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Internal Fixation for Intraarticular Distal Radius Fractures

Barrie, Kimberly A. M.D.; Wolfe, Scott W. M.D.

Techniques in Hand and Upper Extremity Surgery: March 2002 - Volume 6 - Issue 1 - p 10-20
Technique

Department of Orthopaedic Surgery,

Division of Hand and Microvascular Surgery,

Mayo Clinic,

Rochester, MN, U.S.A.

Hospital for Special Surgery,

Weill–Cornell Medical Center,

New York, NY, U.S.A.

Address correspondence and reprint requests to Scott W. Wolfe, M.D., Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021, U.S.A.; E-mail: wolfes@hss.edu.

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INTRODUCTION

Fractures of the distal radius are the most common fractures of the upper extremity. Unlike the more common, lower-energy, extraarticular fractures, intraarticular distal radius fractures represent a complex injury that is associated with considerable morbidity. 1 Generally, prognosis is less favorable for displaced, comminuted, intraarticular fractures. The primary reason behind these less favorable outcomes is attributed to problems restoring and maintaining an anatomic reduction of the articular surface. 1–5

When faced with small, impacted, osteoarticular fragments, articular congruency is difficult to restore anatomically using traditional techniques. Longitudinal traction and manipulative reduction are generally ineffective, as articular fragments often lack capsular or ligamentous attachments and, thus, do not respond to “ligamentotaxis.”6–8 More aggressive treatment regimens are generally required to anatomically restore the articular surface. 5,9,10 Even when satisfactory reduction is obtained, maintenance of reduction with fixation using pins and plaster or external fixation is difficult, because the inherent instability of the fracture and the tendency for articular fragments to settle after stress relaxation of the tensioned soft-tissue envelope. In addition, it is not uncommon for patients with displaced, intraarticular distal radius fractures to have concomitant, ipsilateral, upper-extremity injuries that complicate their treatment. 10–12

Open-reduction and internal-fixation techniques have been developed to address the comminuted intraarticular distal radius fracture that cannot be anatomically reduced and maintained through external manipulation and ligamentotaxis. 1,5,13–15 Open techniques allow direct reduction and rigid internal fixation of intraarticular fragments with restoration of normal joint anatomy and articular congruency. By creating a more stable construct through internal fixation, early rehabilitation can be initiated with the goal of improved functional outcome.

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HISTORICAL PERSPECTIVE

Numerous techniques have been described for the treatment of patients with intraarticular distal radius fractures; the common objective of these techniques is to restore upper-limb function. 11,16 Historically, it was common practice to manage intraarticular distal radius fractures in a fashion similar to the management of extraarticular fractures. 1,6,11,17–19 Percutaneous pins and external fixation were routinely used to reduce and maintain alignment. Prolonged immobilization and distraction were often required, and loss of wrist motion and soft-tissue complications were frequently reported as a result of the inherent instability of these fractures. 6,20 Problems associated with late collapse were not uncommon, including malunion, pain, distal radioulnar joint dysfunction, and secondary carpal instability. 3

For more than 2 decades, the treatment of patients with intraarticular distal radius fractures has evolved to provide stable fixation that will permit early motion and avoid the negative sequelae associated with prolonged immobilization. 6,20 Proponents of internal fixation demonstrate the benefits of rigid fixation for unstable fractures in laboratory and clinical reports. 1,14,15,21,22 The addition of bone graft to prevent radial shortening and support the reduced articular surface has also shown improved functional outcomes. 1,7,9,16,23,24 Although internal fixation creates a more rigid mechanic construct that will accommodate early mobilization, open techniques generally require extensive soft-tissue dissection and have been associated with higher complication rates than the complication rates associated with closed techniques. 1,21

In an effort to avoid soft-tissue complications associated with open-fixation techniques, limited incision approaches and low-profile modular implants have been introduced. 15,22,25 These new implants are designed to contour to the surface of the distal radius and consequently require less surgical dissection. Theoretically, low-profile implants are less irritating to the overlying tendons; however, high rates of implant removal continue to be reported. 25

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INDICATIONS/CONTRAINDICATIONS

Laboratory and clinical studies help define the criteria for acceptable deformity to achieve a good functional outcome after intraarticular distal radius fractures occur. 1,2,5,18,26–28 It is important that prereduction injury films be closely inspected for any of the five critical indices of instability as outlined by Lafontaine et al. 29 (Table 1). These authors demonstrated that loss of fracture–fragment position after successful closed reduction was directly related to the number of instability indices present on the initial fracture films.

