77: Volar Plating of Distal Radius Fractures

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Procedure 77 Volar Plating of Distal Radius Fractures

John T. Capo

imageSee Video 58: Volar Locking Plate Fixation for Distal Radius Fractures

Indications

image Unstable displaced extra-articular fractures

image Displaced intra-articular fractures

image Volar shearing fractures

Examination/Imaging

Clinical Examination

image The extremity of the patient should be examined for open injuries and neurovascular status, particularly median nerve function.

image The distal ulna should be examined for dorsal prominence or instability.

image The elbow should be examined for tenderness at the radial head and collateral ligaments.

Imaging

image Anteroposterior view of a right distal radius fracture in 32-year-old male laborer (Fig. 77-1A)

image Lateral view of fracture demonstrating intra-articular extension of fracture and dorsal angulation and displacement (Fig. 77-1B)

image

FIGURE 77-1

Surgical Anatomy

image Drawing of volar anatomy of forearm and wrist. The surgical interval is between the flexor carpi radialis (FCR) tendon and radial artery and brachioradialis (BR) insertion (Fig. 77-2).

image The palmar cutaneous branch of the median nerve arises 5 cm proximal to the radial styloid between the palmaris longus and the FCR.

image The flexor pollicis longus (FPL) muscle belly covers the pronator quadratus (PQ) and must be reflected from radial to ulnar.

image The PQ muscle is sharply divided radially and is elevated from the distal radius to expose the fracture.

image The BR inserts into the distal radius and may be detached to decrease the deforming forces on the distal fragment.

image

FIGURE 77-2

Positioning

image The operation is performed with the arm supinated on a hand table under tourniquet control.

Exposures

image An incision about 7 cm in length is made over the forearm between the radial artery and the FCR. The distal aspect of the incision stops at the volar wrist crease (Fig. 77-3). If the incision needs to be extended more distally, a V-shaped zigzag extension should be made.

image The FCR tendon is exposed and released from its sheath. The dissection should remain on the radial aspect of the FCR (Fig. 77-4).

image The radial artery and its accompanying venae comitantes are exposed and retracted radially. All ulnar crossing vessels are coagulated (Fig. 77-5).

image The PQ is elevated from the distal radius by making an L-shaped incision and releasing it radially and distally (Fig. 77-6). The PQ is sharply released from the radius to expose the fracture (Fig. 77-7).

image

FIGURE 77-3

image

FIGURE 77-4

image

FIGURE 77-5

image

FIGURE 77-6

image

FIGURE 77-7

Pearls

It is helpful to mobilize the radial artery and ligate its small crossing branches during the exposure. This minimizes bleeding and also allows for better exposure of the BR for release.

Do not take the reflection of the soft tissue too far distally on the radius. This may result in release of the volar carpal ligaments from the distal radius and induce carpal instability.

Pitfalls

Dissection should not be performed ulnar to the FCR tendon because the palmar cutaneous branch of the median nerve may be damaged.

During release of the BR tendon, the dissection must remain entirely on bone, or the tendons of the first dorsal compartment tendons may be damaged.

Procedure

Step 1

image The volar radius is exposed, and the distal fragment is exposed by releasing the BR tendon. The distal fragment is usually displaced dorsally (Fig. 77-8).

image A Freer elevator may be used to lever the distal fragment for fracture reduction (Fig. 77-9). The elevator should be inserted to the dorsal cortex to completely disimpact the distal fragment to aid in reduction.

image Alternatively, the distal fragment can be reduced to the radial shaft by flexing the hand and wrist, thereby realigning the distal fragment and promoting reduction.

image

FIGURE 77-8

image

FIGURE 77-9

Step 1 Pearls

The hand and distal fragment may be placed on a large towel-bump to aid in reducing the fragment.

Step 1 Pitfalls

Care should be taken not to over-reduce the fracture, thus creating increased volar displacement.

Step 2

image The reduced fracture may be provisionally held with K-wires placed through the open approach or through a small separate radial styloid incision (Fig. 77-10).

image The plate is placed centrally on the radial shaft and as far distally as necessary to capture the distal fragment. It is crucial to be familiar with the specific plate distal locking screw trajectory for proper plate placement (Fig. 77-11).

image The volar plate is then applied to the radial shaft, and a screw is inserted first in the elongated elliptical hole. A 2.0-mm drill bit is drilled in the center of the hole, and a 2.7-mm screw is then placed (Fig. 77-12).

image The plate placement is checked with fluoroscopy. The plate may be shifted distally or proximally by loosening and then retightening the shaft screw.

image Once plate placement is confirmed as ideal, a second 2.7-mm screw is placed in the shaft to fix the plate placement.

image

FIGURE 77-10

image

FIGURE 77-11

image

FIGURE 77-12

Step 2 Pearls

During radiographic assessment of plate placement, the anteroposterior view confirms proper radioulnar placement, whereas the lateral view is critical in determining proper proximal-distal placement.

