Indications

This technique is indicated in patients with any type of distal radius fracture with extension into the radial metadiaphysis as well as polytrauma patients with associated lower extremity injuries requiring early weight bearing through the upper extremities, those with multiple injuries, especially those with injuries to the pelvis and lower extremities, and those who require use of the upper extremities for transfers and weight bearing.

Contraindications

General orthopaedic contraindications include medical comorbidity precluding surgical procedure and active infection. The only specific contraindication is metacarpal fracture of index and middle fingers, which would compromise the distal fixation of the bridge plate.

Technique and Surgical Approach

With the patient anesthetized and supine on the operating table, the involved extremity is draped free and centered on a radiolucent hand table. Finger traps are applied to the index and middle fingers, and 4.5 kg of longitudinal traction is applied through a rope and pulley system. Under image intensification, the closed reduction maneuver described by Agee is performed²⁰ (Fig. 19-1). Longitudinal traction is first used to restore length and to assess the benefit of ligamentotaxis for the restoration of articular step-off (Fig. 19-2). Next, the hand is translated palmarly relative to the forearm to restore sagittal tilt and to assess the integrity of the volar lip of the radius (Fig. 19-3). Finally, pronation of the hand relative to the forearm is performed to correct the supination deformity. Once the initial reduction maneuver is completed, the bridge plate is then applied.

FIGURE 19-1 Picture of our setup for this procedure, with longitudinal traction applied through finger traps and the C-arm coming in from above or below the hand table.

FIGURE 19-2 Anteroposterior radiographs of the wrist. A, Injury film. B, After distraction is applied.

FIGURE 19-3 A, Clinical pictures showing the wrist deformity before (top) and after (bottom) application of the Agee reduction maneuver, which is a combination of longitudinal traction and volar translation of the carpus. B, Radiographs showing the wrist deformity before (top) and after (bottom) application of the Agee reduction maneuver.

The DRB plate is superimposed on the skin from the radial diaphysis to the distal metadiaphysis of the second metacarpal. The position of the plate is verified with image intensification, and markings are placed on the skin at the level of the proximal and distal four screw holes of the plate (Fig. 19-4). The subcutaneous tissues are infiltrated with 0.25% bupivacaine with epinephrine to promote hemostasis. A 5-cm incision is made at the base of the second metacarpal and continued along the second metacarpal shaft. In the depths of this incision, the insertions of the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) are identified as they pass beneath the distal edge of the second dorsal wrist compartment to insert on the second and third metacarpal bases, respectively. A second incision is made just proximal to the outcropper muscle bellies (abductor pollicis longus [APL]) and the extensor pollicis brevis (EPB), in line with the ECRL and ECRB tendons. The interval between the ECRL and ECRB is developed, and the diaphysis of the radius is exposed (Fig. 19-5). The DRB plate is introduced beneath the muscle bellies of the outcroppers extraperiosteally and advanced distally between the ECRL and ECRB tendons (Fig. 19-6). Some resistance may be encountered as the plate emerges distally, but this can usually be easily overcome with gentle manipulation of the plate. Occasionally, the plate will not pass through the compartment. In these cases, a guidewire or stout suture retriever is passed along the compartment from distal to proximal. The plate is secured to the distal end of the wire and delivered into the hand. In the rare instance that these measures fail, a third incision is made directly over the metaphysis of the radius, the proximal one half of the second compartment is incised, and the plate is passed under direct vision. The third, or periarticular, incision may also be used to assess the articular surface, reduce die-punch fragments, and introduce bone graft (Fig. 19-7).

FIGURE 19-4 A, The plate is placed over the forearm and hand. Radiographs can be taken to confirm the position of the plate. The plate should be centered over the second metacarpal distally and the radius proximally. This will be along the course of the ECRL. B, The outline of the plate. C, The incisions made over the second metacarpal and the radius.

FIGURE 19-5 A, The ECRL and ECRB tendons just proximal to the APL in the forearm. B, The development of the interval between the ECRL and ECRB tendons to gain access to the radius shaft.

