From the Guidelines
The dorsal plating approach for distal radius fractures is a viable treatment option, particularly for fractures with dorsal comminution or significant dorsal displacement, and involves a step-by-step procedure to restore radial length, inclination, and volar tilt. The procedure begins with positioning the patient supine with the affected arm on a hand table under general or regional anesthesia, as described in the treatment of distal radius fractures 1.
Preoperative Preparation
After standard surgical preparation, a longitudinal incision is made on the dorsal aspect of the wrist, typically centered over the Lister's tubercle. The extensor retinaculum is incised, and the extensor pollicis longus tendon is identified and retracted. The third and fourth extensor compartments are elevated to expose the dorsal radius. Careful dissection is performed to protect the sensory branches of the radial nerve, which is crucial to avoid complications.
Reduction and Fixation
The fracture is then identified and reduced under direct visualization and fluoroscopic guidance. Provisional K-wires may be used to maintain the reduction. A dorsal plate is selected based on fracture pattern and patient anatomy, then positioned on the dorsal surface of the radius. The plate is secured with screws proximally in the radial shaft and distally in the distal fragment, ensuring proper alignment and restoration of radial length, inclination, and volar tilt, as recommended for successful treatment of distal radius fractures 1.
Postoperative Care
After confirming proper placement with fluoroscopy, the wound is irrigated, the extensor retinaculum is repaired, and the skin is closed in layers. A sterile dressing and splint are applied. Dorsal plating is particularly useful for dorsally displaced fractures with dorsal comminution, though volar plating has become more common due to fewer tendon complications. Postoperatively, early finger motion is encouraged, with wrist rehabilitation beginning after initial healing, typically at 2 weeks. The goal of treatment is to achieve <2 mm of residual articular surface step-off to avoid long-term complications, such as osteoarthritis 1.
Key Considerations
Key considerations for the dorsal plating approach include:
- Restoration of radial length, inclination, and volar tilt
- Realignment of the articular fracture fragments
- Protection of the sensory branches of the radial nerve
- Selection of the appropriate dorsal plate based on fracture pattern and patient anatomy
- Postoperative rehabilitation to promote early finger motion and wrist healing. According to the acr appropriateness criteria for acute hand and wrist trauma, conventional radiographs provide sufficient diagnostic information to guide the treating physician, but delayed diagnosis is common, especially for distal radius and scaphoid fractures 1.
From the Research
Step-by-Step Procedure for Fracture Distal End Radius by Plating Dorsal Approach
- The dorsal plating approach for treating fractures of the distal end of the radius involves several key steps, as outlined in various studies 2, 3, 4, 5, 6.
- Preoperative Planning: The choice of plate fixation should depend on fracture type, patient factors, and surgeon experience 2.
- Surgical Approach: The dorsal approach can be used to visualize the articular surface and provide direct fracture reduction and buttressing 3.
- Plate Fixation: Dorsal plates can be used for specific fracture patterns, but may be prominent and can cause tendon irritation 2, 4.
- Surgical Technique: The surgical technique is guided by the fracture pattern, and palmar plating is most commonly performed 5.
- Postoperative Care: A functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing, and short-term splinting can provide pain relief 5.
- Complications: The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal 5.
Key Considerations
- The dorsal plating approach may not be recommended for complex intra-articular fractures of the distal radius due to higher complication rates and longer surgical times 4.
- The choice of surgical approach and plate fixation should be individualized based on the patient's specific fracture pattern and needs 2, 3, 5.
- Patients should be encouraged to mobilize as soon as it is safe to do so to prevent stiffness, and median nerve compression is the most common complication followed by tendon rupture, arthrosis, and malunion 6.