78: Dorsal Plate Fixation and Dorsal Distraction (Bridge) Plating for Distal Radius Fractures

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Procedure 78 Dorsal Plate Fixation and Dorsal Distraction (Bridge) Plating for Distal Radius Fractures

Safi R. Faruqui, Peter J. Stern

Dorsal Plating of Distal Radius Fractures

Indications

Highly comminuted, articular distal radius fractures

Dorsal shearing fractures

Die-punch lunate facet fractures

Dorsal radiocarpal fracture dislocations

Examination/Imaging

Clinical Examination

Initial examination is usually performed in the emergency department and needs to include mechanism and time of injury, hand dominance, medical comorbidities that may alter treatment, and occupation.

Assess whether the fracture is an open or closed injury.

Thorough musculoskeletal examination, especially the ipsilateral extremity, is necessary to rule out concomitant injuries.

Identify any associated neurovascular and soft tissue injuries.

Identify whether patient has any sign or symptoms of acute median or ulnar nerve injury.

Imaging

Initial radiographic evaluation must include posteroanterior, lateral, and oblique views (Fig. 78-1).

Assessment must include fracture angulation, displacement, radial shortening, comminution, intra-articular extension, and any ulnar-sided injuries.

Combined lesion of a radial styloid with a dorsal marginal or facet fracture (AO type B2.2) is common and can be misdiagnosed as a Colles fracture on lateral radiographs.

The lunate facet often has a coronal fracture line that separates this facet into dorsal and volar fragments.

Computed tomography scan provides excellent delineation of intra-articular extension as well as characterization of fracture comminution for preoperative planning (Fig. 78-2).

There is also typically subchondral collapse of the lunate facet that must be addressed to ensure articular reduction.

Proximal injuries must be ruled out by physical examination and radiographs of the elbow.

FIGURE 78-1

FIGURE 78-2

Surgical Anatomy

Knowledge of the anatomic relationships of the extensor retinaculum, six dorsal extensor compartments, and convex dorsoradial cortex is essential for understanding surgical approaches as well as placement of implants on the dorsum of the radius (Fig. 78-3).

Extensor retinaculum prevents the extensor tendons from dorsal displacement (bowstringing) and divides the tendons into six extensor compartments by vertical septae.

The extensor pollicis longus (EPL) tendon, which lies in the third dorsal compartment, passes ulnar to the Lister tubercle and is mobilized during exposure of the dorsal distal radius.

The extensor indicis proprius tendon and the extensor digitorum communis tendon lie in the fourth dorsal compartment and are elevated subperiosteally to minimize tendon contact with dorsally placed implants.

Elevation of the second dorsal compartment, which contains the radial wrist extensors, puts the dorsal sensory branch of the radial nerve and the dorsal radial artery at risk, particularly if the dissection is extended distally.

The terminal branch of the posterior interosseous nerve lies on the floor of the fourth dorsal compartment along its radial side; it can be sacrificed, if necessary, without clinical consequence.

The articular surface of the distal radius is biconcave and triangular, with the surface divided into two hyaline covered, concave facets for articulation with the scaphoid and lunate.

There are two dorsal ligaments that are intimately associated with the dorsal capsule: the dorsal radiocarpal (DRC) (radiotriquetral) and dorsal intercarpal (DIC) (scaphotriquetral) ligaments (Fig. 78-4).

FIGURE 78-3

FIGURE 78-4

Exposures

The dorsal distal radius is approached through a straight, longitudinal incision in line with the third metacarpal and centered just ulnar to the Lister tubercle, between the third and fourth dorsal compartments (Fig. 78-5).

Care is taken to identify and avoid injury to the superficial branch of the radial nerve.

Full-thickness flaps containing the skin, subcutaneous tissues, and superficial fascia are raised together to expose the extensor retinaculum and the third and fourth dorsal compartments.

The third dorsal compartment is longitudinally incised to mobilize the EPL tendon (Fig. 78-6).

After mobilizing the EPL, the retinaculum is divided between the septa of the third and fourth dorsal compartments.

Using a periosteal elevator or sharp dissection, the fourth compartment is then elevated subperiosteally from the dorsum of the distal radius, keeping the deep surface of the compartment intact.

The distal radius is exposed sharply by elevation of the periosteum.

Exposure of the intermediate column requires dissection to continue in an ulnar direction to the distal radioulnar joint (DRUJ).