FIGURE 19-6 A, Insertion of the plate through the distal wound. The interval between the ECRL and ECRB distally can be developed for plate passage within the second dorsal compartment. B, The proximal aspect of the plate over the radius and in between the ECRL and ECRB. It is important to ensure that the plate runs within the second compartment and not superficial to the first and third compartment tendons.

FIGURE 19-7 A, A third incision is marked out just ulnar to Lister’s tubercle. B, The EPL tendon has been released from its compartment, and bone graft is inserted through the dorsal fracture line just ulnar to the bridge plate.

After passing the bridge plate, it is then secured to the second metacarpal by placing a nonlocking fully threaded 2.4-mm cortical screw through the most distal plate hole. The proximal end of the plate is then identified in the forearm. If the radial length has not been restored, then the plate, secured to the second metacarpal, is pushed distally until the length is reestablished and a fully threaded 2.4-mm nonlocking screw is placed in the most proximal plate hole. By using nonlocking screws the plate is effectively lagged onto the intact bone. Plate alignment along the longitudinal axis of the radius is guaranteed by securing the most distal and most proximal screw holes first. The remaining holes are secured with fully threaded locking screws inserted with bicortical purchase (Fig. 19-8).

FIGURE 19-8 Final anteroposterior (A), oblique (B), and lateral (C) radiographs.

It has been our experience that as the plate is passed along the radial diaphysis, through the second compartment and along the second metacarpal, extra-articular alignment, radial inclination, volar tilt, and radial length are restored. Intra-articular reduction may be further adjusted by using limited periarticular incisions to allow for direct manipulation of articular fragments, placement of subchondral bone grafts, repair of intercarpal ligament injuries, and augmentation of fracture fixation with Kirschner wires (K-wires) and periarticular plates. Displaced volar medial fracture fragments that are not reduced with this technique require a separate volar incision and appropriate buttress support.

The stability of the DRUJ is assessed after radius reconstruction. If the DRUJ is stable, the limb is immobilized in a long arm splint with the forearm in supination for the first 10 to 14 days postoperatively. If the DRUJ is unstable, and there are no contraindications to prolonging the operation, repair or reconstruction of the DRUJ and triangular fibrocartilage complex is undertaken. If, however, the patient’s condition does not allow prolonging the operation, the ulnar head is reduced manually into the sigmoid notch and the ulna is transfixed to the radius with a minimum of two 1.6-mm K-wires passed proximal to the DRUJ.

Postoperative Rehabilitation

Digit range of motion exercises start within 24 hours of surgery. Load bearing through the forearm and elbow is allowed immediately, as well as the use of a platform crutch when the patient is physiologically stable. At 1 month postoperatively the platform is removed and weight bearing is allowed through the hand grip of regular crutches. Lifting and carrying is restricted to approximately 4.5 kg until the fracture has healed.

DRUJ stability and forearm motion are assessed 2 weeks after reduction. If the patient can supinate the forearm with little effort and the DRUJ is stable, then splinting is discontinued. Axial loading through the extremity is allowed at this point for transfers and for all weight-bearing needs. If the patient has difficulty maintaining supination, or if the DRUJ was reconstructed acutely, then a removable long arm splint is fabricated. If the DRUJ was transfixed with K-wires, then the wires are removed on the third postoperative week and DRUJ stability is reassessed.

Supplemental K-wires for articular fixation are removed 6 weeks postoperatively. The DRB plate and screws are removed usually no earlier than 12 weeks after injury.

Clinical Pearls

If a mandibular reconstruction plate was used, at the time of hardware extraction the screws are removed and the plate is twisted axially 720 degrees to break up the soft tissue adhesions and callus that grow around and onto the scalloped edges of the titanium plate. This maneuver is not usually required when the smooth-edged stainless steel DRB plate is used. A removable short arm splint is worn for 2 to 3 weeks after plate removal. Hand therapy at this point is directed at regaining motion and strength.