Step 2 Pitfalls

Do not place the plate too distal because this may result in radiocarpal screw penetration.

Step 3

image The distal screws are next placed in the plate with the wrist in a flexed position. These screws are 2.4 mm in size and are drilled with a 1.8-mm drill bit. If the fracture is properly reduced, a locking screw may be placed (Fig. 77-13).

image If there is some separation between the distal fragment and the plate, a nonlocking screw may be placed first to draw the bone to the plate and thus improve the reduction. This screw may be later exchanged for a locked screw if desired.

image A sufficient number of screws should be placed in the distal aspect of the plate to ensure adequate purchase of all the fracture fragments (Fig. 77-14).

image The provisional K-wires can be removed, or left in place for 3 weeks if added support of the fracture is required.

image

FIGURE 77-13

image

FIGURE 77-14

Step 3 Pearls

A fossa lateral view of the distal radius should be taken to ensure no joint penetration of the screws. A fossa lateral view is taken by holding the forearm at about 22 degrees of inclination with regard to the hand table. This corrects the overlap of the articular surface caused by the radial inclination on a standard lateral view (Fig. 77-15).

The designed purpose of the distal screw row is for subchondral support, whereas the proximal screw row provides distal-dorsal fixation.

image

FIGURE 77-15

Step 3 Pitfalls

The screws should not be placed too long because their self-tapping design makes the tips sharp and may cause an attritional tendon rupture.

Care should be taken to avoid joint penetration with the screws in both the radiocarpal and distal-radial ulnar joints.

Step 4

image The PQ is replaced over the plate and sutured to its radial attachment and periosteum (Fig. 77-16).

image The wound is closed with 3-0 Vicryl sutures in the subcutaneous tissue and interrupted 3-0 nylon sutures in the skin (Fig. 77-17).

image The patient is placed in a short-arm volar splint at the end of the surgical procedure.

image

FIGURE 77-16

image

FIGURE 77-17

Step 4 Pearls

• The PQ often cannot be completely reattached, but even a partial closure provides some soft tissue coverage of the plate.

• If the BR was released, it may be reattached in a step-cut lengthening fashion.

Step 4 Pitfalls

When reattaching the PQ, ensure that no sutures are placed in the first dorsal compartment tendons.

Postoperative Care and Expected Outcomes

image The patient is seen 10 to 14 days after surgery, and the sutures are removed.

image Gentle range of motion (ROM) of the wrist is begun at that time.

image Aggressive finger ROM is begun immediately after surgery to decrease edema and avoid digital stiffness.

image Final postoperative radiographs should show a well-reduced fracture with a congruent joint surface (Fig. 77-18).

image

FIGURE 77-18

Evidence

Orbay J, Badia A, Khoury RK, et al. Volar fixed-angle fixation of distal radius fractures: the DVR plate. Tech Hand Up Extrem Surg. 2004;8:142-148.

This article reviews the technique for volar fixed-angle fixation of distal radius fractures, which provides the advantage of stable internal fixation without incurring the complications of the dorsal approach. This fixed-angle plate was introduced specifically for the purpose of managing both dorsal and volar displaced fractures from the volar aspect. The surgical approach is an extended form of the flexor carpi radialis exposure, which allows improved dorsal access by mobilizing the proximal radius out of the way, allowing access to the fracture fragments. This approach addressed the need for reducing fractures with significant articular displacement that also needed débridement of the dorsal organized hematoma or callus (in old fractures). The plate’s ability to stabilize the distal radius by taking full advantage of the principles of subchondral support and buttress fixation enabled the use of this implant in severely osteoporotic bone and in fractures with severe articular fragmentation or displacement. (Level V evidence)

Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am]. 2004;29:96-102.

