What is the step-by-step procedure for managing a fracture of the distal end of the radius using Open Reduction Internal Fixation (ORIF) with volar and dorsal plating?

From the Guidelines

The management of a distal radius fracture using ORIF with volar and dorsal plating involves several key steps, with the most critical aspect being the anatomical reduction and stable fixation of the fracture to allow for early range of motion exercises and prevent complications such as finger stiffness and tendon irritation, as emphasized by the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand in their 2022 clinical practice guideline summary 1.

Preoperative Preparation

The patient is positioned supine on the operating table with the affected arm on a radiolucent hand table under general or regional anesthesia. After standard surgical preparation and draping, a tourniquet is applied to the upper arm and inflated.

Surgical Approach

For the volar approach, a longitudinal or modified Henry incision is made along the flexor carpi radialis tendon. The surgeon dissects through the flexor carpi radialis sheath, retracts the flexor tendons medially, and identifies the pronator quadratus, which is elevated from the radius.

• The fracture is then exposed and anatomically reduced under direct visualization and fluoroscopic guidance.
• A pre-contoured 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.

For the dorsal approach, a straight or slightly curved incision is made over the dorsal aspect of the wrist, typically between the third and fourth extensor compartments.

• The extensor retinaculum is incised, and the extensor tendons are retracted to expose the dorsal aspect of the radius.
• After fracture reduction, a dorsal plate is applied.

Fixation and Closure

Multiple locking screws are placed in both plates to secure the fracture fragments. Intraoperative fluoroscopy confirms proper reduction and hardware placement.

• The pronator quadratus is repaired when possible, and the wounds are closed in layers.
• Postoperatively, a splint is applied for 1-2 weeks, followed by early range of motion exercises, as recommended by the 2017 EULAR/EFORT guidelines for the management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures 1.

Postoperative Care

Prophylactic antibiotics (typically cefazolin 1-2g IV) are administered before incision and may be continued for 24 hours.

• Early finger motion is essential to prevent oedema and stiffness, as highlighted in the 2010 study on the treatment of distal radius fractures 1.
• This dual plating technique provides enhanced stability for complex distal radius fractures with both volar and dorsal comminution, though it carries increased risks of soft tissue irritation and tendon complications compared to single plate fixation.

From the Research

Step-by-Step Procedure for Managing Fracture of Distal End of Radius using ORIF with Volar and Dorsal Plating

• Preoperative planning: The choice of plate fixation should depend on fracture type, patient factors, and surgeon experience 2.
• Surgical approach:
  • Volar approach: Volar plating has broad applicability and consistent outcomes, and thus is the most commonly used plate type 2.
  • Dorsal approach: 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.
• Reduction and fixation:
  • Reduction: The fracture is reduced using a combination of manipulation and instrumentation.
  • Fixation: Volar and dorsal plates are used to stabilize the fracture, with the volar plate providing stable fixed-angle support and the dorsal plate providing additional support and buttressing.
• Intraoperative imaging:
  • Fluoroscopy: Used to confirm the reduction and fixation of the fracture.
  • Dorsal tangential views (DTV): Used to detect dorsally protruding screws and avoid tendon irritation 3.
• Screw placement:
  • Screws are placed in the volar and dorsal plates to secure the fracture.
  • The screws in the two most radial screws in the plate are at the highest risk of being revised 3.
• Postoperative care:
  • Early active wrist rehabilitation is permitted due to the stable fixed-angle support provided by the volar plate 4.
  • Patients are monitored for complications such as tendon irritation and screw penetration.

Indications for Volar and Dorsal Plating

• Volar plating:
  • Indicated for most fracture patterns due to its broad applicability and consistent outcomes 2.
  • Advantages include stable fixed-angle support, direct fracture reduction, and fewer soft-tissue and tendon problems 4.
• Dorsal plating:
  • Indicated for specific fracture patterns, such as irreducible dorsal die-punch fractures 5.
  • Advantages include direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation 2.

Complications and Outcomes

• Complications:
  • Tendon irritation and screw penetration are potential complications of dorsal plating 2, 3.
  • Volar plating has fewer soft-tissue and tendon problems compared to dorsal plating 4.
• Outcomes:
  • Similar clinical results have been reported for volar and dorsal plating in the treatment of intra-articular distal radius fractures 5.
  • Early active wrist rehabilitation is permitted due to the stable fixed-angle support provided by the volar plate, resulting in improved functional outcomes 4.