A longitudinal capsulotomy may be needed to expose the distal radius articular surface, which requires detaching the dorsal capsular insertions on the distal nonarticular lunate.

FIGURE 78-5

FIGURE 78-6

Pearls

Large, longitudinal veins should be preserved if possible, but crossing veins may be divided.

Full-thickness flaps will contain the dorsal sensory branches of the ulnar and radial nerve and protect them.

Subperiosteal elevation of the fourth compartment minimizes implant contact with the extensor tendons.

Pitfalls

If the distal extension of the incision is past the base of the third metacarpal, the dorsal sensory branches of both the radial and ulnar nerves are at risk.

The EPL tendon is left above the retinaculum at closure to minimize the risk for tendon injury by ischemia or direct contact with an implant.

Care must be exercised not to enter the DRUJ. If the dorsal radioulnar ligament is divided during ulnar dissection, radioulnar instability can result.

The intercarpal ligaments must be protected during capsulotomy.

Procedure

Dorsal Plate Fixation for Distal Radius Fractures

Step 1: Reduction of Dorsally Angulated Fractures

Once the proximal fracture lines and articular surface are exposed and assessed, all hematoma is evacuated.

Lister tubercle is removed with a rongeur or small osteotome (Fig. 78-7).

Reduction of the dorsal angulation can be performed with the use of narrow-angled Homan retractors along the proximal fragment.

With gentle traction and lifting of the bone retractors, reduction of the dorsal angulation can be achieved.

Provisional fixation with Kirschner wires (0.045-in.) can be used to hold the reduction and is checked fluoroscopically.

FIGURE 78-7

Step 1 Pearls

Removal of the Lister tubercle will allow the plate to sit flush with the dorsal cortex and hence be less prominent.

Step 1 Pitfalls

Failure to reduce articular fragments may lead to symptomatic radiocarpal arthrosis.

Use of the nick-and-spread method to insert percutaneous K-wire fixation is imperative to prevent injury to the branches of the superficial radial nerve.

Step 2: Fixation of Dorsally Angulated Fractures

After satisfactory reduction is performed, a 2.4-mm low-profile dorsal T-plate (Fig. 78-8) can be placed directly over the dorsal surface of the distal radius.

Preliminary fixation of the plate with a single, bicortical compression screw placed in the oblong hole of the plate will allow for proximal-distal adjustments in plate position as determined clinically and fluoroscopically.

It is important to provisionally bend the plate to fit the contour of the dorsal radial cortex so that the plate lies flush with the dorsal cortex.

Although several options for plating are available, including locking and nonlocking plates, one must consider contouring a fixed-angle plate by threading a locking guide into the plate before contouring; this will avoid damage to the threads of the locking mechanism.

The final placement is checked by fluoroscopy in anteroposterior and lateral views to confirm proper positioning of the plate.

Three to five 2.7-mm screws are then placed bicortically along the distal row of the plate, using fluoroscopy to confirm placement.

Two additional proximal screws are then inserted bicortically, and final fluoroscopic assessment is performed.

FIGURE 78-8

Step 2 Pearls

Allograft or bone graft substitute may be utilized to fill in metaphyseal defects to enhance stability.

Step 2 Pitfalls

Care must be taken not to insert screws into the radiocarpal joint. Rotational fluoroscopy and direct visualization are critical to avoid this error.

Step 3: Reduction and Fixation of Dorsal Marginal Fractures

It is important to assess carpal subluxation and initially restore the radial styloid fragment if present (Fig. 78-9A).

This reduction is usually accomplished with traction and ulnar deviation of the hand and wrist, and then provisional K-wire fixation (Figs. 78-9B and 78-10).

Once the appropriate-sized 2.4-mm plate has been contoured, the locking screw guide is placed in the proximal screw hole and is used to hold and contour the plate.

Preliminary fixation of the plate with a single, bicortical screw placed in the oblong hole will allow for proximal-distal plate adjustments as determined clinically and fluoroscopically (Fig. 78-11).

A provisional K-wire is then placed through the threaded locking guide at the distal end of the plate but not into the radius to facilitate quick placement after reduction of the carpus.

The dorsal lip or marginal fracture can be reduced now against the scaphoid and lunate, which will correct any associated dorsal carpal subluxation.

The marginal fracture will then be provisionally fixed into the volar cortex through the provisional K-wire that had been previously placed into the threaded locking guide at the distal end of the plate.