Results

The bridge plating technique for distal radius fractures was reviewed in a retrospective study consisting of 62 consecutive patients treated in this fashion and representing 10-year experience with the technique at a level 1 trauma center.¹⁵ Patients managed with bridge plating either for distal radius fractures with extensive metadiaphyseal comminution or patients with distal radius fractures associated with other injuries requiring weight bearing through the affected extremity represented 13% of distal radius fractures requiring operative fixation during this time period. Fracture healing occurred in all 62 patients. In each case radial length was within 5 mm of ulnar-neutral variance, radial inclination was more than 5 degrees, and palmar tilt was at least neutral. There were also no articular gaps or step-offs greater than 2 mm, and the DRUJ was stable in all cases. Similarly, Ruch and coworkers showed 14 of 22 patients obtained excellent radiographic and functional results and another 6 of 22 patients obtained good results in their prospective cohort of patients with comparable pathological processes.¹⁴

All fractures united by an average of 110 days. Radiographs showed an average palmar tilt of 4.6 degrees and an average ulnar variance of neutral (0 degrees), whereas loss of radial length averaged 2 mm. Flexion and extension averaged 57 degrees and 65 degrees, respectively, and pronation and supination averaged 77 degrees and 76 degrees, respectively. The average Disabilities of the Arm, Shoulder, and Hand (DASH) scores were 34 points at 6 months, 15 points at 1 year, and 11.5 points at the time of final follow-up (at an average of 24.8 months). According to the Gartland-Werley rating system, 14 patients had an excellent result, 6 had a good result, and 2 had a fair result.

The plate was removed on average 112 days after placement. One outlying patient had the bridge plate in place upwards of 19 months because he did not wish to take time off work to have the plate removed. The plate in this case eventually failed at 16 months, but the patient continued to work until the broken hardware became increasingly prominent and symptomatic. Finally, at the time of plate removal the patient sustained an ECRL rupture that was treated with ECRL-to-ECRB tenodesis. There were no other documented complications in the series. In addition, there were no cases of excessive postoperative finger stiffness of reflex sympathetic dystrophy. This reflects the overall infrequent complications reported in the literature for bridge plating of the distal radius. In fact, Burke and Singer¹⁸ reported no complications and Ruch and associates¹⁴ reported no hardware failures and only 3 patients who developed long finger extensor lag of 10 to 15 degrees.

Excluding bridge plate removal, only 1 patient required a secondary operative procedure for fracture care. The patient underwent bridge plate removal at 4 weeks after injury and conversion to a 3.5-mm nonspanning DC plate by a separate surgeon closer to her home. The fracture went on to heal uneventfully and her range of motion at 1 year after injury was reported as 80% of her contralateral side. This patient eventually returned to all her previous activities.

Forty-one of the 62 patients have returned to their previous levels of employment. Of the remaining 21 patients, 8 were unemployed at the time of injury and remain so. Thirteen patients sustained multiple injuries requiring considerable changes in occupation and lifestyle. Only one of these 13 patients considers the wrist fracture to be the limiting factor in failing to return to work.

Overall, these results compare favorably with the findings of Burke and Singer¹⁸ and Ruch and associates.¹⁴ The bridge plates were removed at a mean of 110 days in the Ruch cohort versus 112 days in the senior author’s series. Ruch and associates¹⁴ reported 35 degrees of flexion, 45 degrees of extension, 69 degrees of pronation, and 72 degrees of supination at 6 months with a mean grip strength of 41% of the contralateral side. At 1 year, flexion and extension averaged 57 and 65 degrees, respectively; pronation and supination averaged 77 and 76 degrees, respectively; and grip strength improved to 69% of the contralateral side. DASH scores in their study decreased from 33.8 points at 6 months, to 15.4 points at 1 year, and 11.5 points at the time of final follow-up at an average of 24.8 months. Using the rating system of Gartland and Werley²¹ at 1 year postoperatively, 63.6% of results were graded as excellent, 27.2% were graded as good, and 9.0% as fair. The authors of each of these studies proposed that distraction plating allows fracture reduction and fixation over a broad metadiaphyseal area while effectively diverting compression forces away from the fracture site.

