From the Guidelines
The management of a distal radius fracture using ORIF with volar and dorsal plating involves several key steps, with the goal of achieving optimal reduction and stability to minimize morbidity, mortality, and improve quality of life.
Step-by-Step Procedure
The procedure begins with the patient positioned supine on the operating table with the affected arm on a radiolucent hand table under general or regional anesthesia, as noted in various studies 1.
- After standard surgical preparation and draping, a tourniquet is applied to the upper arm and inflated to provide a bloodless field.
- For the volar approach, a longitudinal or modified Henry incision is made along the flexor carpi radialis tendon.
- The pronator quadratus is elevated from the radius, exposing the fracture site.
- The fracture is then reduced under direct visualization and fluoroscopic guidance.
- A volar locking plate is positioned on the volar surface of the distal radius, ensuring it does not extend beyond the watershed line to prevent flexor tendon irritation.
- Multiple locking screws are placed distally to support the articular surface, followed by proximal screws for shaft fixation.
Dorsal Approach
For the dorsal approach:
- A straight or curved incision is made over the dorsal wrist, with careful protection of the extensor tendons and the dorsal sensory branch of the radial nerve.
- The dorsal plate is applied to provide additional support for dorsal comminution or specific fracture patterns that require dorsal buttressing.
Postoperative Care
After confirming proper reduction and hardware placement with fluoroscopy:
- The pronator quadratus is repaired over the volar plate when possible, and the wounds are closed in layers.
- Postoperatively, the wrist is immobilized in a splint for 1-2 weeks, followed by early protected range of motion exercises.
- Weight-bearing restrictions are typically maintained for 6-8 weeks, with gradual return to activities as healing progresses. This combined plating approach provides superior stability for complex distal radius fractures with both volar and dorsal involvement, though it carries increased risks of soft tissue complications and should be reserved for fractures that cannot be adequately stabilized with a single plate 1.
Key Considerations
- The decision to use ORIF with volar and dorsal plating should be based on the individual patient's fracture pattern, age, and functional demands, as well as the surgeon's expertise and experience, as emphasized by the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand 1.
- The use of arthroscopic assistance for evaluation of the articular surface during operative treatment of distal radius fractures is not supported by moderate evidence, according to a randomized controlled trial evaluating the functional and radiographic outcomes after distal radius fractures 1.
- A home exercise program and supervised therapy following the treatment of distal radius fractures may be beneficial, but the evidence is inconsistent, and more investigation is needed to determine the optimal rehabilitation protocol 1.
From the Research
Step-by-Step Procedure for Fracture Distal End Radius Managed by ORIF with Volar and Dorsal Plating
- Preoperative preparation: The patient is prepared for surgery, and the affected arm is positioned to allow access to both the volar and dorsal aspects of the wrist 2.
- Incision and dissection: A volar incision is made, and the soft tissues are dissected to expose the fracture site. A dorsal incision may also be made to allow for dorsal plating 3.
- Reduction of the fracture: The fracture is reduced, and the bone fragments are aligned using a combination of manual manipulation and instrumentation 4.
- Volar plating: A volar plate is applied to the fracture site, and screws are inserted to secure the plate to the bone. The volar plate provides support to the fracture and helps to maintain alignment 5.
- Dorsal plating: A dorsal plate is applied to the fracture site, and screws are inserted to secure the plate to the bone. The dorsal plate provides additional support to the fracture and helps to prevent dorsal displacement 3.
- Verification of reduction: The reduction of the fracture is verified using fluoroscopy or other imaging modalities to ensure that the bone fragments are properly aligned 2.
- Closure: The incisions are closed, and the wound is dressed. The patient is then taken to the recovery room for postoperative care 6.
Considerations for Plate Fixation
- The choice of plate fixation should depend on the fracture type, patient factors, and surgeon experience 2.
- Volar plating has broad applicability and consistent outcomes, and is the most commonly used plate type 2.
- Dorsal plates are advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation 2.
- Combined volar and dorsal plating can provide additional support to the fracture, but may result in inferior wrist range of motion and a higher frequency of hardware removal 6.