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ORIF of Distal Radius Fractures


- Discussion:
 (distal radius fracture menu and colles fracture)
- volar surface of distal part of radius is slightly flattened, except for its distal margin, which
slopes volarly to form a prominent ridge from which volar radiocarpal ligaments originate.
- short radiolunate ligament originates off of volar margin of lunate facet and attaches to
volar surface of lunate and helps maintaining stability of the radiolunate articulation;
- ulnar volar margin of lunate facet slopes volarly as viewed from proximal to distal and may not be
effectively supported by standard implants;
- volar rim of the distal part of the radius is not straight but slopes volarly from radial to ulnar;
- ulnar aspect of the volar rim of the radius is convex distally, forming a palmar prominenceof the lunate facet;
- volar lunate facet extends more distally than is expected, which makes it more difficult to achieve adequate support w/
volar plate fixation;

This is a detailed step by step instruction through fragment specific dorsal plating of a distal radius fracture using Depuy SynthesTM 2.4mm variable angle plating system.

This is a procedure undertaken for complex comminuted intra-articular distal radius fractures. It allows for fragment specific fixation of the fracture and can be combined with arthroscopic assessment if necessary.

The post-operative regimen will depend on the complexity of the fracture and the confidence of the surgeon in the hold of the fixation.

Commonly the patient is placed into plaster cast for 7-10 days for comfort and to allow post-operative swelling to settle and then mobilisation begins with the hand therapy team with a Futuro wrist splint to be used for comfort at the patients discretion.

Heavy loading of the wrist and aggressive passive exercises are not started before 6 weeks post-operatively.

Author: Mr Mark Brewster FRCS (Tr & Orth)

Institution: The Royal Orthopaedic Hospital, Birmingham, UK.

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- fractures of lunate fossa:
             - volar shearing fracture with comminution creates a functional radiolunate ligament avulsion, which can lead to instability;
- volar aspect of the lunate fossa bears more load than the scaphoid fossa;
- fractures involving the volar lunate facet articular fragment can therefore be difficult to treat;
- references:
Loss of Fixation of the Volar Lunate Facet Fragment in Fractures of the Distal Part of the Radius
- The volar extension of the lunate facet of the distal radius: a quantitative anatomic study.
             - controversies: should associated ulnar styloid frx be fixed at the time of ORIF?
                     - ref: Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture?

- Preoperative Planning:
       - exam:
                - if there is significant swelling the case may have to be delayed;
- patients should be examined for carpal tunnel symptoms before and after reduction;
- carpal tunnel symptoms that do not resolve following reduction will require carpal tunnel release;
       - radiographs distal radius frx:
                - w/ volar Barton's frx, note whether there is more ulnar or radial sided comminution (since this can affect
choice of surgical approach);
- intra-articular frxs w/ > 2 millimeters of displacement;
- restoration of articular anatomy is most critical factor in obtaining a good functional result;
- wrist traction, 2 K wires, one parallel to joint line;
- risk factors for inadequate reduction (unstable fracture)
- dorsal comminution;
- interposition of volar soft tissues;
- tendency for dorsal displacement & dorsal angulation;
       - ref: No Difference in Adverse Events Between Surgically Treated Reduced and Unreduced Distal Radius Fractures.

 

- Surgical Approach and Plate Position:

- dorsal approach and fixation:

This is a detailed step by step instruction through a arthroscopic assisted dorsal plating of a distal radius.

The operation is performed to restore the bone anatomy of the distal radius following a wrist fracture. Specific attention is paid to the congruency of the distal radius articular surface viewed by the arthroscopy.

Adding an arthroscopy to a plating of a distal radius is only necessary for intra-articular fractures. It could be argued that all intra-articular fractures would benefit from an addition of arthroscopy to check joint congruence, however most intra-articular wrist fixation takes place without arthroscopy. For those surgeons who routinely perform arthroscopy of the wrist, its addition to a plating of a distal radius can be valuable, particularly in the presence of die punch or stepped fractures not easily seen or  reduced by other means.