TABLE 1

TABLE 1

In addition to the instability factors cited above, surgical intervention is generally recommended when greater than 1 mm of displaced intraarticular fragments persists after closed reduction, or satisfactory alignment cannot be attained or maintained in plaster. In a physiologically young individual, no greater than 1 mm of articular incongruity, 10° of dorsal tilt, or 2–3 mm of increased ulnar variance should be accepted on postreduction films. Investigators showed that residual articular displacement of 1–2 mm corresponds to an increase incidence of posttraumatic arthritis. 1,2,4,20 Restoration of radial tilt, inclination, and length are also essential to preserve normal load transmission to the radius and ulna. 27,28 Failure to achieve these goals may lead to adaptive carpal instabilities, ulnar impaction, and posttraumatic arthritis. 5,26

There are three major categories of intraarticular fractures that generally require open reduction and internal fixation. Shear fractures of the dorsal or palmar articular lip of the distal radius (known as Barton's or reverse Barton's fractures) and displaced radial styloid fractures are considered inherently unstable and are not generally amenable to closed management. The third major fracture pattern that necessitates open reduction includes any fracture that involves depression of the articular surface that cannot be adequately reduced using ligamentotaxis and closed manipulation. 30

A relative contraindication to internal fixation is poor bone quality. In elderly patients, inadequate bone stock may result in poor screw purchase and compromised fixation (Fig. 1). Another relative contraindication to open management is excessive swelling or traumatized soft tissue. Because of the high-energy nature of these fractures, it is not uncommon for patients to experience severely contused and swollen wrists. It is advisable to wait until soft tissues recover before proceeding with open techniques to avoid problems with wound closure or dehiscence. 30

FIG. 1.

FIG. 1.

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DIAGNOSIS

Physical Examination

Intraarticular fractures of the distal radius tend to cluster in two age groups: young adults, after they experienced a high-energy trauma, and elderly individuals with weakened periarticular bone. Patients typically experience gross deformity of the wrist and moderate–severe swelling. A thorough neurologic and vascular exam is critical, because the potential for compartment syndrome or compressive neuropathies of the median or ulnar nerves exists. Median neuropathy may be present as a result of the direct pressure from displaced fragments or secondary to excessive swelling. Symptoms of nerve compression mandate immediate attention as they may represent an impending compartment syndrome. 12

In the setting of high-energy trauma, concomitant ligament injuries may also be present. Specific dynamic examination maneuvers to diagnose carpal instability are not usually possible in the acute setting and are better assessed with radiographic or arthroscopic techniques. 9 Examination of the elbow and distal radioulnar joint must be performed to evaluate longitudinal stability of the forearm. Depending on the mechanism of injury, disruption of the distal radioulnar joint ligaments, interosseous membrane, or radial head may be present. 1,2,11,12

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Radiographic Examination

Radiographic evaluation of distal radius fractures requires plain radiographs of the wrist in the posteroanterior and lateral planes. Oblique views may help to profile marginal lip fractures of the sigmoid notch. In many instances, as a result of the high-energy nature of these injuries and resultant displaced and comminuted fracture, radiographs are obtained in traction to better visualize the different components of the fracture. 9 Radiographic measurements, which are used to assess the adequacy of a reduction, include radial height, radial inclination, palmar tilt, and ulnar variance 27 (Fig. 2). In addition to wrist radiographs, ipsilateral elbow films should be obtained to assess concurrent bony or ligamentous injuries.