Congruity of the articular surface must be confirmed with direct visualization as well as fluoroscopically.

If the plate is acting purely as a buttress, distal locking screws are not necessary.

If additional fixation for stability is necessary, 2.4-mm screws are then placed bicortically along the distal row of the plate, using fluoroscopy to confirm placement.

One or two additional bicortical screws are placed proximally to the proximal extent of the fracture to finalize construct (Figure 78-12).

FIGURE 78-9

FIGURE 78-10

FIGURE 78-11

FIGURE 78-12

Step 3 Pearls

Having small and mini-implants as well as external fixation available can be invaluable to address difficult fracture patterns.

Metaphyseal bone defects should be addressed with cancellous bone grafting to help support the articular anatomy.

Step 3 Pitfalls

Failure to recognize styloid component or any volar-ulnar fragments will lead to incongruity of articular surface and radiocarpal arthrosis.

These fractures may be associated with dorsal radiocarpal subluxation, volar ligament injuries, articular surface impaction, and avulsion fractures.

All bicortical fixations should be checked radiographically to ensure that they are not prominent volarly.

Step 4: Reduction and Fixation of Lunate Facet Fractures

Subchondral collapse of the lunate facet can be addressed with the use of a Freer elevator or dental pick placed into the facet fracture line in the metaphysic.

The lunate facet fragment is then manually reduced by elevating the depressed surface and checked both by fluoroscopy and directly if an arthrotomy has been made to ensure adequate reduction.

A provisional K-wire can be placed along the subchondral surface from the radial styloid to the sigmoid notch to act as a buttress for the reduced lunate facet fracture.

For provisional reduction of coronal facet fractures, temporary K-wires can also be placed to stabilize the coronal fracture line.

For sagittal splits, intrafragmentary compression is possible using a large bone reduction clamp.

One point of the clamp is placed along the ulnar border of the lunate facet, one point is placed along the radial styloid, and after compression of the clamp, a transverse provisional K-wire is placed to hold reduction.

When an impacted fragment is elevated, there will often be a metaphyseal void that must be filled with cancellous allograft or bone graft substitute to support the articular surface.

After preliminary reduction is confirmed both by direct visualization and fluoroscopy, an L-shaped 2.4-mm plate is typically used for buttress fixation of the intermediate column and articular surface (see Fig. 78-8).

The dorsoulnar plate usually needs to be contoured to allow placement along the dorsoulnar aspect of the distal part of the radius.

The plate is then fixed proximally to the shaft well distally along the L-portion of the plate.

It is especially important to obtain bicortical screw fixation along the ulnar side of the radius if there is a coronal split in the facet because it is vital to obtain compression of the volar ulnar fragment.

If stable fixation cannot be obtained with only a dorsal approach, a volar approach between the FCR and radial artery may be used to stabilize the volar cortex.

If this fails, an external fixator can be applied.

The wrist is taken through a range of motion, including flexion, extension, supination, and pronation, to ensure clinical stability.

Step 4 Pearls

If there are nonarticular fragments seen along the dorsal aspects of the scaphoid and lunate facet that still have capsular attachments, an effort should be made to save them with their attachments.

Bone grafting metaphyseal defects after elevation of depressed articular fragments is essential to maintain reduction.

Step 4 Pitfalls

Failure to appreciate the volar-ulnar fragment may lead to displacement and insufficient buttressing of the fracture.

Step 5: Assessment of DRUJ Stability and Wound Closure

After stabilization of the radius, any instability of the DRUJ should be assessed (defined as greater than 8 mm of palmar to dorsal translation of the ulna relative to the radius).

Large fractures of the ulnar styloid, as well as displaced ulnar head fractures, should raise suspicions of instability.

If instability is noted, consideration should be given to a closed reduction and percutaneous pinning of the DRUJ with the forearm maintained in supination.

If no instability is noted, no immobilization is necessary.

If an arthrotomy has been made, the dorsal capsule should be closed with 3-0 nonabsorbable suture.

The extensor retinaculum should be repaired with interrupted 2-0 absorbable suture, making sure the EPL tendon remains in its transposed position superficial to the retinaculum.

After wound irrigation, the skin should be closed with either nylon or Prolene sutures in an interrupted fashion.

Postoperative Care and Expected Outcomes

A bulky sterile dressing and volar splint, leaving the thumb and fingers free, is applied for postoperative comfort for 7 to 10 days (except in those with DRUJ instability).

