- Discussion:
- anterior approach is useful for frxs w/ anterior displacement or rotation of articular
fragments such as volar Barton's frx;
- Surgical Approach:
- standard volar approach:
- most indicated for simple extra articular fractures and when there is absence of ulnar comminution / displacement:
- incision starts at thenar crease of palm, curves toward middle of forearm, w/ transverse segment as it crosses volar flexion crease of wrist;
- dissection goes thru FCR tendon tendon sheath and then the FCR is then retracted ulnarly and the incision is continued thru dorsal sheath,
down to pronator quadratus muscle;
- obtain more exposure by extending incision along border of thenar crease, and by releasing FCR from its attachement to trapezium;
- alternatively, the incision is carried down between the FCR and radial artery - radial artery need not be exposed;
- it is simply retracted radially and protected by the surrounding soft tissues;
- w/ CTS symptoms use standard open approach, but do not extend incision to the more proximal wound (inorder that injury
to palmar cutaneous branch is avoided);
- pronator quadratus muscle is taken down from its radial origin to expose the underlying fracture;
- this will need to be repaired at the end of the case;
- since repair of the pronator can be difficult, it can be tied down to the radial edge of the butress plate;
- avoid excessive retraction of the median nerve;
- reduction:
- reduction is achieved with supination and dorsiflexion over rolled towel, and is confirmed w/ flouroscopy;
- reduction is held w/ K wires inserted from volar to dorsal, which are oriented to allow holes of the T plate to slide down wire;
- volar capsule should not be opened for inspection as this violates radioscaphocapitate and radioscapholunate ligaments;
- articular reconstruction is supported by autogenous cancellous-bone graft, as well as a small buttress plate;
-
ulnar sided comminution / displacement:
- if predominate comminution or displacement is on ulnar side of volar radius, then consider an extended
carpal tunnel incision which crosses
proximal wrist crease obliquely and which then courses further proximally ulnar to palmaris longus tendon;
- a wide exposure is needed inorder to achieve adequate exposure of the volar radius;
- approach radius on ulnar side of flexor tendons inorder to avoid trauma to median nerve and its palmar cutaneous branch;
- excessive ulnar retraction of the median nerve (w/ a standard Henry approach) may lead to RSD;
- Implants:
- volar plates are well tolerated, and seldom need to be removed;
-
synthes volar locking plates
-
T plate:
- plate is bent in mid portion to effect
prebending effect;
- ensure that the distal margin of the plate does not encroach on the articular surface (using flouro);
- slight dorsal articular penetration may be allowable;
- begin w/ a proximal screw (
3.5 cortical) placed into distal side of the oval hole, which will have
effect of moving plate distally (which then applies compression to periarticular fragments);
- subsequently, insert the distal screw (
4.0 cancellous) only if it is needed;
Year Book: Fractures of the Lower End of the Radius Anteriorly Displaced Treated by Plating.
Internal fixation of volar-displaced distal radial fractures.
Anterior Margin Articular Fractures of the Distal Radius. T.R. Sprenger J. Orthop. Trauma. 1993. Vol 7. No 1, p 6-10.
Barton's and Smith's fractures. DS Louis. Hand Clin Vol 4. 1988. p 399-402.
Volar fixed-angle plating of distal radius extension frxs: influence of plate position on secondary loss of reduction--a biomechanic study in a cadaveric model.
Treatment of Unstable Distal Radial Fractures with the Volar Locking Plating System. Surgical Technique