FIG. 2.

FIG. 2.

Computed tomography (CT) can be used as an adjunct to plain radiographs in evaluating severe intraarticular distal radius fractures. Computed tomographs better define the degree of radiocarpal and radioulnar congruency by imaging the fracture in multiple planes using thin cut tomographic slices 31,32 (Fig. 3).

FIG. 3.

FIG. 3.

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TREATMENT PRINCIPLES

The selection of optimal management of intraarticular distal radius fractures is based on several factors—age of the patient, degree of articular incongruity, amount of metaphyseal bone loss, and the presence of associated ligamentous injuries—relating to the mechanism of injury. The goal of any treatment is to anatomically restore the articular surface, while creating a sufficiently stable construct to allow motion early in the patient's recovery period after surgery.

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TECHNIQUE

Preliminary Reduction

In the presence of excessive soft-tissue swelling, surgical intervention should be postponed until the wound can be primarily closed without tension. 30 In the case of complex intraarticular fractures, when the decision to proceed with open reduction and internal fixation is readily apparent, closed reduction is performed in the operating room on a traction table or with the use of finger traps. In cases where a combination of internal- and external-fixation techniques is anticipated, an external-fixator frame is initially applied to provide distraction and assist in reduction of the fracture.

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Surgical Exposure

Planning before surgery is essential to adequately recognize and address the specific details of the fracture configuration. Surgical approach is based on the nature of the fracture and, in the majority of cases, is dictated by the direction of displacement of the major fragment on trauma films. Although it is preferable to minimize the number of incisions, in the case of complex intraarticular fractures or in the presence of associated soft-tissue trauma, two, and occasionally three incisions may be necessary. Regardless of the approach, the first priority is to obtain satisfactory articular alignment and provisional fixation using K-wires (Kirschner wires).

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Dorsal approach

In the setting of dorsal comminution and or displacement, a universal dorsal longitudinal incision is most commonly used. The extensor retinaculum is divided in line over the third dorsal compartment, and the extensor pollicis longus tendon is retracted to the radial side. Limited subperiosteal elevation of the second–fifth dorsal compartments is performed to expose the underlying fracture. Often, a 1-cm segment of the posterior interosseous nerve is resected to help reduce discomfort after surgery. Depending on the fracture pattern, dorsal comminution may be present. Elevation of the comminuted dorsal roof permits access to the metaphysis and indirect elevation of depressed articular fragments. Manipulation of intraarticular fragments can be performed using a dental probe or small periosteal elevator under fluoroscopic guidance. If direct visualization of the articular surface is deemed necessary, a transverse arthrotomy is made in line with the fibers of the dorsal radiocarpal ligament. A cuff of tissue should be left to facilitate repair of the dorsal radiocarpal ligament at the time of closure. In most cases, elevation of the depressed articular fragments creates a residual metaphyseal void. Autogenous bone graft or bone-graft substitute is inserted beneath the articular cartilage to fill the metaphyseal void and support the articular surface. 24 Once the articular components are reduced, definitive fixation is achieved with any of a number of dorsal plating systems (see “Plate Design” below). Before the plate is applied, intraoperative radiographs should be obtained to confirm the adequacy of the reduction and plate position.