The joint fragments can be reduced using probes or wires through the fracture site once the wrist is opened and the reduction checked by the arthroscopy or the fragments may be reduced using the probe through the arthroscopy portals and position checked once the plate(s) is applied.

It is sometimes unnerving how the radiographic images taken intra-operatively can appear well reduced and only when the joint is directly viewed through an arthroscope is it noted how much of an articular step remains.

As far back as 1999 Doi et al (1) showed of the 82 patients treated there was a decreased incidence of mid term arthritis in the arthroscopic assisted fixation group rather than those with no arthroscopy, 47% versus 58%.  Abe et al (2) revealed why this may be the case as they showed that in 35% of patients who appeared to have an anatomical reduction on fluoroscopy had a step-off or gap in the articular surface >2mm found at arthroscopy.

Other advantages of arthroscopic assisted distal radius fixation are to discover any concomitant ligament or cartilage injuries and any screw penetration.

Addition of an arthroscopy does prolong the procedure aiming to improve joint congruence and reduce later arthritic changes. The procedure take from 90-150 mins depending on the complexity of the fracture and the delay between injury and operation.

The operation is performed as a daycase procedure and the patient is placed in cast for 4-6 weeks following the procedure to start focussed rehabilitation once casting is complete.

Patients often return to light work at 8 weeks, heavy work at 3 months and continue to strength and improve up to a year post-operation.

The plating system used in this particular case was the 2.4mm Variable angle LCP Dorsal Distal radius plates from DePuy Synthes. The features of the plates are an array of short and long anatomically contoured options including a radial column plate to place on the Radial styloid. Variable angle holes allowing a 15 degree arc in each direction (which is easily drilled with a specially designed variable angle drill guide) for more accurate screw placement in relation to the fracture fragments.  They are low profile and have undercut notches to allow bending. They have k-wire holes to allow temporary plate placement and an oval non-locking hole for the first shaft screw to allow minor adjustments.

This operation should be read after first studying and understanding the wrist arthroscopy technique on OrthOracle https://www.orthoracle.com/library/diagnostic-wrist-arthroscopy-acumed-arc-tower/

Doi  K, Hatturi T, Otusaka K, et al. Intraarticular fractures of the distal aspect of the radius arthroscopically assisted reduction comparedwith open reduction and internal fixation. J Bone Joint Surg1999;81A:1093–1110. Abe Y, Yoshida K, Tominaga Y. Less invasive surgery with wrist arthroscopy for distal radius fracture. J Orthop Sci 2013;18:398–404.

Author: Mr Mark Brewster FRCS (Tr & Orth).

Institution: The Royal Orthopaedic Hospital, Birmingham, UK.

Read more »

This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

Take the Tour

View this procedure on OrthOracle.com

- ref:  - Combined Dorsal and Volar Plate Fixation of Complex Fractures of the Distal Part of the Radius.

anterior approach and fixation:

Distal radius fractures are one of the most common injuries of the upper limb. They commonly occur after a fall on the outstretched hand. The demographics of this condition have changed in the past few decades – with many more occurring after high-energy injuries, resulting in increasingly complex and unstable fractures. These require reduction and stabilization with internal fixation devices.

The following is a step-by-step guide on internal fixation of distal radius fractures using a Synthes® 2.4 mm Variable Angle LCP  Two-Column Distal Radius System.

