Distal Radius Intraarticular Fracture ORIF with Dorsal Approach

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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Identify fracture characteristics

  • distal radius fracture pattern
  • bone quality
  • DRUJ disruption
  • amount of comminution
  • presence of intra-articular extension(s)

2

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • ensure precontoured dorsal locking plate system of choice is present in the room

2

Room setup and equipment

  • 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

3

Patient positioning

  • supine with shoulder at edge of bed centered at level of patient’s shoulder
  • hand centered on hand table, pronate arm
  • arm tourniquet placed on arm with webril underneath (optional)
G

Dorsal Approach

1

Mark out the anatomy

  • mark out the anatomy of the distal radius

2

Make the incision

  • make a longitudinal incision 8 to 10 cm long on the dorsal aspect of the wrist just ulnar to Lister`s tubercle

3

Dissect through the subcutaneous tissue

  • carry the dissection down through the subcutaneous tissue
  • be careful to take care of the small cutaneous nerve branches

4

Incise skin flaps and subcutaneous fat

  • dissect down to the extensor retinaculum
H

Deep Dissection

1

Expose the EPL

  • identify the third dorsal compartment
  • make an incision in the third dorsal extensor compartment
  • incise the extensor retinaculum just ulnar to Lister`s tubercle
  • retract the EPL radially

2

Identify the fourth dorsal compartment

  • subperiosteally elevate the fourth compartment and retract ulnarly
  • be careful to avoid entering the fourth compartment

3

Expose the dorsal cortex of the distal radius

4

Expose the articular surface

  • make a longitudinal incision through the dorsal capsule /dorsal radiocarpal ligament
  • this gives exposure to the proximal row and the articular surface of the distal radius

5

Place mini Hohmann retractors to keep visualization

I

Fracture Preparation

1

Remove Lister`s tubercle

  • use a rongeur to remove Lister`s tubercle as it is almost always involved in the fracture

2

Free the fracture fragments

  • remove the fracture hematoma
  • mobilize the fracture fragments with a freer elevator
  • these are often impacted

3

Debride the fragments

J

Fracture Reduction and Provisional Fixation

1

Reduce the articular surface

2

Reduce the radial styloid fracture fragment

  • this is done by traction that is placed along the thumb or the index finger and long fingers

3

Place Kwires for provisional fixation

  • if fragment(s) unstable use 0.062 inch K-wires
  • place the radial styloid K wire obliquely starting at the tip of the radial styloid
K

Final Fixation

1

Place the plate

  • place the plate directly on the shaft of the radius

2

Secure the plate

  • place a bicortical screw in the oval sliding hole of the plate

3

Confirm plate placement and fracture reduction with fluoroscopy

4

Secure the plate distal fragment

  • secure the plate to the distal fragment using one or two cancellous screws
  • try to avoid placing the distal ulnar screw due to possible irritation of extensor tendons of the fourth compartment

5

Add screws

  • add cortical screws to the radius shaft

6

Confirm placement and reduction using fluoroscopy

L

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Deep closure

  • use 0-vicryl to close the retinaculum deep to the transposed EPL
  • incorporate the periosteum that forms the floor of the extensor compartment

3

Superficial layer

  • use 3-0 vicryl to close the subcutaneous tissue
  • use 3-0 monocryl on skin

4

Immobilization

  • place in volar splint
Postoperative Patient Care
 

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