUCTION

Some articular fractures of the distal part of the radius are so complex that a bridging plate1 or even primary wrist arthrodesis2 is considered to be the best form of treatment (Figs. 1-A and 1-B). These fractures often have a combination of complex articular and metaphyseal comminution. The articular comminution includes fractures in both the coronal and the sagittal plane as well as impacted central articular fragments. The metaphyseal comminution leaves very little support for the articular fragments, so the surgeon must rely on the implants to maintain the length of the radius. In this setting, neither external fixation alone nor a single volar or dorsal implant is likely to provide adequate stability. We have had some success with combined dorsal and volar internal fixation.

Back to Top | Article Outline

SURGICAL TECHNIQUE

Intraoperative traction with use of temporary intraoperative external fixation or skeletal distraction is very helpful. We usually use external fixation and then keep it in place for three to six weeks after the surgery to provide additional support and to avoid the need for a tight circumferential dressing (Fig. 2-A).

Such complex fractures usually require simultaneous dorsal and volar exposure. The dorsal exposure provides direct access to the articular surface. The volar exposure allows interdigitation of the stout volar cortex—the strongest bone in the distal part of the radius and one of the few areas where the surgeon is likely to be able to judge appropriate length and alignment and to achieve bone-to-bone contact for additional stability3.

Volar exposure is usually achieved with the approach described by Henry4 in line with the flexor carpi radialis, but a volarulnar exposure or an extended carpal tunnel release5 can be used when exposure to the volar lunate facet is more important than exposure to the radial styloid. Many patients also have a carpal tunnel syndrome, which is addressed with a volar-ulnar exposure but requires a second incision in patients treated through a Henry exposure in order to avoid injury to the palmar cutaneous branch of the median nerve (Fig. 2-B).

Extending the skin incision across the transverse wrist flexion creases is helpful when a more extensive exposure is needed. These flexion creases should be crossed obliquely. The radial edge of the distal portion of the origin of the flexor pollicis longus is elevated from the radius to increase exposure of the pronator quadratus. The radial edge of the radius is exposed, and the radial edge of the pronator quadratus is incised.

FIG. 1-A

FIG. 1-A

FIG. 1-B

FIG. 1-B

The pronator quadratus is then elevated subperiosteally. Leaving the periosteum attached to the undersurface of the pronator may provide additional stout tissue for repair as repair of muscle fibers alone is difficult and often impossible. Release or z-lengthening of the brachioradialis can reduce the radial deviation stress on the fragments (Fig. 2-C).

All fragments of the volar metaphyseal cortex are saved and used as puzzle pieces to judge restoration of length and alignment. They are wedged into place and provisionally fixed with smooth Kirschner wires if necessary (Fig. 2-D).

Dorsally, a longitudinal incision is centered over the Lister tubercle, or in line with the third metacarpal and radial shaft given that the Lister tubercle is deformed or cannot be palpated in the majority of these complex fractures. The incision extends distal to the radiocarpal joint to allow for a generous capsulotomy to provide good visualization of the joint (Fig. 2-E). Broad skin flaps are developed to protect the radial sensory and dorsal ulnar cutaneous nerve branches while allowing broad access to the dorsal aspect of the radius (Fig. 2-F).

FIG. 2-A

FIG. 2-A

FIG. 2-B

FIG. 2-B

FIG. 2-C

FIG. 2-C

FIG. 2-D

FIG. 2-D

FIG. 2-E

FIG. 2-E

FIG. 2-F

FIG. 2-F

FIG. 2-G

FIG. 2-G

FIG. 2-H

FIG. 2-H

FIG. 2-I

FIG. 2-I

FIG. 2-J

FIG. 2-J

FIG. 2-K

FIG. 2-K

FIG. 2-L

FIG. 2-L

FIG. 2-M

FIG. 2-M

FIG. 2-N

FIG. 2-N

FIG. 2-O

FIG. 2-O

FIG. 2-P

FIG. 2-P

FIG. 2-Q

FIG. 2-Q

FIG. 2-R

FIG. 2-R

FIG. 2-S

FIG. 2-S

FIG. 2-T

FIG. 2-T

FIG. 3-A

FIG. 3-A

FIG. 3-B

FIG. 3-B

The extensor pollicis longus is identified and mobilized (Fig. 2-G). It is transposed dorsally and radially into the subcutaneous tissues and left there at the end of the operation. The radial wrist extensors are retracted radially. An attempt should be made to keep the fourth dorsal compartment intact by elevating it subperiosteally in the ulnar direction (Fig. 2-H).