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Palmar approach

The palmar approach is commonly used to manage palmar shearing fractures, or to provide additional plate fixation for highly comminuted fractures after dorsal fixation. A longitudinal incision is made between the flexor carpi radialis tendon and the radial artery. Branches of the radial sensory nerve are identified and retracted radially with the radial artery. The median nerve is retracted ulnarly with the flexor digitorum profundus tendons. Care must be taken throughout the case to minimize excessive retraction on the median, palmar, cutaneous, and radial sensory nerves. Special care should be taken to avoid injury to the small terminal branches of the lateral antebrachial cutaneous nerve that arborize near the radial styloid and innervate the radial border of the thumb. The insertion of the pronator quadratus on the distal radius is sharply elevated using an L-shaped incision in a radial to ulnar fashion. A cuff of tendon is taken with the muscle to facilitate later repair. At this point, the palmar surface of the distal radius is readily exposed, and the fracture is visualized. Fracture reduction is performed by manipulation of the fragments using a dental probe or periosteal elevator. Care should be taken to minimize disruption of soft-tissue attachments to avoid devitalizing the bone. Articular fragments are reduced through indirect and direct manipulation through a cortical window that is created by elevation of the palmar-fracture fragments. Autogenous bone graft or bone-graft substitute is inserted beneath the articular cartilage to fill the metaphyseal void and support the articular surface. 24 Although it is possible to perform an arthrotomy of the radiocarpal joint for direct visualization of the joint surface, the arthrotomy is discouraged, because the probability of causing additional capsular or palmar ligament injury is high, and the potential for arthrofibrosis to occur after surgery exists. The palmar ligaments are critical in maintaining carpal alignment and should not be incised.

Fixation of the reduced fracture is provisionally held with multiple smooth 0.045-inch K-wires. The placement of these wires should not interfere with the placement of definitive internal fixation. Radiographs or fluoroscopy should be obtained before the definitive fixation is placed to confirm reduction and position of the plate. Historically, the most common palmar plate used has been a 3.5-mm, straight or angled T-plate that can be used as a buttress plate or for direct fixation of the proximal and distal fragments. Most palmar plates are precontoured to accommodate the inherent palmar tilt present in the uninjured distal radius; however, fine adjustments are required frequently. Once the buttress plate is secured to the distal radius, the pronator quadratus is reapproximated to the periosteal edge of the distal radius, and the overlying skin is closed.

If an extensile approach is required as a result of associated injuries such as median neuropathy, concomitant carpal fracture, or ligamentous injury, the palmar incision can be extended distally to release the transverse carpal ligament. Care should be taken to protect the palmar cutaneous branch of the median nerve that lies in the plane between the median nerve and the flexor carpi radialis.

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Modified palmar incision

If a radial styloid implant is planned for use (see Fragment-Specific Fixation section) along the radial column, an alternative modified palmar approach may be used to simultaneously address the styloid and palmar lip-fracture fragments. 15 Palmar buttress and radial column implants can be applied through this versatile incision if necessary. A longitudinal incision, originating just distal to the tip of the radial styloid, is carried proximally 4–5 cm. The incision lies just palmar to the first dorsal compartment, overlying the brachioradialis tendon. The radial artery is not exposed, but is retracted with the palmar skin flap to the ulnar side. Care must be taken to identify and protect the dorsal radial sensory and antebrachial cutaneous nerve branches. To facilitate visualization of the fracture, the brachioradialis is split longitudinally and elevated in a subperiosteal fashion palmarly and dorsally. In addition to releasing the brachioradialis, the proximal portion of the first dorsal compartment is released to allow contoured application of the radial implant obliquely under the first extensor compartment tendons. To expose the palmar cortex, the pronator quadratus is readily elevated in continuity with the palmar portion of the brachioradialis and the periosteal sleeve (Fig. 4). After completing fixation, the brachioradialis tendon and attached pronator quadratus may be repaired to interpose a soft-tissue sleeve and promote smooth gliding of the overlying tendons.

FIG. 4.

FIG. 4.

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Closure: Dorsal Incision

If there is insufficient periosteum below the extensor tendons, a transverse division can be made along the distal one third of the extensor retinaculum to create a flap that may be interposed between the hardware and overlying extensor tendons. The extensor pollicis longus tendon is generally transposed subcutaneously. The remaining portion of the extensor retinaculum is closed over the fourth dorsal compartment tendons to prevent bowstringing.