After removal of dressing, active and passive digital range-of-motion exercises are initiated.

A custom, short-arm volar splint is applied in neutral position, which can be removed five to seven times daily to perform active wrist range-of-motion exercises.

An elastic garment should be used to control postoperative edema.

Weaning of splint for activities of daily living can be started at 4 weeks.

After clinical and radiographic evidence of fracture healing is seen (6 to 8 weeks), the splint is discontinued completely.

Dorsal Distraction (Bridge) Plating

Indications

Highly comminuted, articular distal radius fractures as well as those associated with significant metaphyseal and diaphyseal comminution

Polytrauma patients to facilitate activities of daily living

Extensive tendon injuries that may require multiple procedures and an extended period of time for soft tissue and osseous healing

Severe osteoporosis in which fracture fixation is expected to be poor

Patients who refuse external fixation for psychological or aesthetic concerns

Surgical Anatomy

The EPL tendon should be released from its compartment and freed from its groove to prevent injury or impingement of the plate onto the tendon if an open articular reduction is necessary.

The plate should pass superficial to the joint capsule and periosteum and within the second dorsal compartment, occupied by the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB).

The extensor tendons over the index finger metacarpal must be identified and retracted to facilitate distal fixation.

The proximal portion of the plate will be placed along the dorsoradial aspect of the radial shaft adjacent to the brachioradialis and outcropping muscles.

The superficial branch of the radial nerve is at risk during the proximal dissection of the radial shaft.

Exposures

The exposure involves two or three dorsal incisions and is performed under tourniquet control (Fig. 78-16).

A 4-cm incision is made dorsally over the midpart of the shaft of the index finger metacarpal, with the extensor tendons identified and retracted.

A second 4- to 6-cm incision is made on the dorsoradial aspect of the radial shaft, just proximal to the outcropping muscle bellies (extensor pollicis brevis and abductor pollicis longus).

The interval between the ECRL and ECRB is used to expose the radial diaphysis.

The surgeon must expose enough radial shaft to secure three screws proximal to the fracture site, no less than 4 cm proximal to the most proximal comminuted segment.

A third incision, about 3 cm in length over the Lister tubercle, can be made if an articular reduction or bone graft is necessary; the EPL is mobilized to facilitate reduction.

FIGURE 78-16

Pearls

Placement of incisions is facilitated with fluoroscopic guidance.

The surgeon holds the distal end of the plate at the index metacarpal neck-shaft junction and identifies the proximal extent of the plate over the radial shaft to ensure placement of three screws proximal to the fracture.

The third incision also allows for exposure of the fracture when necessary, permitting metaphyseal bone grafting and articular reduction.

Pitfalls

The superficial branch of the radial nerve must be identified and protected.

Procedure

Dorsal Distraction (Bridge) Plating

Step 2: Retrograde Passage of the Plate

After exposures have been made, a periosteal elevator or long Metzenbaum scissors is carefully inserted proximal to distal along the floor of the second compartment to create a tunnel between the extensor tendons and the periosteum and joint capsule (Fig. 78-18).

The plate should lie superficial to the periosteum and along the floor of the second dorsal compartment.

The plate is then passed from the distal to proximal incision under the index finger extensor tendons (Fig. 78-19).

FIGURE 78-18

FIGURE 78-19

Step 2 Pearls

Retraction of the ECRB and ECRL in the proximal wound will allow for visualization of the radial shaft and the periosteal elevator so that long scissors can be passed subperiosteally.

The trajectory of the plate is parallel to the radial aspect of the undersurface of the extensor tendons to the index finger.

Step 2 Pitfalls

Evaluate the position of the plate to ensure that it does not impinge on the ECRB or ECRL.

Step 3: Initial Plate Fixation to the Index Metacarpal

The fracture is initially reduced with manual traction of the wrist.

Using fluoroscopy, the plate is then aligned centrally over the index metacarpal distally and the radial shaft proximally.

A bicortical screw is placed in the second-to-last hole in the center of the metacarpal shaft.

Step 3 Pearls

Using only a single screw will allow, if necessary, slight adjustments of the plate position for fracture reduction and plate alignment.

To avoid possible rotary displacement of the hand in relation to the shaft, it is important to obtain provisional reduction of both radial inclination and length before securing the plate to the metacarpal shaft.