FIG. 4-A

FIG. 4-A

FIG. 4-B

FIG. 4-B

The wrist capsule can be divided in a myriad of ways, but in most cases it makes sense to incise it longitudinally, leaving it attached to the dorsal fracture fragments. The fragments and capsule can then be retracted to expose the joint (Fig. 2-I). Exposure of the joint is more difficult through the volar wound, primarily because a volar capsulotomy is not advisable. The volar capsule is stouter and structurally more important than the dorsal capsule. Some joint exposure can be obtained volarly by mobilizing the fracture fragments or by mobilizing the radial shaft and rotating it out of the way, but this is not necessary when a combined dorsal and volar exposure is used.

Joint exposure allows identification and treatment of a scapholunate ligament injury when one is present (Fig. 2-J), allows the surgeon to be sure that the volar articular fragments are properly rotated (Fig. 2-K), and permits identification and realignment of impacted central articular fragments (Fig. 2-L).

It is sometimes useful to place the distal screws first so that bringing the plate down to the bone proximally will improve alignment of the volar fragments (Figs. 2-M and 2-N). Screws that lock to the plate (angular stable screws) are very useful for complex injuries, particularly when there is poor-quality bone.

FIG. 4-C

FIG. 4-C

FIG. 4-D

FIG. 4-D

A large radial styloid fragment can be repaired with a plate applied to the dorsal-radial surface of the distal part of the radius between the first and second dorsal compartments (Fig. 2-O). With the volar and radial fragments realigned and stabilized, the extent of the central dorsal and metaphyseal comminution is apparent (Fig. 2-P). While angular stable screws provide a great deal of support to the articular surface, the surgeon should also be prepared to apply an autogenous bone graft or a bone-graft substitute to support the articular surface, particularly the central fragments. In young patients, it is sometimes possible to fill the defect with all of the loose and displaced bone fragments collected during the operation (Fig. 2-Q).

Carpal injuries are repaired prior to repair of the dorsal fragments (Fig. 2-R). The dorsal-ulnar fragments are then replaced along with the dorsal capsule, are stabilized with provisional smooth Kirschner wires, and then are fixed with a plate and screws (Fig. 2-S). This completes a cage, or matrix, of angular stable screws that support the articular fragments. The dorsal capsule is not repaired. The wounds are closed (Fig. 2-T), and a bulky, nonconstrictive dressing is applied.

Active and active-assisted finger and forearm exercises are initiated immediately after the surgery. Patients treated without external fixation wear a volar thermoplastic wrist splint for three to six weeks. Functional use of the limb for light daily tasks is encouraged. Use of external fixation and wrist splints is discontinued between three and six weeks after the surgery, and wrist motion exercises are begun. Resistive exercises are not allowed until radiographic signs of healing have been established.

FIG. 4-E

FIG. 4-E

FIG. 4-F

FIG. 4-F

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation (D.R. and J.B.J.). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Klinik fur Handchirurgie, Bad Neustadt, Germany, and Massachusetts General Hospital, Boston, Massachusetts

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1646-1652, August 2004

Back to Top | Article Outline

References

1. Becton JL, Colborn GL, Goodrich JA. Use of an internal fixator device to treat comminuted fractures of the distal radius: report of a technique. Am J Orthop. 1998;27: 619-23.
2. Freeland AE, Sud V, Jemison DM. Early wrist arthrodesis for irreparable intra-articular distal radial fractures. Hand Surg. 2000;5: 113-8.
3. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am]. 2002;27: 205-15.
4. Henry AK. Extensile exposure. 2nd ed. New York: Churchill Livingstone; 1973.
5. Fernandez DL, Jupiter JB. Fractures of the distal radius: a practical approach to management. New York: Springer; 1996.
6. Swigart CR, Wolfe SW. Limited incision open techniques for distal radius fracture management. Orthop Clin North Am. 2001;32: 317-27.
Copyright © 2005 by The Journal of Bone and Joint Surgery, Incorporated