What are the steps involved in treating a fracture of the distal end of the radius via plating?

From the Guidelines

Treating a fracture of the distal end of the radius via plating is a complex procedure that involves several key steps to restore normal anatomy and prevent long-term complications, such as osteoarthritis, as highlighted in the study by 1. The procedure begins with a preoperative assessment, including radiographs to determine the fracture pattern and displacement, which is crucial in planning the surgical approach, as noted in the study by 1. After appropriate anesthesia, typically regional or general, the surgical approach commences with a volar or dorsal incision, with the volar approach being more common due to better soft tissue coverage. The key steps involved in the procedure are:

• Preoperative assessment and planning
• Surgical approach through a volar or dorsal incision
• Fracture exposure and reduction to restore normal anatomy
• Temporary K-wire fixation to maintain the reduction
• Positioning and securing a pre-contoured plate with screws
• Intraoperative fluoroscopy to confirm proper plate position and fracture reduction
• Wound irrigation and closure in layers
• Application of a splint or cast for initial immobilization
• Postoperative rehabilitation, including early finger motion and physical therapy to restore strength and range of motion. The goal of the procedure is to achieve stable fixation that allows for earlier mobilization, which is particularly beneficial for complex or unstable fractures, as emphasized by the importance of restoring radial length, inclination, and tilt, as well as the realignment of the articular fracture fragments, as discussed in the study by 1. The use of internal fixation, such as plating, has been increasing, especially in elderly patients with osteoporosis, as it provides a more stable fixation and allows for earlier mobilization, which can help prevent long-term complications, such as osteoarthritis, as noted in the study by 1. In terms of specific considerations, the presence of a coronally oriented fracture line, die-punch depression, or more than three articular fracture fragments are common indications for operative reduction, as highlighted in the study by 1. Additionally, operative fixation resulting in <2 mm of residual articular surface step-off is usually considered necessary to avoid long-term complications, such as osteoarthritis, as discussed in the study by 1. Overall, the procedure requires careful planning and execution to achieve optimal outcomes and prevent long-term complications.

From the Research

Pre-Operative Steps

• Assessment of the fracture: determining the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms 2
• Investigations: radiographs to evaluate for intra-articular involvement and fracture displacement 2
• Choice of anesthesia: considering the use of wide-awake local anesthesia no tourniquet (WALANT) approach as an alternative to general or regional anesthesia 3
• Selection of plate type: depending on fracture type, patient factors, and surgeon experience, options include volar plating, dorsal plates, and bridge plates 4

Operative Steps

• Administration of local anesthesia: injecting lidocaine and epinephrine into the surgical field without using a tourniquet (WALANT approach) 3
• Incision and exposure: making an incision and exposing the fracture site
• Reduction of the fracture: reducing the fracture under direct vision
• Plate fixation: fixing the fracture with a plate, using a volar fixed-angle plate fixation or other suitable fixation strategy 4, 5
• Confirmation of reduction: confirming the reduction of the fracture using radiographs

Post-Operative Steps

• Immobilization: immobilizing the wrist in a cast or splint to allow for healing
• Mobilization: encouraging patients to mobilize as soon as it is safe to do so, to prevent stiffness 2
• Follow-up: monitoring the patient for complications such as median nerve compression, tendon rupture, arthrosis, and malunion 2
• Plate removal: removing the plate if necessary, such as in the case of bridge plates 4

Considerations

• Fracture complexity: recognizing and treating complex fracture patterns, which may require alternative fixation strategies 5
• Patient factors: considering patient comorbidities and desired functional outcome when selecting a treatment plan 2
• Surgeon experience: taking into account the surgeon's experience and expertise when selecting a plate type and fixation strategy 4