Step 3 Pitfalls

Rotary displacement of the fracture will occur if the distal screw is not in the midline of the metacarpal shaft.

Step 4: Plate Fixation to the Radial Shaft

Reapply traction to the arm to restore radial length and confirm alignment with fluoroscopy.

Maintain traction, centralize the proximal portion of plate over the radial shaft, and clamp the plate to the proximal radial shaft using serrated bone-holding clamps.

Reassess the fracture alignment using fluoroscopy to ensure restoration of radial length, inclination, and palmar tilt.

Perform a clinical as well as a fluoroscopic assessment to ensure proper fracture alignment and absence of rotational abnormalities.

Three bicortical proximal screws are placed in the shaft to secure the plate.

Two additional bicortical screws are applied to the metacarpal shaft to ensure three distal points of fixation (Fig. 78-20).

Final radiographic assessment is repeated to ensure maintenance of reduction (Fig. 78-21).

FIGURE 78-20

FIGURE 78-21

Step 4 Pearls

Assess supination and pronation of the forearm with the plate clamped proximally to the radial shaft to confirm a full range of motion.

It is very helpful to maintain the arm in 45 to 60 degrees of supination while maintaining distraction before the serrated clamp is applied proximally to avoid pronation of the distal fragment.

Once plate placement has been determined with at least one proximal and distal screw, locking screws can be used, particularly in osteopenic bone.

Step 4 Pitfalls

Overdistraction (defined as a radiocarpal space greater than 5 mm) must be avoided to prevent possible permanent loss of finger range of motion as well as the potential development of complex regional pain syndrome.

Extrinsic extensor tightness can also develop with overdistraction; it is vital to ensure full passive digital range of motion after plate fixation.

Step 5: Fixation of the Articular Surface and Diaphyseal Fragments (if Necessary)

If there are any diaphyseal fragments that are amenable to lag screw fixation to the shaft, this can be performed at this time.

Reduction of the articular surface can be performed through the third incision used to free the EPL tendon and pass the plate proximally.

Using a dental pick or Freer elevator, the articular incongruity can be reduced through an empty hole in the plate or adjacent to the plate.

Subchondral and metaphyseal support for maintaining articular reduction can be achieved with allograft or bone graft substitute.

When feasible, a 2.7-mm cortical screw is then inserted through the plate directly under the lunate fossa to act as a buttress against subchondral collapse.

K-wires (0.45 or 0.62 inch) can also be placed percutaneously to hold small articular fragments reduced.

Case series: Posteroanterior radiograph of another case (Fig. 78-22A)

Case series: Radiographs of the plate bridging the fracture (Fig. 78-22B).

FIGURE 78-22

Step 5 Pearls

It is absolutely essential to address any depressed articular fragments that do not reduce with ligamentotaxis.

Bone grafting for both subchondral and metaphyseal defects that are magnified or created by the distraction is an essential component for long-term maintenance of articular reduction and fracture healing.

K-wires should be left outside or deep to the skin and removed at 6 weeks.

Step 5 Pitfalls

Failure to reduce articular fragments may lead to symptomatic radiocarpal arthrosis.

Use of the nick-and-spread method to insert percutaneous K-wire fixation is imperative to prevent injury to the branches of the superficial radial nerve.

Contraindications to bone grafting include grade III open fractures with gross contamination and soft tissue defects that preclude primary wound closure.

After stabilization of the radius, any instability of the DRUJ should be assessed (defined as greater than 8 mm of palmar to dorsal translation of the ulna relative to the radius).

Large fractures of the ulnar styloid as well as displaced ulnar head fractures should raise suspicions of instability.

If instability is noted, the forearm should be maintained in supination for 3 to 4 weeks.

If no instability is noted, immobilization is unnecessary.

If an arthrotomy has been made, the dorsal capsule should be closed with 3-0 nonabsorbable suture.

Postoperative Care and Expected Outcomes

A bulky dressing and splint are used postoperatively for pain control for a few days (except in those with DRUJ instability).

Active and passive digital range-of-motion exercises are started immediately and maintained throughout the distraction period.

After the first postoperative visit at 7 to 10 days, a thermoplastic short-arm splint is applied, and an elastic garment is applied to control edema.

Pronation and supination are encouraged.

Patients may use the affected extremity for activities of daily living.

Patients may not lift greater than 5 pounds.

As noted by Hanel and colleagues (2006), the duration of plate immobilization does not correlate with the range of motion of the wrist or with the DASH score at 1 year.

