What is the step-by-step operative procedure for a distal radius fracture treated with open reduction and internal fixation (ORIF) using plating?

From the Guidelines

The operative procedure for distal radius fracture fixation with plating begins with patient positioning in the supine position with the affected arm on a radiolucent hand table under general or regional anesthesia. This approach is crucial for successful treatment of distal radius fractures, which requires restoration of radial length, inclination, and tilt, as well as the realignment of the articular fracture fragments 1. The goal of operative fixation is to achieve <2 mm of residual articular surface step-off to avoid long-term complications, such as osteoarthritis 1.

Key Steps in the Operative Procedure

• Patient positioning and preparation: The patient is positioned in the supine position with the affected arm on a radiolucent hand table under general or regional anesthesia.
• Approach: The most common approach is the volar (Henry) approach, where a 10-12 cm longitudinal incision is made along the flexor carpi radialis tendon.
• Exposure: The incision is deepened through the fascia, and the flexor carpi radialis tendon is retracted ulnarly to expose the pronator quadratus.
• Fracture reduction: The fracture site is identified and debrided of hematoma and debris, and reduction of the fracture is performed under direct visualization and confirmed with fluoroscopy.
• Plate fixation: A pre-contoured volar locking plate is then positioned on the volar surface of the distal radius, ensuring it is placed proximal to the watershed line to avoid flexor tendon irritation.

Important Considerations

• The presence of a coronally oriented fracture line, die-punch depression, or more than three articular fracture fragments are common indications for operative reduction 1.
• The use of internal fixation has a much higher cost than nonoperative treatment as well as increased rates of hospitalization 1.
• Successful treatment of distal radius fractures requires careful attention to detail and a thorough understanding of the anatomy and fracture patterns 1.

Postoperative Care

• Early finger motion is encouraged, with wrist motion typically beginning at 2 weeks depending on fracture stability and surgeon preference.
• A sterile dressing and a volar splint in slight wrist extension are applied to support the wrist and promote healing.

From the Research

Step-by-Step Operative Procedure for Distal Radius Fracture Treated with ORIF using Plating

• The procedure for open reduction and internal fixation (ORIF) of distal radius fractures using plating involves several key steps, although the exact steps may vary depending on the specific fracture and patient factors 2.
• The choice of plate fixation should depend on fracture type, patient factors, and surgeon experience 2.
• Volar plating is a commonly used approach for many fractures, but dorsal plates and bridge plates may be advantageous for specific fracture patterns 2.
• The use of wide-awake local anesthesia with no tourniquet (WALANT) has been shown to be a safe and effective alternative to traditional anesthetic techniques for ORIF of distal radius fractures 3, 4, 5.
• The WALANT technique involves injecting local anesthetic into the surgical field, allowing the patient to remain awake and alert during the procedure 3, 4, 5.
• The surgical procedure typically involves making an incision, reducing the fracture, and fixing it with an anatomic locking plate 5.
• The use of WALANT has been shown to have similar outcomes to general anesthesia, with the added benefits of reduced risk and faster recovery time 4.

Key Considerations

• The type of plate used should be chosen based on the specific fracture pattern and patient factors 2.
• The use of WALANT requires careful attention to patient selection and anesthesia administration 3, 4, 5.
• The surgical procedure should be performed by an experienced surgeon with expertise in hand surgery and ORIF of distal radius fractures 6, 2.