Discussion

In the treatment of patients with extensive metadiaphyseal comminution there existed no other implants in our armamentarium that could effectively bridge the fracture and allow for early weight bearing through the extremity at the time the patients in our series were treated. There are currently several plates that have recently been developed with longer diaphyseal limbs. These new implants may circumvent the need for bridge plating in a select group of patients with isolated injuries and adequate distal bony purchase. However, in patients with multiple injuries, the need to bear weight through the affected extremity places excessive stress on the implants securing the fracture and therefore risks loss of reduction and hardware failure. Even with the advent of newer and longer implants, the subset of patients with extensive metadiaphyseal comminution and/or associated lower limb injuries may continue to benefit from spanning internal fixation.

Before the introduction of this technique, treatment of these injuries was limited to cast immobilization or external fixation with or without K-wire augmentation. Both of these methods are associated with unacceptably high complication rates. Lafontaine and coworkers showed that the end results of comminuted distal radius fractures treated by closed methods resembled the prereduction radiographs more than any other radiographs during treatment even when the reduction successfully restored wrist anatomy.²² Szabo and Weber reported a greater than 50% complication rate when using external fixation alone, with the most frequent complications being pin tract infections.²³ This latter complication becomes an even more frequent occurrence in the patients confined to intensive care units.

The biomechanical stability of spanning plates is strong and predictable. Behrens and Johnson, studying the rigidity of external fixator configurations, demonstrated that rigidity is directly proportional to how close the longitudinal fixator bar is to the bone and the fracture.²⁴ A bridge plate, resting directly against the radius proximally and metacarpals distally, therefore, optimizes the conditions to obtain the strongest possible fixator construct. A DRB plate fixed with a minimum of three screws at either end of the plate confers significantly more stability than would an external fixator used to stabilize a comparable fracture.²⁵

With prolonged immobilization and distraction there may be concerns that wrist stiffness will result and fracture nonunion will occur.^14,15 However, in the senior author’s series, there were no nonunions and a functional range of motion was attained within a year of plate removal in all cases.¹⁵

The technique described here varies from that described by Burke and Singer.¹⁸ The bridge plate used in this description is smaller, using 2.4-mm screws instead of 3.5-mm screws, and is converted to a fixed-angle device by the use of locking screws. The plate is placed in the second dorsal compartment rather than the fourth and secured to the second metacarpal rather than the third metacarpal. Becton and colleagues first suggested this position while presenting a fixation plate specific to the task.²⁶ However, we do not use the implant Becton and colleagues suggested because it is too short for most of the fractures we encounter and cannot be converted to a fixed-angle device. However, similar to Becton and colleagues, we note that the dorsal radial aspect of the radial diaphysis, the floor of the second extensor compartment, and the dorsal radial aspect of the second metacarpal are collinear. Passing a fixation plate along these surfaces through the intact retinaculum of the second dorsal compartment while applying longitudinal traction effectively restores radial length, radial inclination, and volar tilt of the radial styloid and scaphoid facet. Depression fractures of the lunate facet and volar shearing fractures, especially those involving the critical volar ulnar corner of the radius, may require separate manipulation and fixation. Burke and Singer¹⁸ cite a significant intra-articular component of the fracture as the major advantage to a fourth dorsal compartment approach in these injuries. However, we use indirect reduction techniques, percutaneous wires, limited dorsal incisions, and open reduction of volar shearing fractures as needed to address the articular component of the fractures and maintain reductions.

Conclusion

The use of bridge plating in the treatment of distal radius fractures avoids the complications of external fixation. A bridge plate can remain implanted for extended periods of time, without deleterious effects on functional outcome. All patients in our series went on to heal with acceptable metadiaphyseal and intra-articular alignment. In patients with multiple traumatic injuries, bridge plating allowed earlier postoperative load bearing across the affected wrist. This enabled independent transfers and the use of ambulatory aids. Application of bridge plates is simple, and surgical time is comparable with the application of an external fixator.