Pearls

Patients may return to work with distraction in place if they can maintain their restrictions.

A platform walker for mobilization may be used in polytrauma patients if the fixation is deemed stable enough intraoperatively.

Hardware removal can electively be scheduled for about 8 to 12 weeks after surgery depending on the nature of the fracture and documentation of radiographic union.

Range-of-motion exercises of the wrist and fingers are started immediately after plate removal, and no splinting is required.

Pitfalls

Maintain distraction plate until radiographic osseous healing has occurred (bridging callous seen in both the coronal and sagittal plane).

Judging osseous healing may be difficult to visualize with the 3.5-mm plate.

Early removal may lead to late fracture collapse.

Late removal can lead to possible extensor tendon attrition and rupture and permanent wrist stiffness.

Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Upper Extrem Surg. 1998;2:248-252.

The authors describe the original technique of dorsal distraction plating using a 3.5-mm plate. They provide the rationale behind use of this plating as well as an example case. (Level V evidence)

Carter PR, Frederick HA, Georgiann FL. Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surg [Am]. 1998;23:300-307.

This was a multicenter, prospective study with excellent follow-up that was used to determine the safety and efficacy of a new low-profile plate for unstable distal radius fractures. Seventy-one patients were followed for a minimum of 1 year. Autologous bone graft was used in 64 fractures. After fixation, active wrist motion was begun at an average of 14 days, and satisfactory open reduction was obtained in 93% of the fractures and maintained in 88%. Ninety-five percent of the fractures demonstrated good or excellent outcomes using a standardized evaluation. Eighty-one percent of the outcomes were rated as excellent. (Level IV evidence)

Ginn TA, Ruch DS, Yang CC, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution: surgical technique. J Bone Joint Surg [Am]. 2006;88:29-36.

An updated surgical technique is presented by the authors in excellent detail. They describe their method with updated pitfalls and pearls that they have learned from their experience in distraction plating. This is a follow-up to their prospective review of distraction plating, which demonstrated good results for this difficult problem. (Level V evidence)

Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius fractures: the Harborview method. Clin Orthop Relat Res. 2006;445:91-99.

This article, as well as the article by Ginn and colleagues, is the basis of the technique described in this chapter. The authors performed a retrospective chart review of 62 consecutive patients treated with dorsal distraction plating. Inclusion criterion included patients with high-energy injuries that had fracture extension into the radius and ulna diaphysis and patients with multiple injuries that required load bearing through the injured wrist to assist with mobilization. The authors describe their technique in detail and review their experience. Fracture healing occurred in all 62 patients. There were no articular gaps or step-offs greater than 2 mm, and the distal radioulnar joint was stable. There were no cases of excessive postoperative finger stiffness or reflex sympathetic dystrophy. There was one broken fixation plate and one ruptured ECRL tendon in a patient who did not follow the author’s recommendation for time frame of removal. (Level V evidence)

Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg [Am]. 2006;31:1061-1067.

This study evaluated the functional outcome of dorsal plating for dorsally angulated distal radius fractures at a single institution. Thirty patients, with a median age of 59 years, had fixation performed with low-profile, stainless-steel dorsal plates and were then followed for an average of 18 months. Four patients had AO type A fractures, 5 had type B fractures, and 21 had type C fractures. Radiographic parameters, range of motion, and strength compared with the uninjured side were recorded. The functional outcome was evaluated by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Gartland-Werley scoring system. Outcomes found that compared with the contralateral side, the mean extension and flexion were 88% and 81%, respectively; pronation and supination were 89% and 87%, respectively; and grip strength and thumb pinch were 78% and 94%, respectively. The mean postoperative DASH questionnaire score was 15 points, and 28 patients had Gartland-Werley scores of good or excellent. No patients needed to have their plates removed, and no extensor tendon rupture was reported. The authors found that on average, patients can expect to have 80% of their range of motion and strength after dorsal plating for distal radius fractures. In addition, about 93% of the patients can expect to have good to excellent functional outcomes. (Level IV evidence)

Lozano-Calderón SA, Doornberg J, Ring D. Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation. J Bone Joint Surg [Am]. 2006;88:1486-1493.

