Dorsal Plating Procedure for Distal Radius Fracture: Step-by-Step
Dorsal plating is a viable surgical approach for distal radius fractures requiring buttressing of comminuted fractures, particularly in cases with dorsal displacement, though volar locked plates lead to earlier recovery of function in the short term (3 months). 1
Preoperative Planning
- Obtain standard radiographs (3 views) to assess fracture pattern, displacement, angulation, rotation, and articular involvement
- Consider CT scan for complex fracture patterns to better visualize fracture morphology
- Evaluate patient factors: age, bone quality, functional demands, and comorbidities
Surgical Steps for Dorsal Plating
1. Patient Positioning and Anesthesia
- Position patient supine with arm on radiolucent hand table
- Apply tourniquet to upper arm
- Administer appropriate anesthesia (regional or general)
- Prep and drape the extremity in sterile fashion
2. Surgical Approach
- Make a longitudinal or transverse dorsal incision centered over the fracture site (typically 6-8 cm)
- Identify and protect the superficial sensory branches of the radial nerve
- Identify the extensor retinaculum and create a flap between the 3rd and 4th compartments (Lister's tubercle approach)
- Retract the extensor pollicis longus (EPL) tendon radially after releasing it from the third compartment
3. Fracture Exposure
- Elevate the extensor tendons with their periosteal sleeve
- Create subperiosteal flaps to expose the fracture site
- Identify and protect the posterior interosseous nerve
- Clean the fracture site of hematoma and debris
4. Fracture Reduction
- Reduce the fracture under direct visualization and fluoroscopic guidance
- Restore articular congruity, radial length, radial inclination, and volar tilt
- Use temporary K-wires to maintain reduction if necessary
- Confirm reduction with fluoroscopy
5. Plate Application
- Select an appropriate low-profile dorsal plate (preferable over traditional pi plates to reduce tendon complications) 2
- Contour the plate as needed to match the dorsal surface of the distal radius
- Position the plate on the dorsal surface ensuring proper alignment
- Secure the plate temporarily with K-wires
6. Screw Fixation
- Drill and place distal locking screws first to secure the distal fragment
- Ensure screws do not penetrate the articular surface (confirm with fluoroscopy)
- Place proximal screws in the shaft to secure the plate to the radius
- Verify screw length and position with fluoroscopy
7. Final Assessment
- Perform final fluoroscopic check to confirm:
- Restoration of radial length
- Restoration of radial inclination
- Restoration of volar tilt
- Articular congruity
- Proper hardware placement
8. Wound Closure
- Irrigate the wound thoroughly
- Repair the extensor retinaculum, creating a new compartment for the EPL tendon to prevent direct contact with the plate
- Close subcutaneous tissue with absorbable sutures
- Close skin with sutures or staples
- Apply sterile dressing and splint
Postoperative Management
- Immobilize in a splint for approximately 2 weeks
- Begin early finger motion to prevent stiffness
- Transition to removable splint at 2 weeks and begin gentle wrist motion exercises
- Radiographic follow-up at 2-3 weeks to evaluate fracture healing progression 3
- Average immobilization duration is 3-4 weeks 3
- Progressive range of motion exercises after immobilization period
- Full recovery typically expected within 6-8 weeks 3
Potential Complications and Prevention
- Extensor tendon irritation or rupture: Use low-profile plates and create separate compartment for EPL tendon 2
- Hardware prominence: Ensure proper plate contouring and positioning
- Screw penetration into joint: Use fluoroscopy to confirm screw length and position
- Inadequate reduction: Confirm reduction with fluoroscopy before final fixation
- Infection: Proper sterile technique and perioperative antibiotics
- Complex regional pain syndrome: Consider vitamin C supplementation 3
Special Considerations
- Consider multimodal and opioid-sparing pain management protocols 1
- For elderly patients (>65 years), non-operative treatment may be preferred as surgical fixation has not shown improved long-term outcomes 1
- For younger patients (<65 years) with post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement >2mm, surgical fixation is recommended 1
Dorsal plating provides excellent buttressing of dorsally displaced fractures but requires meticulous technique to avoid tendon complications. Low-profile plates have significantly reduced complication rates compared to older pi-plate designs 2.