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EVOLUTION OF PLATE DESIGN

The growing use of internal fixation implants has led to an evolution in plate design. Traditionally, a standard dorsal 3.5-mm T-plate, either alone or in conjunction with K-wires, has been used to restore and maintain the reduction of unstable, dorsally comminuted, intraarticular distal radius fractures. Axelrod and McMurty 1 evaluated 17 severely comminuted distal radius fractures managed with a dorsal AO (Synthes, Paoli, PA, U.S.A.) buttress plate. Average follow-up examination occurred at 39 months. The authors reported an overall complication rate of 50%, with 15% experiencing early complications, and 35% experiencing late complications. However, despite the high-complication rate, overall patient satisfaction was high, with 89% of the patients returning to their previous occupations.

In lieu of the more traditional 3.5-mm T-plates, lower-profile implants are increasingly being used to maintain reduction and provide rigid internal fixation and early range of motion. 15,22,25 Low-profile contoured plates designed specifically for dorsally displaced distal radius fractures are exemplified by the recent LoCon T plate (Wright Medical Technology, Arlington, TN, U.S.A.) and the Forte plate (Zimmer, Inc., Warsaw, IN, U.S.A.). Both plates are applied through a universal dorsal approach. For the Forte system, a fracture-reduction clamp with a template preshaped to the contour of an uninjured dorsal distal radius is used as an aide to reduction and drilling. Screw heads are countersunk to create a flush surface under the overlying extensor tendons. In one report, 95% of dorsally displaced distal radius fractures managed with a Forte plate and autogenous bone graft had good or excellent functional outcomes. 25 The LoCon T plating system contains palmar and dorsal plate designs. Both plates share a low-profile design and countersunk screw holes; they also have modular outrigger attachments that enable the screw fixation of small styloid or dorsoulnar sigmoid notch fragments (Fig. 5).

FIG. 5.

FIG. 5.

The Pi plate (Synthes, Paoli, PA, U.S.A.) is an alternative low-countered plate design, which is comprised of a distal juxta-articular band and two separate longitudinal bands extending proximally (Fig. 6). The distal limb is precontoured to mold to the dorsal distal radius. As necessitated by the fracture pattern, the design of the plate permits trimming and contouring of the plate. Either 2.4-mm screws or 1.8-mm threaded buttress pins are used to stabilize individual fracture fragments. 22 Initial reports were complicated by high incidences of tendonopathy and tendon rupture. 22 The plate was recently redesigned to create smooth transitions at the screw-hole edges, and the composition changed from titanium alloys to stainless steel to minimize interaction with the overlying soft tissues and tendons.

FIG. 6.

FIG. 6.

In an effort to minimize extensor tendon complications associated with dorsal plating of comminuted and dorsally displaced distal radius fractures, a fixed-angle palmar plating system has been proposed. In contrast to a buttress plate, the DVR system (Hand Innovations, Miami, FL, U.S.A.) uses subchondral support pegs that are screwed into the plate to create a fixed-angle device to support the distal radius fracture fragments. Proximal metaphyseal fixation is achieved with conventional screws.

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FRAGMENT-SPECIFIC FIXATION

Peine et al. 33 conceptually divided the distal radius and ulna in three columns—radial, intermediate, and ulnar—in an effort to define the mechanic elements that were critical to the reduction and maintenance of fracture stability (Fig. 7). These authors proposed that maximum stability of a complex intraarticular fracture could be achieved by restoration of stability to each disrupted column. The authors compared the structural rigidity of a simulated distal radius fracture managed with bicolumnar fixation against the traditional 3.5-mm dorsal T-plate and Pi plate fixation systems. The data demonstrated that lower-profile less-rigid implants, when placed in an orthogonal relation to the deforming forces of the wrist, maximized their combined mechanic stability. The double-plating technique led to a statistically significant increase in stiffness compared with traditional 3.5-mm dorsal T-plate and Pi plate fixation systems. 33 Employing this concept, Jakob et al. 34 reported statistically significant improvement in range of motion and grip strength between 6 months and 1 year in 68 intraarticular and extraarticular distal radius fractures managed with the double-plating technique and early mobilization.

FIG. 7.

FIG. 7.