The authors retrospectively reviewed 20 patients with a fracture of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation. They found a wide spectrum of associated injuries, including torn volar ligaments, displaced and rotated volar marginal lip fractures, and impaction of the volar and central articular surface. Eighteen patients underwent surgical reconstruction of the articular surface and application of dorsal buttress plates with use of a variety of surgical approaches. Outcomes were assessed radiographically and with use of the modified Mayo wrist score and the DASH questionnaire. Average follow-up was 30 months postoperatively. Nineteen fractures had healed without substantial loss of alignment, and 1 patient had recurrent dorsal subluxation after plate removal. The final average amounts of wrist and forearm motion were 59 degrees of flexion, 56 degrees of extension, 87 degrees of pronation, and 85 degrees of supination. The average grip strength was 85% of that of the contralateral, uninjured hand. The final functional results using Mayo and DASH scores were overall good despite the complex nature of the fracture and associated injuries. (Level V evidence)

Papadonikolakis A, Ruch DS. Internal distraction plating of distal radius fractures. Tech Hand Upper Extrem Surg. 2005;9:2-6.

The authors describe their method for internal distraction plating for highly comminuted distal radius fractures, especially in elderly patients. Their technique involves the use of 3.5, 2.7, or 2.5 dynamic compression plates. An excellent step-by-step description of their techniques, as well as a thorough historical perspective, is included their manuscript. Their indications, contraindications, complications, and expected rehabilitation are also well described. They conclude that their current approach represents an alternative that provides union of the fracture with excellent alignment, functional range of motion, and minimal functional disability. (Level V evidence)

Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg [Am]. 2003;85:1956-1960.

This excellent study reviewed the functional outcome and complications after dorsal plating for dorsally displaced, unstable fractures of the distal part of the radius. Twenty-eight patients with a mean age of 42 years were followed for 21 months. Nineteen patients had been treated with a Synthes titanium pi plate, and 9 had been treated with a low-profile stainless steel plate. There were no instances of loss of reduction, malunion, or nonunion. The mean score on the DASH questionnaire was 14.5 points. All patients had an excellent (19 patients) or good (9 patients) result according to the scoring system of Gartland and Werley. Nine patients had postoperative complications requiring repeat surgical treatment for hardware removal or extensor tendon reconstruction. All nine reoperations were performed in patients who had been treated with a Synthes plate, whereas none was performed in patients who had been treated with a low-profile plate. Regardless of the type of plate used, all of the patients in the study had a good or excellent long-term functional outcome. (Level IV evidence)

Ruch DS, Ginn TA, Yang CC, et al. Use of a distraction plate for distal radial fractures. J Bone Joint Surg [Am]. 2005;87:945-954.

This is a prospective review of 22 patients treated with a distraction plate for a comminuted distal radial fracture. All patients were followed prospectively with use of radiographs, physical examination, and DASH scores. All fractures united by an average of 110 days. Radiographs showed good restoration of palmar tilt (average of 4.6 degrees) and neutral ulnar variance. Flexion and extension averaged 57 degrees and 65 degrees, respectively, and pronation and supination averaged 77 degrees and 76 degrees, respectively. Both DASH scores as well as Gartland-Werley ratings were mostly “excellent” and “good.” The duration of plate immobilization did not correlate with the range of motion of the wrist or with the DASH score at 1 year. (Level IV evidence)

Simic PM, Robison J, Gardner MJ, et al. Treatment of distal radius fractures with a low-profile dorsal plating system: an outcomes assessment. J Hand Surg [Am]. 2006;31:382-386.

Functional and radiographic outcomes after internal fixation of acute, displaced, and unstable distal radius fractures were reviewed by the authors. Sixty consecutive unstable fractures were treated using a low-profile dorsal plating system. There were 29 type A, 14 type B, and 8 type C fractures (AO classification system). Fifty patients with 51 fractures returned for outcomes assessment by physical examination, plain radiographs, and completion of a validated musculoskeletal function assessment questionnaire. Minimum follow-up was set at 1 year, and the mean follow-up period was 24 months. Objective functional assessment was obtained through the DASH questionnaire. Outcomes analysis showed no cases of extensor tendon irritation or rupture. Hardware removal was performed in 1 patient, but no extensor tendon irritation or rupture was evidenced. The mean DASH score was 11.9; implant-related discomfort was minimal. All patients had an excellent (31 patients) or good (19 patients) result according to the scoring system of Gartland and Werley. All patients were found to have full extensor tendon glide and metacarpophalangeal joint motion and uniformly good to excellent recovery of wrist and hand function. (Level IV evidence)

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