What is the step by step procedure for treating a fracture of the distal end of the radius with open reduction and internal fixation (ORIF) using plating?

From the Guidelines

The treatment of a distal radius fracture with open reduction and internal fixation (ORIF) using plating involves several key steps, with the most recent and highest quality study 1 supporting the use of a volar locking plate and early mobilization to improve functional outcomes. The procedure begins with the patient receiving appropriate anesthesia, typically regional or general. After sterile preparation and draping, a volar or dorsal approach is selected based on fracture pattern, with the volar Henry approach being most common, as noted in the study by 1.

Key Steps in the Procedure

• An incision is made along the distal forearm, and careful dissection is performed to protect the flexor tendons and median nerve.
• The fracture site is exposed, and hematoma is evacuated.
• The fracture fragments are then anatomically reduced using direct visualization and fluoroscopic guidance, with temporary K-wires used to hold the reduction if necessary.
• A pre-contoured volar locking plate is selected and positioned on the volar surface of the radius, as recommended by 1.
• The plate is secured with screws, including locking screws in the distal fragment and cortical screws proximally, taking care to ensure screws do not penetrate the dorsal cortex or enter the joint.

Postoperative Care

• Fluoroscopy confirms proper plate and screw placement, anatomic reduction, and restoration of radial length, inclination, and volar tilt.
• The wound is irrigated, and layered closure is performed.
• A sterile dressing and splint are applied.
• Postoperatively, early finger motion is encouraged, with wrist motion typically beginning at 2 weeks, and physical therapy starts after splint removal, with strengthening exercises added at 6-8 weeks, as supported by the study 1. The goal of this procedure is to provide stable fixation, allowing early mobilization, which helps prevent stiffness and improves functional outcomes compared to cast immobilization alone, with the most recent study 1 providing strong evidence for this approach.

From the Research

Step-by-Step Procedure for Fracture Distal End Radius by Plating

The treatment of a fracture of the distal end of the radius with open reduction and internal fixation (ORIF) using plating involves several steps:

• Preoperative preparation: The patient is prepared for surgery, and antibiotics are administered to prevent infection 2.
• Anesthesia: The patient is given anesthesia to ensure comfort during the procedure.
• Incision: An incision is made in the skin to access the fracture site, typically through a volar approach 3.
• Exposure: The soft tissues are carefully exposed to visualize the fracture site.
• Reduction: The fracture is reduced, and the bone fragments are aligned properly.
• Plate fixation: A volar plate is applied to the fracture site to stabilize the bone fragments 3.
• Screw fixation: Screws are inserted into the plate to secure it to the bone, with careful measurement of screw length to minimize postoperative tendon irritation 3.
• Closure: The soft tissues are closed, and the skin is sutured.

Postoperative Care

• The patient is monitored for complications, such as infection or nerve damage.
• Pain management: The patient is given pain medication to manage postoperative pain.
• Rehabilitation: The patient is encouraged to mobilize the wrist as soon as possible to prevent stiffness, with early postoperative rehabilitation emphasized 3.
• Follow-up: The patient is followed up regularly to assess the healing of the fracture and the functional outcome.

Considerations

• The choice of treatment depends on the severity of the fracture, the patient's age, and comorbidities 4.
• The use of dorsal plates has been associated with a higher complication rate compared to external fixators 5.
• Delayed ORIF may be considered for type I open distal radius fractures, provided that the wound is clean and antibiotics are initiated appropriately 2.
• Open reduction and internal fixation with plates and screws is a safe and effective treatment alternative for patients over 60 years with displaced and comminuted fractures of the distal radius 6.