Author : Manish Gupta,  Consultant Hand Surgeon

Institution: Queen Elizabeth Hospital, Birmingham ,UK

Read more »

This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

Take the Tour

View this procedure on OrthOracle.com

- reduction:
                 - have assistant apply traction as three point reduction is applied directly with surgeon fingers and thumb;
- single k wire through the radial styloid for extraarticular fractures and an addition k wire parallel to the
joint line for intra-articular frxs

- internal fixation: (implants for distal radius fractures):
- plating techniques: (Synthes Distal Radius Plates)
                 - plate placement:
                         - distal end of plate should be placed far enough proximally to avoid insertion of screws into articular surface;
- be aware of the watershead line;
- references:
- Volar Locking Plate Implant Prominence and Flexor Tendon Rupture
                                - Effect of distal radius volar plate position on contact pressure between the flexor pollicis longus tendon and the distal plate edge.
- Volar Plate Position and Flexor Tendon Rupture Following Distal Radius Fracture Fixation
- Three-dimensional kinematics of the flexor pollicis longus tendon in relation to the position of the FPL plate and distal radius width.

                 - contour plate:
                         - bend plate to comform to the normal configuration of the radius (contour plate around the radial styloid);
- apply locking adaptors on each end of the plate and use these to radially controur plate;
                 - screw placement
                         - consider insertion of ulnar screws first to ensure that there is no joint tresspass (radial screws obstruct view
of ulnar screws);
- screws placed in diaphyseal bone will act as a butress for distal fragment;
                 - screw length
                         - references:
- The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates
- Predicting a safe screw length for volar plate fixation of distal radius fractures: lunate depth as a marker for distal radius depth.
- The dorsal tangential X-ray view to determine dorsal screw penetration during volar plating of distal radius fractures.
- Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius: a cadaveric study.
                                - Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius
- Dorsal Screw Penetration With the Use of Volar Plating of Distal Radius Fractures: How Can You Best Detect?

- restoration of volar tilt
- ref: Leveraging the Plate: Reliably Restoring Volar Tilt of Distal Radius Fractures
- final radiographic evaluation:
- references:
- Fluoroscopic evaluation of intra-articular screw placement during locked volar plating of the distal radius: a cadaveric study.
                                  - Use of articular wrist views to assess intra-articular screw penetration in surgical fixation of distal radius fractures.
- Comparison of 4 Fluoroscopic Views for Dorsal Cortex Screw Penetration After Volar Plating of Distal Radius
- Risk Assessment of Tendon Attrition Following Treatment of Distal Radius Fractures With Volar Locking Plates Using Audible Crepitus and Placement of the Plate: A Prospective Clinical Cohort Study.

- Post Operative Care:
- Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study..

- Complications of ORIF

- references:
- Loss of Fixation of the Volar Lunate Facet Fragment in Fractures of the Distal Part of the Radius.
- Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate.

 

- References
- A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating.
- Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation.
- Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates.
- Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius.
- Operative management of distal radial fractures with 2.4-millimeter locking plates. A multicenter prospective case series.
- Prospective study of distal radius fractures treated with a volar locking plate system
- A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation.
- Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures?
- Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation.
- Comparison of External and Percutaneous Pin Fixation with Plate Fixation for Intra-articular Distal Radial Fractures
- Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial.
- Distal Radius Fractures: Choice of Treatment Procedures
- Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial.


Historical References (Non Locking Technology)

Intra-articular fractures of the distal end of the radius in young adults.
The surgical treatment of severe comminuted intraarticular fractures of the distal radius with the small AO external fixation device. A prospective three-and-one-half-year follow-up study..
Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius.
Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius.
Open treatment for displaced articular fractures of the distal radius.
Comminuted intraarticular fractures of the distal radius.
Displaced intraarticular fractures of the distal radius.
Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius.
An effective treatment of comminuted fractures of the distal radius.
Open treatment for displaced articular fractures of the distal radius.
Treatment of displaced articular fractures of the radius.
Open reduction and internal fixation for distal radius fractures
Factors affecting functional outcome of displaced intra-articular distal radius fractures.
The operative treatment of intraarticular fractures of the distal radius.
Indications and Techniques of Open Reduction. Internal Fixation of Distal Radius Fractures.
Treatment of displaced intra-articular fractures of the distal end of the radius with plates.

 - Case Example: