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

Step-by-Step Procedure for Distal End Radius Fracture Plating

Volar locked plating is the recommended surgical approach for distal radius fractures due to earlier recovery of function in the short term, though multiple fixation techniques can achieve similar long-term outcomes. 1

Preoperative Assessment and Planning

1. Radiographic Evaluation:

   • Obtain standard posteroanterior and lateral radiographs
   • Assess for specific surgical indications:
     • Radial shortening >3 mm
     • Dorsal tilt >10°
     • Intra-articular displacement
     • DRUJ instability
     • Large displaced base fractures involving >50% of the styloid 2

2. Anesthesia Options:

   • General or regional anesthesia is standard
   • Consider wide-awake local anesthesia no tourniquet (WALANT) for patients with medical comorbidities who may not tolerate general anesthesia 3

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position patient supine with arm extended on hand table
• Apply tourniquet to upper arm (unless using WALANT technique)
• Prepare and drape the extremity in sterile fashion
• If using WALANT technique, inject local anesthetic (lidocaine with epinephrine) into the surgical field 3

Step 2: Surgical Approach

• For volar plating (most common approach):

  • Make a longitudinal or transverse incision over the volar aspect of the distal radius (typically along the course of the flexor carpi radialis tendon)
  • Develop the interval between the flexor carpi radialis and radial artery
  • Retract the flexor tendons ulnarly
  • Identify and protect the median nerve
  • Elevate the pronator quadratus from its radial attachment

• For dorsal plating (specific fracture patterns):

  • Make a longitudinal incision over the dorsal aspect of the wrist
  • Identify and protect the extensor tendons
  • Create intervals between the extensor compartments to access the fracture 4

Step 3: Fracture Reduction

• Manually reduce the fracture under direct visualization
• Use provisional K-wires to maintain reduction if needed
• Confirm reduction with fluoroscopy
• For complex intra-articular fractures, consider arthroscopic assistance for direct visualization of the articular surface

Step 4: Plate Application

• Select appropriate plate (typically a volar locking plate)
• Position the plate on the reduced fracture
• Secure the plate to the shaft with a screw
• Confirm plate position with fluoroscopy
• Insert remaining screws into the distal fragment, ensuring they do not penetrate the dorsal cortex or enter the joint
• For volar plates, ensure screws do not extend beyond the dorsal cortex to prevent extensor tendon irritation
• For dorsal plates, use low-profile systems to minimize extensor tendon complications 5

Step 5: Final Assessment

• Obtain final fluoroscopic images in multiple planes to confirm:
  • Adequate reduction
  • Proper plate and screw positioning
  • No intra-articular screw penetration
  • Restoration of radial height, inclination, and volar tilt
• Test wrist range of motion to ensure stability of fixation

Step 6: Wound Closure

• For volar approach, repair the pronator quadratus if possible
• Close the deep fascia, subcutaneous tissue, and skin in layers
• Apply sterile dressing and splint

Postoperative Management

1. Immediate Postoperative Care:

   • Elevate the extremity
   • Apply ice for the first 3-5 days to reduce swelling 2
   • Consider multimodal and opioid-sparing pain management protocols 1

2. Immobilization and Rehabilitation:

   • Short-term immobilization (1-2 weeks) in a splint
   • Begin active finger motion exercises immediately to prevent stiffness 2
   • Progress to wrist range of motion exercises after splint removal
   • Initiate strengthening exercises as healing progresses

3. Follow-up:

   • Radiographic follow-up at 1-2 weeks, 6 weeks, and 3 months
   • Note: Evidence suggests that reducing the frequency of radiographic follow-up does not impact outcomes 1
   • Evaluate for any signs of complications at each visit

Potential Complications

• Hardware-related complications (screw penetration into joint, plate prominence)
• Extensor or flexor tendon irritation or rupture
• Median nerve injury or compression
• Malunion or delayed union
• Complex regional pain syndrome
• Stiffness and reduced range of motion

Key Considerations

• Volar locked plating leads to earlier functional recovery compared to other fixation methods, though long-term outcomes are similar across techniques 1
• Low-profile dorsal plating systems can be used for specific fracture patterns while minimizing extensor tendon complications 5
• For elderly patients with comorbidities, consider WALANT technique as an alternative to general anesthesia 3
• Begin active finger motion immediately after surgery to prevent stiffness 2