Updated: 5/2/2017

[Blocked from Release] Distal Radius Fracture ORIF

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Pearls & Pitfalls
 
Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I
  • Preparation
    • identify fracture pattern, amount of comminution, and intra-articular extension
  • Positioning
    • supine with shoulder at edge of bed centered on hand table
    • radiolucent hand table with bed turned 90°
    • c-arm perpendicular to bed
  • Approach
    • volar approach to distal radius: flexor carpi radialis (FCR) 
  • Reduction
    • reduce fracture using traction and direct manipulation techniques
  • Fixation
    • temporary stabilization with k-wires through radial styloid across fracture site
    • volar locking wrist plate with distal screws into subchondral bone
  • Closure
    • coagulate any bleeders for hemostasis, carefully examine radial artery
  • Postoperative
    • soft dressing, 2 weeks volar slab splint for immobilization
    • postop vitamin C to reduce incidence of CRPS
    • rehabilitation
      • 2 weeks non-weight bearing in splint
      • 4 weeks non-weight bearing in removable wrist splint with range of motion exercises
Planning & Preparation
  • Template Fracture
    • identify fracture characteristics
      • distal radius fracture pattern 
      • bone quality
      • DRUJ disruption
      • amount of comminution
      • presence of intra-articular extension(s)
    • complex fractures may benefit from pre-operative CT scan
    • compare to contralateral wrist xray for:
      • radial height, inclination, ulnar variance, and volar tilt
    • check radial/ulnar artery patency of operative extremity with Allen’s test
  • Plan Approach
    • plan out volar approach to distal radius 
    • may add dorsal approach to wrist as needed 
  • Table and Imaging 
    • setup OR with standard operating table and radiolucent hand table
    • turn table 90° so that operative extremity points away from anesthesia machines
    • c-arm perpendicular to hand table with monitor in surgeon's direct line of site
 
Equipment & Positioning
  • Potential Hardware Systems 
    • precontoured volar locking plate system of choice
  • Patient Position
    • supine with shoulder at edge of bed centered at level of patient’s shoulder, 
      • hand centered on hand table, supinate arm
    • arm tourniquet placed on arm with webril underneath (optional)
 
Surgical Technique
  • Approach 
    • FCR-based approach to the volar wrist 
    • internervous plane is FCR (median nerve) and FPL (AIN)
  • Soft Tissue Dissection 
    • incision made along course of FCR tendon
      • incise FCR tendon sheath to allow tendon mobilization
    • retract FCR tendon ulnarly 
      • can retract radially if access needed to carpal tunnel
    • sharply incise deep FCR sheath
    • retract underlying FPL in an ulnar direction
    • be careful of palmar cutaneous branch of median nerve 
      • arises 5cm proximal to wrist joint, ulnar to FCR
    • visualize the proximal extent of pronator quadratus and take down sharply with knife
      • incise radial and distal borders of quadratus and take down in L-shaped fashion
      • bipolar to cauterize branching vessels from radial artery          
    • brachioradialis can be released if needed (optional)
      • removes deforming force 
      • dorsal radial sensory nerve branch is deep to brachioradialis
  • Fracture Preparation and Reduction 
    • interposing periosteum and hematoma removed from fracture site 
      • Freer elevator to open fracture site
    • traction and manipulation of the hand is used intially to obtain a reduction
      • further reduction can be performed with direct fragment manipulation
    • rolled blue towels under dorsal wrist to aid in volar translation or radial/ulnar deviation
    • if fragment(s) unstable use 1.6mm K-wires 
      • from radial styloid proximally across fracture line
  • Plate and Screw Fixation
    • distal fixation first
      • after fracture reduction check size, length, and rotation of plate on distal radius
        • use K-wires into plate to temporarily fix distally
          • hold plate down to bone distally
          • K-wires in distal row of plate will show angle/location of distal screws
          • want screws as distal as possible for subchondral bone support
        • proximal aspect of plate held off bone with screw or elevator
        • drill and insert distal row screws
        • fluoro AP and radial inclination view (distal radius angled 20° off of hand table)
        • remove K-wires from distal plate
        • bring plate down to bone proximally and hold with 3 non-locking screws
    • proximal fixation first
      • place cortical screw in proximal oval hole of plate using 3.5mm screw
        • plate can be readjusted later on due to oval hole
      • insert distal ulnar cortical screw after drilling through guide for preliminary fixation or locking screw if confident regarding plate location 
      • check screw lengths after inserting all distal row locking screws
      • obtain fluoroscopic views to make sure no screw penetration into joint
        • radial inclination view critical (lateral xray with distal radius lifted 20° off hand table) 
      • drill and insert screws into plate shaft proximal to fracture
      • if bony defect, can add auto/allograft bone as needed
  • Confirm Plate & Screw Position 
    • take final fluoroscopic images
      • can compare to pre-op or intraop radiographs of contralateral wrist
Closure
  • Irrigation & Hemostasis
    • irrigate wounds thoroughly and deflate tourniquet (if utilized)
    • coagulate any bleeders carefully, 
    • evaluate for damage to radial artery
    • quadratus can be laid over plate
      • repair of quadratus does not improve outcomes
  • Closure
    • subcutaneous layer with 3-0 absorbable suture
    • 3-0 nylon vertical/horizontal mattress for skin
      • alternatively, can use running 4-0 or 5-0 Monocryl for subcuticular stitch
  • Dressing & Splint
    • incision dressing (gauze, webril) followed by volar slab splint for immobilization
      • allow wrist to rest in neutral position while splint sets
    • post-operative vitamin C 500mg x 50 days to reduce incidence of RSD/CRPS (2010 AAOS Clinical Practice Guidelines)
Postoperative Care
  • 2 Weeks
    • wound check and remove sutures
    • remove surgical splint and place in removable splint
    • begin range of motion exercises to wrist and hand
  • 6 Weeks 
    • advance weight-bearing status in removable wrist brace
    • advance rehabilitation
Complications
  • Complications 
    • median nerve neuropathy (carpal tunnel syndrome, 1-30%)
    • superficial and deep infections (1-2%, up to 20% in diabetics, peripheral neuropathy)
    • neurovascular injury (palmar cutaneous branch of median nerve, radial artery)
    • radiocarpal instability from release of volar wrist capsule ligaments
    • wound breakdown
    • screw penetration into joint
    • post-traumatic radiocarpal arthritis
    • malunion and nonunion
    • RSD/CRPS

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