A hybrid system based on this concept that combines K-wires with miniature plates and screws has been introduced (TriMed, Valencia, CA, U.S.A.) to allow ultra-low–profile fixation of individual fracture fragments. By simultaneously addressing the radial and intermediate columns of a distal radius fracture, a rigid construct is created that will tolerate early wrist motion. 15 Unlike the standard and modified solitary T-plate configurations, the concept of “fragment-specific fixation” involves reconstruction of each column with separate implants customized for each major fracture fragment. 33 Any of several modular “wire-form” devices may be contoured and used to fix unstable dorsal cortical fragments. A precontoured ulnar pin plate may be applied to secure unstable dorsoulnar fragments of the lunate facet. Anatomic restoration of the dorsoulnar fragment is critical to restore the bony architecture of the sigmoid notch and minimize the potential for late distal radioulnar joint instability. The construct is usually completed by the application of a radial styloid pin plate, fixed at right angles to the dorsal implants (Figs. 8A and B).

FIG. 8.

FIG. 8.

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Radial Styloid Fixation

Accurate and stable reduction of a large radial styloid fragment is critical to the restoration of distal radius anatomy in severely comminuted fractures and is analogous to restoration of malleolar alignment in comminuted ankle fractures. Likewise, failure to appreciate and stabilize this fragment when using traditional methods of radius fixation can result in disappointing late settling and resultant loss of radial length and articular congruity.

Reduction of the radial styloid fragment is performed through a modified palmar incision using longitudinal traction and direct manipulation and secured with a 0.045-inch K-wire placed through the extreme tip of the radial styloid. A 3-, 5-, or 7-hole radial pin plate is then applied over the K-wire and beneath the overlying first dorsal compartment's tendons. The radial styloid fragment is secured to the distal diaphysis by securing the plate to the radius with 2.7-mm cortical screws. K-wires are withdrawn and bent before impacting them in position within the distal holes of the plate (Figs. 8A–B).

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BONE GRAFT

A major concern with high-energy, intraarticular, distal radius fractures and fractures within the elderly population, is the presence of metaphyseal bone deficiency caused by impaction and cortical comminution. As a result of the high-energy forces associated with these fractures, the articular surface is commonly displaced and impacted. After elevating and reducing the depressed articular surface and restoring radial length, large metaphyseal voids are created, resulting in a loss of structural support for the reduced articular surface. 9,23 Autogenous bone graft or bone-graft substitutes are important to fill the void, provide structural support, and promote bone healing. Autogenous iliac crest bone graft has the strongest mechanic properties as well as osteoprogenitor cells and bone-inducing growth factors to accelerate healing. Concern over donor-site morbidity 35–37 has led to increasing use of bone-graft substitutes. 24,38–41,45

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COMBINED INTERNAL AND EXTERNAL FIXATION

The decision to use supplemental percutaneous pins or external fixation is based on the need to maintain reduction when internal fixation alone is deemed insufficient. 2,5,16,42 The external fixator neutralizes the high muscular forces across the wrist joint in cases of extensive comminution of the dorsal and/or palmar metaphyseal and diaphyseal surfaces.

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ASSOCIATED INJURIES

Of equal importance in the treatment of patients with intraarticular distal radius fractures is recognition of associated ipsilateral soft-tissue and skeletal injuries. In particular, the distal radioulnar joint has been a frequent cause of added morbidity after distal radius fractures occur. 3,4,13 Fracture lines that extend into the distal or radial ulnar joint should be anatomically reduced and stabilized to avoid the negative sequalae associated with distal radial ulnar joint instability. After fixation of the distal radius, manual stability of the distal ulna must be assessed, and fixation of large basilar fractures of the ulnar styloid can be performed as necessary to successfully restore stability to this joint. Ulnar styloid fractures can usually be addressed through a limited incision on the ulnar border of the wrist between the extensor carpi ulnaris and flexor carpi ulnaris, taking care to identify and protect the dorsal ulnar sensory branch of the ulnar nerve. Fixation with a K-wire and tension band, or a contoured mini-plate is straightforward and generally sufficiently stable to initiate early range of motion. If the ulna is grossly unstable and the styloid is intact, disruption of the dorsal and palmar radioulnar ligaments of the triangular fibrocartilage complex is present by definition. Ligament repair and/or temporary transosseous K-wire fixation in the position of maximum stability is required 43 (Fig. 9).

