This article is more than 5 years old. Information may no longer be current.
Surgical Technique: Volar approach to dorsally displaced distal radius fractures
A volar plate with locked fixation provides balanced stable fixation of the distal fragments.
Click Here to Manage Email Alerts
Distal radius fractures are among the most common injuries of the wrist that orthopedic surgeons will face in a trauma practice. The fractures may be minimal or stable without significant shortening of bone and without direct involvement of the radiocarpal joint. Most of these fractures can be treated adequately in a supportive case or splint including recently designed airbladder support splints.
Many distal radius fractures however, are more serious with dorsal displacement, comminution and involvement of the wrist joint (intra-articular fractures). In the past, these types of more unstable fractures were treated by percutaneous pins, external fixation or a combination of both. With advances in internal plate fixation, there has been a definite move by orthopedic surgeons to treat the more unstable fractures by open reduction and internal fixation. In fact, a survey of the members of the American Society for Surgery of the Hand clearly favored plate fixation for unstable distal radius fractures, with a slight trend toward volar vs. dorsal plate fixation. Recent biomechanical studies have addressed the issue of stability from pin vs. plate fixation and compared volar locked plate fixation vs. volar and dorsal unlocked plate fixation. The locked volar plate provided the most rigid stability with least amount of fracture gap formation during laboratory testing in sawbone models. In this synopsis, we describe the most common surgical approach for application of the volar plate. There are several variations on the theme, but the approach through the flexor carpi radialis sheath described below appears to be the most direct and safest approach to the volar aspect of the distal radius for plate fixation.
The volar approach for dorsally displaced distal radius fractures utilizes an incision that is centered longitudinally upon the flexor carpi radialis (FCR) tendon. This approach, popularized by Orbay et al, (2000, 2002, 2004) allows distal and radial exposure through the use of a distal and radial limb to the incision that begins at the junction of the FCR and the proximal wrist crease. This protects the palmar cutaneous branch of the median nerve and allows balanced exposure over the fracture site.
The superficial branch of the radial artery is identified and protected, and the anterior and posterior sheaths of the FCR are incised and the space of Parona is developed. The flexor tendons and median nerve are retracted ulnarly and the pronator quadratus fascia is incised on its radial and distal borders. The muscle is reflected ulnarly protecting the ulnarly based metaphyseal blood supply and the innervation by the anterior interosseous nerve.
Depending upon the fracture deformity and need for further exposure, the brachioradialis tendon may either be elevated off the radial styloid or identified just proximal to its insertion and released using a Z-step tenotomy (Orbay 2001). Debridement of the fracture site is completed under manual traction and a provisional reduction is performed.
The proximal radial metaphysis typically is displaced ulnarly to the distal fragments and a Homan retractor may be used to lift the ulnar border of the metaphysis to reduce the volar ulnar cortex. Following reduction of the volar ulnar cortex, traction and ulnar deviation of the wrist combined with a dorsal to volar translation of the lunate with some wrist flexion will assist the surgeon in maintaining the fracture reduction. Percutaneous pin fixation may be necessary as an adjunct to help to maintain the reduction.
|
|
|
Obtain a provisional reduction
A volar plate, with locked distal fixation, is positioned such that there is balanced support across the distal fragment and that the proximal portion of the plate is centered upon the volar radius. The plate should be positioned distal enough to buttress the volar cortex, but should not protrude more volar or distal than the volar rim of the either the lunate or scaphoid facets to prevent any intrusion into the flexor tendons. The plate is provisionally fixed to the radius with a K-wire and fluoroscopic evaluation is examined to check the position of the plate and the trial reduction.
The plate is then secured to the shaft with a cortical screw placed through the oblong hole to allow for positional adjustment if needed. The distal fragments are then held reduced to the plate and a K-wire may be placed through the distal K-wire holes in the volar plate giving temporary fixed-angle fixation. K-wires are drilled in with oscillation to minimize risk to soft tissues.
