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).
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).
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.
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.
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
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