FIG. 9.

FIG. 9.

Often in the case of high-energy injuries, associated carpal interosseous ligament injuries may be present. It has been shown that the incidence of acute ligament disruption ranges from 0.9% to 30.6% after a distal radius fracture. 44 Ligament-injury incidence is greatest in comminuted intraarticular fracture patterns. The most common pattern encountered is scapholunate ligament injury; long-term sequelae of an unrecognized complete injury can include dorsal intercalated segmental instability. It is important to recognize complete injuries and address them at the time that the distal radius fracture is managed. In most cases, patients with scapholunate and lunotriquetral ligament partial disruptions can be treated with percutaneous pinning, or, in the case of complete disruption, patients can be treated with a dorsal capsulotomy and direct repair.

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REHABILITATION

The initiation of early motion is the ultimate goal in the treatment of patients with intraarticular distal radius fractures. The method of fixation, degree of stability, and presence of associated injuries dictates the regimen after surgery. All patients are initially placed in a bulky compressive dressing with the digits free. Digital range of motion and anti-edema techniques are initiated on day 1 after surgery. If rigid fixation is achieved, the dressing is removed 5–7 days after surgery and the patient is placed in a removable forearm based palmar thermoplast splint. The splint is removed for active range of motion exercises. Sutures are removed 10–14 days after surgery. Splints are progressively removed between 1–6 weeks. Initiation of passive range of motion and strengthening exercises are based on radiographic and clinical evidence of healing, which usually occurs between 4–6 weeks.

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COMPLICATIONS

Early Complications

Many early complications encountered with internal fixation techniques are caused by the injury's high-energy nature. Symptoms of median neuropathy are not uncommon and are frequently present before surgery. 3,21 If addressed appropriately at the time of presentation, either by strict elevation or by surgical release, consequences such as compartment syndrome and complex regional pain syndromes (CRPS) can be avoided. 1,6,20 Historically, the use of internal fixation required large incisions with extensive soft-tissue dissection that frequently resulted in soft-tissue complications. The majority of soft-tissue complications can be avoided by adherence to meticulous technique and awareness of the soft tissue's condition before surgery.

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Late Complications

Late complications can be attributed to failure to achieve or maintain articular congruity and anatomic alignment. Loss of fixation can lead to malunion or nonunion, distal radioulnar joint instability, or adaptive carpal instability. 3 The use of internal fixation has also been associated with flexor- and extensor-tendon ruptures. 1,21 In recent series, the incidence of secondary surgery for plate removal caused by tendon irritation or rupture is approximately 19%. 22,25 The new low-profile plates, which are designed to mimic the contour of the distal radius, are expected to decrease the incidence of tendonopathy and tendon rupture, but long-term studies are not available 15,22,25

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CONCLUSION

Restoration of upper-extremity function is the primary goal in the treatment of patients with intraarticular distal radius fractures. The means to which this is accomplished depends on several patient-related factors—the “personality” of the fracture and the operative technique involved. Open reduction and internal fixation is indicated in the treatment of patients with unstable distal radius fractures and those with articular incongruity, provided sufficient bone stock is present to permit a stable construct and early range of motion. The accurate early diagnosis and treatment of patients with these injuries is critical in preventing the negative sequelae associated with these fractures. Of equal importance is the appreciation and treatment of patients with any associated ipsilateral soft-tissue or skeletal injuries. With refinement of open-reduction techniques utilizing lower-profile implants and mechanic constructs designed to support each column of the injured wrist, earlier range of motion, and improved functional results can be achieved.

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