From the Guidelines
The treatment of a distal radius fracture with volar and dorsal plating involves a comprehensive surgical procedure that prioritizes morbidity, mortality, and quality of life as the primary outcomes. The procedure begins with the patient undergoing general or regional anesthesia, followed by proper positioning with the arm on a radiolucent table. The surgeon starts with the volar approach, making a longitudinal incision along the flexor carpi radialis tendon, as this approach has been shown to provide excellent exposure and minimize complications 1. After careful dissection through the flexor tendons, the pronator quadratus is elevated to expose the fracture site, allowing for direct visualization and fluoroscopic guidance to reduce the fracture.
The fracture is then reduced under direct visualization and fluoroscopic guidance, and a pre-contoured volar locking plate is positioned on the volar surface of the radius and secured with locking screws. For the dorsal approach, a straight or curved incision is made over the dorsal wrist, with careful protection of the extensor tendons and sensory branches of the radial nerve. The dorsal plate is then applied and secured with screws, providing additional stability to the fracture. Intraoperative fluoroscopy confirms proper reduction and hardware placement, ensuring that the fracture is adequately stabilized.
The pronator quadratus is repaired when possible, and both incisions are closed in layers. Postoperatively, the wrist is immobilized in a splint for 1-2 weeks, followed by early protected range of motion exercises, as recommended by the American Academy of Orthopaedic Surgeons 1. This dual plating technique is particularly useful for complex, comminuted fractures with both volar and dorsal instability, providing enhanced stability through load sharing between the two plates and preventing collapse or displacement during healing.
Some key points to consider during the procedure include:
- The use of arthroscopic assistance for evaluation of the articular surface during operative treatment of distal radius fractures is not recommended, as moderate evidence suggests that it does not improve outcomes 1.
- A home exercise program and supervised therapy following the treatment of distal radius fractures may be beneficial, but the evidence to support its use is inconsistent 1.
- Identification of associated DRUJ dislocation can be difficult, and true lateral radiographs may not be reliable in identifying this condition 1.
- Active finger motion exercises following diagnosis of distal radius fractures are recommended, as hand stiffness is a common and functionally disabling adverse effect 1.
Overall, the treatment of a distal radius fracture with volar and dorsal plating requires careful consideration of the patient's individual needs and circumstances, as well as adherence to established guidelines and recommendations to minimize morbidity, mortality, and improve quality of life.
From the Research
Step-by-Step Procedure for Fracture Distal End Radius by Volar and Dorsal Plating
The treatment of distal radius fractures using volar and dorsal plating involves several steps:
- Preoperative planning: This includes evaluating the fracture pattern, assessing the patient's overall health, and determining the appropriate surgical approach 2, 3.
- Surgical approach: The volar approach is commonly used for distal radius fractures, but the dorsal approach may be necessary for certain fracture patterns 2, 4.
- Reduction and fixation: The fracture is reduced, and a volar plate is applied to stabilize the fracture. In some cases, a dorsal plate may also be used to provide additional support 2, 4.
- Screw placement: Screws are placed through the plate to secure it to the bone. The use of dorsal tangential views can help avoid screw penetration and minimize the risk of complications 5.
- Wound closure: The wound is closed, and the patient is immobilized in a cast or splint to allow for healing 3.
Key Considerations
- Fracture pattern: The type of fracture pattern will influence the choice of surgical approach and fixation method 2, 4.
- Patient factors: The patient's overall health, age, and activity level will also influence the treatment plan 3.
- Surgeon experience: The surgeon's experience and preference will also play a role in determining the best course of treatment 2.
Potential Complications
- Screw penetration: The use of dorsal tangential views can help minimize the risk of screw penetration and associated complications 5.
- Tendon irritation: Dorsal plates can cause tendon irritation, and careful placement is necessary to avoid this complication 2.
- Malunion: The risk of malunion can be minimized with proper reduction and fixation techniques 3.