From the Guidelines
The dorsal approach for plating a distal radius fracture begins with positioning the patient supine with the affected arm on a hand table and a tourniquet applied to the upper arm. After prepping and draping, make a longitudinal incision (approximately 8 cm) centered over the dorsal aspect of the distal radius, typically over Lister's tubercle. Identify and protect the extensor tendons, particularly the extensor pollicis longus (EPL), which should be retracted radially or ulnarly depending on fracture pattern. Create a longitudinal incision in the extensor retinaculum between the third and fourth compartments, and elevate the extensor tendons. Identify the posterior interosseous nerve and protect or consider neurectomy to reduce postoperative pain. Expose the fracture site by elevating the periosteum, and reduce the fracture under direct visualization and fluoroscopic guidance. Apply a dorsal plate (typically a low-profile anatomic plate) to the dorsal cortex, ensuring proper positioning to avoid tendon irritation. Secure the plate with appropriate screws, with distal screws engaging the subchondral bone without penetrating the articular surface. Confirm plate and screw position with fluoroscopy in multiple views. Perform a thorough irrigation, then close the retinaculum loosely to prevent tendon entrapment. Close the skin in layers and apply a well-padded splint with the wrist in slight extension. This approach is particularly useful for dorsally displaced fractures and those with dorsal comminution, though it carries risks of extensor tendon irritation and rupture if the plate is not properly positioned or if a low-profile plate is not used, as noted in the clinical practice guidelines for the management of distal radius fractures 1.
Key Steps:
- Positioning the patient and applying a tourniquet
- Making a longitudinal incision over the dorsal aspect of the distal radius
- Identifying and protecting the extensor tendons
- Creating a longitudinal incision in the extensor retinaculum
- Elevating the extensor tendons and identifying the posterior interosseous nerve
- Exposing the fracture site and reducing the fracture under direct visualization and fluoroscopic guidance
- Applying a dorsal plate and securing it with appropriate screws
- Confirming plate and screw position with fluoroscopy
- Closing the retinaculum and skin in layers and applying a well-padded splint
Important Considerations:
- Proper positioning of the plate to avoid tendon irritation
- Use of a low-profile anatomic plate
- Engagement of distal screws with the subchondral bone without penetrating the articular surface
- Protection of the posterior interosseous nerve to reduce postoperative pain
- Loose closure of the retinaculum to prevent tendon entrapment, as recommended by the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand 1.
From the Research
Procedure Overview
The procedure for plating via a dorsal approach for a fracture of the distal end of the radius involves several steps:
- Preparation of the patient, which may include the use of wide-awake local anesthesia with no tourniquet (WALANT) 2, 3, 4
- Making a dorsal incision to access the distal radius fracture
- Reduction of the fracture under direct visualization
- Placement of a dorsal plate to stabilize the fracture
- Fixation of the plate to the bone using screws
Step-by-Step Procedure
The step-by-step procedure for plating via a dorsal approach for a fracture of the distal end of the radius is as follows:
- Administer local anesthesia, such as lidocaine and epinephrine, to the surgical field if using WALANT 2, 3, 4
- Make a dorsal incision over the distal radius, taking care to avoid damaging surrounding tendons and nerves
- Dissect the soft tissues to expose the fracture site
- Reduce the fracture under direct visualization, using bone clamps and other instruments as needed
- Place a dorsal plate over the fracture site, ensuring proper alignment and positioning
- Fixate the plate to the bone using screws, making sure to avoid compromising the surrounding soft tissues
Considerations and Variations
The choice of plate fixation should depend on the fracture type, patient factors, and surgeon experience 5
- Dorsal plates are advantageous for specific fracture patterns, but may be prominent and cause tendon irritation
- The use of WALANT may offer a safe and reliable alternative to general anesthesia for plating of distal radius fractures, especially in patients with comorbidities 2, 3, 4
- The operating time may be slightly longer with WALANT compared to general anesthesia 4