CHAPTER 19 Bridge Plating of Distal Radius Fractures
Distal radius fractures represent one sixth of all fractures seen and treated in emergency departments.1 The treatment goals for the management of these fractures include restoring congruity to the radiocarpal and distal radioulnar joint (DRUJ) surfaces and maintaining radial length. Currently, there are a number of established surgical options for displaced distal radius fractures as well as newer novel approaches being developed for the surgical management of these injuries.2–13 The choice of surgical technique for reduction and fixation will depend on fracture displacement, joint surface involvement, patient age, bone quality, handedness, occupation, and avocation. Recent advances in the biological and biomechanical understanding of wrist fractures have prompted a more aggressive approach to the fixation of the distal radius. As surgical treatment in general, and plating in particular, ensures more consistent correction of displacement and maintenance of reduction, there has been an increasing trend for operative treatment of these fractures in both the elderly and the young populations. In no area of fracture management has there been such a recent explosion of new treatment modalities as there has been in distal radius fixation.
Two subsets of patients with distal radius fractures continue to represent unique treatment challenges: (1) patients with high-energy wrist injuries with fracture extension into the radial diaphysis and (2) patients with multiple injuries that require load bearing through the injured wrist to assist with mobilization and nursing care. There exist few publications specifically addressing the management of distal radius injuries in the multiply injured patient and/or the problem of distal radius fractures with diaphyseal extension.14,15 High-energy fractures of the distal aspect of the radius with extensive comminution of the articular surface and extension into the diaphysis represent a major treatment challenge. Standard plates and techniques may be inadequate for the management of such fractures.
Patients with multiple injuries, especially those with injuries to the pelvis and lower extremities, require use of the upper extremities for transfers and weight bearing. There exists no evidence that the newer fixation techniques can support such activities. Although it is possible that augmentation of distal radius fixation with a spanning external fixator could improve weight bearing through the upper extremity, this has not been clinically proved. However, it is known that external fixation of fractures presents a set of problems that can be particularly vexing for patients being cared for in intensive care units. These include the burden of pin care and an increased incidence of pin tract contamination and infection.16,17 The ideal fixation device in this setting would assist with and maintain reduction, require no nursing care, and allow the use of the extremity for mobilization.
The use of internal distraction plating or bridge plating for distal radius fractures was first introduced by Burke and Singer.18 The technique was further expanded by Ruch and coworkers, who described the use of a 12- to 16-hole 3.5-mm dynamic compression plate (DCP) (Synthes, Paoli, PA) placed in the floor of the fourth dorsal extensor compartment to span from the intact radius diaphysis to the third metacarpal.14,19 The bridge plating technique provides strong fixation and allows for distraction across impacted articular segments. The technique can be combined with a limited articular fixation approach for those fracture patterns with intra-articular extension. Recently, bridge plating of the distal radius was further refined by Hanel and colleagues.15 The authors described a variant of the bridge plating technique using 2.4-mm AO plates passed extra-articularly through the second dorsal compartment and secured onto the dorsal radial aspect of the radius diaphysis and the second metacarpal. They reviewed the senior author’s experience with bridge plating in a series spanning a 10-year period at a level 1 trauma center. The patients earlier in the series were treated using a 22-hole 2.4-mm titanium mandibular reconstruction plate (Synthes, Paoli, PA) and later in the series with a 2.4-mm stainless steel plate specifically designed for use as a distal radius bridge plate (DRB plate) (Synthes, Paoli, PA). The mandibular reconstruction plate is made of titanium and has square ends and scalloped edges and threaded holes to accept locking screws. The DRB plate that we presently continue to use is made of stainless steel, has tapered ends to facilitate sliding the plate within the extensor compartment, and also has locking screws. The described bridge plating technique is technically easy and achieves the goals of maintenance of fracture reduction, allows weight bearing through the injured extremity, and is associated with few complications (Table 19-1).
TABLE 19-1 Indications for Bridge Plating of Distal Radius Fractures
| Indication | Explanation |
|---|---|
| Metadiaphyseal comminution of the radius | Extensive comminution in metadiaphyseal region is difficult to treat with standard implants used for distal radius fractures. |
| Need for weight bearing through the upper extremity | Patients with associated lower limb injuries may require the need for early weight bearing through the upper extremities. |
| Polytrauma | Nursing care of the multiply injured patient may be easier with spanning internal fixation than with external fixation. |
| Augmented fixation | In osteoporotic bone, bridge plating can be used to augment tenuous fixation. |
| Carpal instability | Carpal instability, particularly radiocarpal, isolated, or in combination with a distal radius fracture, may be held in a reduced position with the help of spanning internal fixation. |
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 19-2 Anteroposterior radiographs of the wrist. A, Injury film. B, After distraction is applied.
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