This is a retrospective study that reviewed the outcome of distal radius fractures in the elderly population treated with a volar fixed-angle internal fixation plate. Postoperative regimen included immediate finger motion, early functional use of the hand, and application of wrist splint for an average of 3 weeks. Standard radiographic fracture parameters were measured, and final functional results were evaluated by documenting finger motion, wrist motion, and grip strength. Twenty-four unstable distal radius fractures in 23 patients were evaluated. Average follow-up was 63 weeks. Average volar tilt was 6 degrees, and radial tilt was 20 degrees. Radial shortening averaged less than 1 mm. Final extension was 58 degrees, flexion 55 degrees, pronation 80 degrees, and supination 76 degrees. Grip strength was 77% of the contralateral side. No plate failures or significant loss of reduction were documented, although there was settling of the distal fragment (1 to 3 mm) in 3 patients. The authors concluded that volar fixed-angle plate for unstable distal radius fractures in the elderly patient provided stable internal fixation and allowed early return to function. This technique minimized morbidity by successfully stabilizing osteopenic bone and was associated with a low complication rate. (Level V evidence)

Rizzo M, Katt BA, Carothers JT. Comparison of locked volar plating versus pinning and external fixation in the treatment of unstable intraarticular distal radius fractures. Hand. 2008;3:111-117.

This is a retrospective study that compared volar locking plate with external fixation with percutaneous pinning for treatment of unstable distal radius fractures. There were 41 patients reviewed for the ORIF group and 14 patients for the external fixation group. Clinical and functional outcomes were measured by the DASH score. Pain scores and radiographic measurements were also documented. Two years after the surgery, range of motion and grip strengths were similar in the two groups. Pain scores using the VAS showed no significant difference. DASH scores were better for the volar locking plate group. For radiographic analysis, significantly better outcome was observed with volar plating in terms of volar tilt, articular step-off, and ulnar variance. Significant difference was also documented in the number of hand therapy visits required, which favored the ORIF group. Two pin tract infections were documented in the external fixation group, whereas no complications were observed in the volar plate group. Overall, the study favors the use of locked volar plate over external fixation based on the parameters examined. (Level IV evidence)

Souer JS, Ring D, Matschke S, et al. Comparison of functional outcome after volar plate fixation with 2.4-mm titanium versus 3.5-mm stainless-steel plate for extra-articular fracture of distal radius. J Hand Surg [Am]. 2010;35:398-405.

This is a level III therapeutic study comparing the functional outcome of use of a titanium 2.4-mm precontoured plate with that of a stainless-steel oblique 3.5-mm T-shaped plate to test. Twenty-four patients treated with a 2.4-mm titanium plate and 38 patients treated with a 3.5-mm stainless-steel plate for an extra-articular and dorsally angulated distal radius fracture were retrospectively analyzed. The two groups were evaluated for differences in motion, grip strength, pain, Gartland and Werley score, DASH score, and Short Form-36 score at 6, 12, and 24 months of follow-up. Regression analysis and the likelihood ratio test were used to determine the group differences and their change over time. There were no significant differences in wrist function and arm-specific health status between patients treated with a 2.4-mm plate and those treated with a 3.5-mm plate at 6, 12, or 24 months of follow-up. However, in patients treated with a 2.4-mm plate, there was an observed trend toward greater wrist flexion at 1 year (66 degrees vs. 55 degrees; P = .07) and greater flexion-extension arc (137 degrees vs. 123 degrees; P = .08) and pronation-supination arc (172 degrees vs. 160 degrees; P = .07) 24 months after surgery. They concluded that similar results can be expected in patients treated with either a precontoured 2.4-mm titanium plate or a 3.5-mm stainless-steel T-shaped plate for a dorsally angulated extra-articular distal radius facture. (Level III evidence)

Wei DH, Raizman NM, Bottino CJ, et al. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate: a prospective randomized trial. J Bone Joint Surg [Am]. 2009;91:1568-1577.

This is a therapeutic level I study that compared the functional outcomes of treatment of unstable distal radial fractures with external fixation, a radial column plate, and a volar plate. Follow-up conducted at varying intervals postoperatively demonstrated that at 6 weeks, the DASH score was better with volar plate than with external fixation, but the score was similar between volar plate and radial column plate use. At 3 months, DASH scores are significantly better with volar plate use than with external fixation and radial column plate use. At 6 months and 1 year, DASH scores for the three groups were comparable with those for the normal population. Grip strength was similar for the three groups at 1 year. Significantly better lateral pinch strength was observed with volar plate use compared with radial column plate use at 3 months and 1 year, but no significant difference was observed at subsequent intervals. The range of motion of the wrist was not significantly different among the three groups from 12 weeks postoperatively. At 1 year, radial inclination and radial length were significantly better in the radial column plate group than in the other two groups. In conclusion, unstable distal radial fractures treated with locked volar plate recovered more quickly compared with external fixation and radial column plate use. However, 1 year after surgery, all three techniques provided good subjective and objective functional outcomes. (Level I evidence)

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