From the Guidelines
The surgical procedure for a distal radius fracture treated with dorsal plating involves several key steps, prioritizing restoration of radial length, inclination, and tilt, as well as realignment of articular fracture fragments to minimize long-term complications such as osteoarthritis 1.
Preoperative Considerations
- The patient is positioned supine with the affected arm on a radiolucent hand table under general or regional anesthesia.
- A thorough evaluation of the fracture pattern and patient anatomy is performed to determine the optimal approach.
Surgical Procedure
- A longitudinal dorsal incision is made, typically 8-10 cm in length, centered over the fracture site between the third and fourth extensor compartments.
- The extensor retinaculum is incised, and the extensor pollicis longus tendon is identified and retracted.
- Careful dissection is performed to expose the fracture site while protecting the surrounding soft tissues and neurovascular structures.
- The fracture is then reduced under direct visualization and confirmed with fluoroscopy.
- Temporary K-wires may be used to maintain the reduction.
- A dorsal plate is selected based on the fracture pattern and patient anatomy, typically a low-profile titanium plate, as recommended by recent guidelines 1.
Plate Fixation and Closure
- The plate is positioned on the dorsal surface of the radius and secured with screws, with distal screws engaging the subchondral bone without penetrating the joint surface.
- Screw placement is verified with fluoroscopy in multiple views.
- Once fixation is complete, the wound is irrigated, and a layered closure is performed, repairing the extensor retinaculum when possible.
- A sterile dressing and a volar splint are applied with the wrist in slight extension.
Postoperative Care
- Postoperatively, early finger motion is encouraged, with wrist motion typically beginning at 2 weeks, as supported by evidence from studies such as 1.
- Physical therapy starts at 4-6 weeks, with strengthening exercises at 8-12 weeks.
- Dorsal plating provides stable fixation for dorsally displaced fractures but carries risks of extensor tendon irritation or rupture, which is why low-profile plates are preferred and plate removal may be necessary after fracture healing in some cases.
- The use of a home exercise program and supervised therapy following the treatment of distal radius fractures is also recommended, although the evidence to support its use remains inconsistent 1.
From the Research
Step-by-Step Procedure for Fracture Distal Radius by Dorsal Plating
- Preparation: The patient is prepared for surgery, and the choice of anesthesia is determined. According to 2, the wide-awake local anesthesia no tourniquet (WALANT) approach can be used as an alternative anesthetic for plating of distal radius fractures.
- Approach: A dorsal approach is used to access the distal radius fracture. This approach allows for direct visualization of the fracture and placement of the dorsal plate.
- Reduction: The fracture is reduced, and the dorsal plate is used to stabilize the fracture. The plate is contoured to fit the dorsal surface of the distal radius.
- Fixation: The dorsal plate is fixed to the distal radius using screws. The screws are placed in a way that provides stable fixation of the fracture.
- Closure: The wound is closed, and the patient is taken to the recovery room.
Considerations for Dorsal Plating
- Fracture type: Dorsal plating is advantageous for specific fracture patterns, such as those with dorsal comminution or instability 3.
- Patient factors: The choice of dorsal plating should take into account patient factors, such as the presence of comorbidities or the need for early mobilization 4.
- Surgeon experience: The choice of dorsal plating should also depend on the surgeon's experience and familiarity with the technique.
Potential Complications
- Tendon irritation: Dorsal plates can cause tendon irritation, particularly if they are prominent or if the screws are placed too close to the tendons 5, 6.
- Hardware removal: Hardware removal may be necessary if there are complications or if the patient experiences discomfort or pain.
- Infection: As with any surgical procedure, there is a risk of infection with dorsal plating.
Outcomes
- Functional outcomes: Studies have shown that dorsal plating can provide good to excellent functional outcomes, with minimal impairment of extensor tendon function and full metacarpophalangeal joint motion 6.
- Radiographic outcomes: Radiographic evaluation has shown that dorsal plating can provide stable internal fixation and maintenance of fracture reduction 6.