Fluoroscopy is used to evaluate the reduction and the trajectory of the K-wires and to estimate the projection of the locking pegs and screws. If the fracture involves a displaced intra-articular component, which has not been reduced through the fracture site or through the pronation of the proximal radius as described by Orbay et al (2001), a dorsal arthrotomy or use of wrist arthroscopy will allow better visualization to either obtain or evaluate the articular reduction. Once again, temporary percutaneous K-wire fixation may be used to maintain the articular reduction and cancellous bone graft may be used to facilitate the reduction and to add stability. The distal locking pegs are then placed into the distal fracture fragment and are locked to the plate.
|
|
| Provisional reduction is obtained with a distal K-wire through the plate and visualized through fluroscopic evaluation. | |
|
|
| Intraoperative AP and lateral (radial tilt) fluoroscopic views of the completed reduction and fixation. | |
Distal fixation
Distal fixation of the less comminuted column is completed first. Manual compression across intra-articular fracture planes will help maintain their reduced position during drilling and placement of the locking pegs or screws. Partially threaded (threads on the distal end) pegs may be used when crossing more coronal fracture planes and may add a lag effect when the peg locks into the plate. Fracture fragments are also checked for stability by manual examination.
The distal radioulnar joint (DRUJ) is examined for motion and stability in the neutral, pronated and supinated positions. If there is associated instability of the DRUJ related to a large, displaced ulnar styloid fragment or a fracture plane that is directed obliquely and proximally, reduction and fixation of the styloid may be completed.
If there is no distal ulna fracture but instability of the DRUJ is present with a concentric reduction of the DRUJ, closed treatment with the wrist in the neutral or supinated position is usually adequate treatment. However, the surgeon may also choose to repair the foveal insertion of the distal radioulnar ligaments. If there is an associated unstable distal ulna fracture this may be addressed at this time with open reduction and internal fixation through an ulnar incision between extensor carpi ulnaris and the flexor carpi ulnaris, with careful protection of the sensory branch of the ulnar nerve. The ulna may be reduced and provisionally fixed with K-wires and stable fixation and union has been demonstrated with the small condylar blade plates (Ring et al 2004) and with our preferred 2-mm locking plate fixation (Dennison 2007).
With respect to the distal radius (and associated distal ulna) fracture(s), fluoroscopic views (AP, lateral, radial tilt and pronated and supinated obliques) are obtained to assess the reduction and the position of the pegs (or combination of pegs and screws) relative to the subchondral bone and the joint spaces (radiocarpal and distal radioulnar joint). Fixation of the proximal plate is completed with the placement of the remaining cortical screws once correct placement of plate and distal fixation has been confirmed.
The pronator fascia may be repaired by sewing it to the repaired brachioradialis tendon or back to its insertion, if possible. Following subcutaneous tissue and skin closure (often with a drain), a bulky dressing is applied with a short volar splint if the DRUJ is stable and a sugar-tong splint in neutral forearm rotation or progressive supination may be applied if there is any DRUJ instability or if a higher energy injury with more severe soft tissue injury is present. Caution should be used when positioning the forearm in extreme supination as stiffness may result in this less functional position.
Rehabilitation
Postoperative rehabilitation begins immediately with finger range of motion, elbow and shoulder motion, and anti-edema measures. Following removal of the postoperative dressing, a removable wrist splint is fabricated. Patients are encouraged to begin activities of daily living as soon as they are comfortable. Hand therapy is not employed routinely, but is reserved for patients who demonstrate any difficulty with getting his or her initial range of motion or if they have sustained a higher energy type injury.
|
|
For more information:
- David G. Dennison, MD, can be reached at Division of Hand Surgery, Department of Orthopaedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905; 507-284-2806; e-mail: dennison.david@mayo.edu.
- William P. Cooney III, MD, can also be reached at the Division of Hand Surgery, Department of Orthopaedic Surgery, Mayo Clinic; e-mail: cooney.william@mayo.edu
References:
- Dennison D. Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg. 2007;32A(6):801-805.
- Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg. 2004;29(1):96-102.
- Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg. 2002;27(2):205-215.
- Orbay JL. The treatment of unstable distal radius fractures with volar fixation. J Hand Surg. 2000;5(2):103-112.
- Orbay JL, Badia A, Indriago IR, Infante A, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg. 2001;5(4):204-211.
- Ring D, McCarty LP, Campbell D, Jupiter JB: Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. J Hand Surg 29A(1):103-109, 2004.
- Willis AA, Kutsumi K, Zobitz ME, Cooney WP 3rd. Internal fixation of dorsally displaced fractures of the distal part of the radius. A biomechanical analysis of volar plate fracture stability. J Bone Joint Surg (AM). 2006;88(11):2411-2417.