What is the operative procedure for a left distal end radius fracture treated with open reduction internal fixation using a distal end radius variable angle plate?

Operative Procedure for Left Distal End Radius Fracture with ORIF Using Variable Angle Plate

The standard operative procedure for a left distal end radius fracture involves open reduction and internal fixation using a volar approach with a variable angle distal radius plate, with four distal locking screws and three proximal screws (two locking, one cortical). This approach provides optimal stability for fracture healing while allowing early mobilization.

Preoperative Planning

• Obtain standard radiographs in multiple views to assess fracture pattern
• CT scan may be considered for complex intra-articular fractures to better visualize fracture morphology
• Evaluate for post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement/step-off >2mm, which are indications for surgical fixation 1

Anesthesia

• Either general anesthesia or regional block (axillary or supraclavicular) with sedation
• Regional anesthesia provides good postoperative pain control, though studies show no significant difference in long-term pain outcomes between anesthesia types 2

Surgical Approach

1. Patient Positioning:

   • Supine position with arm extended on hand table
   • Tourniquet applied to upper arm
   • Prep and drape in standard sterile fashion

2. Incision and Exposure:

   • Longitudinal incision (8-10cm) over volar aspect of wrist, typically along the flexor carpi radialis (FCR) tendon
   • Incise skin and subcutaneous tissue
   • Identify and protect the palmar cutaneous branch of the median nerve
   • Retract FCR tendon radially, open the sheath
   • Develop the interval between FCR and flexor pollicis longus
   • Identify and retract the radial artery laterally
   • Incise the pronator quadratus at its radial border, creating an L-shaped flap

3. Fracture Reduction:

   • Expose the fracture site
   • Remove hematoma and debris
   • Perform anatomic reduction of articular fragments under direct visualization
   • Use fluoroscopic guidance to confirm reduction
   • Consider using a dorsal compression technique with a Weber clamp for reduction, which distributes compression forces broadly and minimizes risk of penetrating skin or fracturing bone 3

4. Plate Application:

   • Apply the variable angle distal radius plate to the volar surface
   • Position the plate just proximal to the watershed line
   • Temporarily secure with K-wires if needed
   • Confirm plate position with fluoroscopy

5. Screw Fixation:

   • Place four distal locking screws into the distal fragment
   • Ensure screws do not penetrate the dorsal cortex or enter the joint
   • Place two locking screws and one cortical screw in the proximal fragment
   • Verify screw placement with fluoroscopy in multiple views

6. Closure:

   • Repair the pronator quadratus over the plate when possible
   • Close the wound in layers
   • Apply sterile dressing and splint

Postoperative Management

1. Immobilization:

   • Short-arm splint for 1-2 weeks
   • Transition to removable splint after initial healing

2. Rehabilitation:

   • Begin active finger motion exercises immediately to prevent stiffness
   • Start progressive wrist range of motion exercises after splint removal
   • Home exercise program is appropriate for most patients, as supervised therapy has not consistently shown superior outcomes 1

3. Pain Management:

   • Multimodal approach including NSAIDs, acetaminophen, and limited opioids
   • Consider vitamin C supplementation (500mg daily for 50 days) to prevent complex regional pain syndrome 1
   • Ice application during the first 3-5 days for symptomatic relief 4

4. Follow-up:

   • First follow-up at 1-2 weeks for wound check and splint removal
   • Radiographic evaluation at 6 weeks to assess healing
   • Final follow-up at 3 months to evaluate function

Expected Outcomes

• Range of motion typically reaches 80-85% of the contralateral side by 3 months
• Grip strength averages 81% of the opposite wrist 5
• Most fractures heal by 3 months post-surgery 5
• DASH scores average around 8 points at final follow-up, indicating good functional outcomes 5

Potential Complications

• Hardware-related issues (tendon irritation, screw penetration into joint)
• Loss of reduction (occurs in <5% of cases) 5
• Infection (<1%)
• Nerve injury (median nerve or superficial radial sensory branches)
• Complex regional pain syndrome
• Stiffness

Key Technical Pearls

• Ensure proper plate positioning just proximal to the watershed line to avoid flexor tendon irritation
• Verify that distal screws do not penetrate the dorsal cortex or enter the radiocarpal joint
• Confirm reduction of both the articular surface and overall alignment
• Arthroscopic assistance is not necessary for most distal radius fractures, as evidence does not support its routine use 1