What is the step-by-step procedure for a fracture of the distal radius treated with dorsal plating?

Step-by-Step Procedure for Distal Radius Fracture Fixation with Dorsal Plating

Dorsal plating for distal radius fractures is a viable surgical option that provides stable fixation for comminuted fractures, though it carries specific risks of tendon complications that must be carefully managed during the procedure.

Preoperative Planning

• Obtain appropriate imaging (radiographs, possibly CT scan) to assess fracture pattern
• Evaluate for:
  • Radial shortening (>3mm)
  • Dorsal tilt (>10°)
  • Intra-articular displacement
  • DRUJ (distal radioulnar joint) alignment 1
• Consider patient factors (age, bone quality, functional demands)

Anesthesia Options

• Traditional: General or regional anesthesia with tourniquet
• Alternative: WALANT (Wide-Awake Local Anesthesia No Tourniquet) technique may be considered for patients with medical comorbidities who cannot tolerate general anesthesia 2

Surgical Approach

1. Patient Positioning

   • Supine position with arm on radiolucent hand table
   • Shoulder abducted to 90°, elbow flexed to 90°

2. Skin Incision

   • Longitudinal incision (approximately 8-10cm) over the dorsal aspect of the wrist
   • Center the incision over Lister's tubercle

3. Exposure of Extensor Compartments

   • Identify the extensor retinaculum
   • Carefully elevate the 3rd extensor compartment (EPL tendon)
   • Retract the EPL tendon radially or ulnarly
   • Protect the extensor tendons throughout the procedure to prevent irritation or rupture 3

4. Fracture Exposure

   • Elevate the extensor pollicis longus (EPL) tendon and retract it
   • Incise and elevate the periosteum to expose the fracture site
   • Clear fracture hematoma and debris

5. Fracture Reduction

   • Perform anatomic reduction of the articular surface
   • Use K-wires for provisional fixation
   • Verify reduction with fluoroscopy
   • Ensure restoration of:
     • Radial inclination (>15°)
     • Palmar tilt (between 15° dorsal and 20° volar)
     • Radial height
     • Articular congruity (step-off <2mm) 4

6. Plate Application

   • Select appropriate dorsal plate (typically 2.4mm or 3.5mm)
   • Position the plate on the dorsal surface of the radius
   • Ensure proper plate positioning to avoid tendon irritation
   • Apply the plate to buttress the dorsal fragments

7. Screw Fixation

   • Drill and place proximal shaft screws first
   • Then place distal subchondral screws
   • Verify screw length with fluoroscopy to avoid intra-articular penetration
   • Ensure screws do not penetrate the volar cortex excessively 3

8. Intraoperative Assessment

   • Confirm adequate reduction and fixation with fluoroscopy
   • Check wrist range of motion
   • If intra-articular fracture, consider arthroscopic evaluation to assess:
     • Articular reduction
     • SLIL (scapholunate interosseous ligament) injuries
     • TFCC (triangular fibrocartilage complex) tears 1

9. Wound Closure

   • Repair the extensor retinaculum but avoid direct closure over the plate
   • Consider creating a retinacular flap to protect the extensor tendons from the plate
   • Close subcutaneous tissue and skin in layers

Postoperative Management

1. Immobilization

   • Apply a well-padded splint in slight wrist extension
   • Early finger range of motion exercises should begin immediately 1

2. Follow-up Care

   • Remove splint at 1-2 weeks for wound check
   • Apply removable splint or cast for additional 2-3 weeks
   • Begin wrist motion exercises after adequate healing (typically 3-4 weeks)
   • Patients do not need to begin early wrist motion routinely following stable fracture fixation 1

3. Rehabilitation

   • Progressive wrist range of motion exercises
   • Strengthening exercises after fracture healing (6-8 weeks)
   • Consider vitamin C supplementation to prevent complex regional pain syndrome 1

Potential Complications

• Tendon Complications (most common with dorsal plating - 57% of all complications)
  • Extensor tendon irritation or tenosynovitis
  • Extensor pollicis longus rupture
  • Flexor tendon irritation 3
• Carpal tunnel syndrome
• Complex regional pain syndrome
• Hardware loosening
• Delayed union
• Intra-articular screw penetration 3

Special Considerations

• For highly comminuted fractures in elderly patients with osteoporotic bone, consider alternative techniques such as internal distraction plating 5
• Plate removal may be necessary if tendon irritation develops
• Dorsal plating has higher rates of tendon complications compared to volar plating approaches

By following this systematic approach and being mindful of potential complications, successful outcomes can be achieved with dorsal plating for distal radius fractures.