What is the step-by-step procedure for open reduction and internal fixation (ORIF) using a plate for a 1-month-old fracture of the distal end of the radius?

Open Reduction and Internal Fixation with Volar Plating for 1-Month-Old Distal Radius Fracture

For a 1-month-old (delayed presentation) distal radius fracture requiring surgical intervention, proceed with open reduction and internal fixation using a volar locking plate via the modified Henry approach, as this provides superior radiological outcomes and allows for immediate active finger motion to prevent the most disabling complication of hand stiffness. 1, 2, 3

Preoperative Assessment

Patient Selection Criteria

• Confirm surgical indications are met: post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement/step-off >2mm in patients under 65 years of age 1
• Evaluate for malunion or early healing in this delayed (1-month-old) fracture, which may require osteotomy rather than simple reduction
• Assess finger stiffness and range of motion, as delayed presentation increases risk of this most functionally disabling complication 1

Imaging and Planning

• Obtain current AP, lateral, and oblique radiographs to assess fracture position and any early healing
• Do not routinely plan for arthroscopic assistance - moderate evidence shows no improvement in outcomes at 48 months when arthroscopy is added to volar plate fixation 1
• Evaluate for associated DRUJ injury on true lateral radiographs 1

Surgical Technique: Step-by-Step Procedure

1. Patient Positioning and Anesthesia

• Position patient supine with arm extended on hand table
• Regional anesthesia (axillary or supraclavicular block) or general anesthesia
• Apply tourniquet to upper arm (typically 250mmHg)

2. Surgical Approach (Modified Henry/Volar Approach)

• Make longitudinal incision along flexor carpi radialis (FCR) tendon, typically 6-8cm in length 2
• Identify and protect the palmar cutaneous branch of median nerve
• Retract FCR tendon ulnarly to expose flexor pollicis longus (FPL)
• Elevate pronator quadratus muscle from radial border in L-shaped fashion, preserving ulnar attachment for later repair
• Expose fracture site and distal radius volar surface

3. Fracture Reduction

• For 1-month-old fractures: May require osteotomy through fracture site if early healing has occurred
• Remove any fibrous tissue or early callus from fracture surfaces
• Use combination of manual traction, direct manipulation, and pointed reduction forceps
• Achieve anatomic reduction with particular attention to:
  • Restoring radial length
  • Correcting dorsal tilt to neutral or slight volar tilt
  • Reducing intra-articular step-off to <2mm 1
• Use fluoroscopic guidance only - arthroscopic assistance provides no additional benefit 1

4. Plate Application

• Select appropriate volar locking plate (typically 2.4mm system) 2, 3
• Position plate on volar surface of distal radius, ensuring:
  • Distal edge sits at watershed line (junction of volar and articular surfaces)
  • Plate does not extend beyond radial styloid laterally
  • Adequate proximal shaft coverage (minimum 3 cortices)
• Temporarily secure plate with K-wire or non-locking screw in oblong hole

5. Screw Fixation

• Distal screws first: Place 3-4 subchondral locking screws in distal fragment
  • Verify screw length under fluoroscopy - screws should be subchondral but not penetrate joint
  • Check AP, lateral, and oblique views to confirm no intra-articular penetration
• Proximal screws: Place 2-3 locking or cortical screws in radial shaft
• Final fluoroscopic confirmation in all planes

6. Closure and Wound Management

• Repair pronator quadratus over plate if possible (reduces tendon irritation) 2
• Close fascia and subcutaneous layers
• Skin closure with interrupted sutures
• Apply well-padded volar splint with wrist in neutral position

Postoperative Management

Immediate Postoperative Period (0-2 Weeks)

• Initiate active finger motion exercises immediately - this is critical to prevent hand stiffness, the most functionally disabling complication 1
• Maintain volar splint for comfort and protection
• Elevate hand above heart level for first 48-72 hours
• Remove sutures at 10-14 days

Early Mobilization Phase (2-6 Weeks)

• Transition to removable splint at 2 weeks 1
• Do NOT routinely begin early wrist motion - moderate evidence shows no benefit to early wrist mobilization after stable plate fixation 1
• Continue active finger motion exercises
• Obtain radiographs at 3 weeks to confirm maintained reduction 1

Progressive Rehabilitation (6 Weeks - 3 Months)

• Begin active wrist range of motion at 6 weeks once radiographic healing confirmed
• Home exercise program is sufficient - supervised therapy shows inconsistent benefit and may not improve outcomes compared to independent exercises 1
• Greatest functional gains occur between 2 weeks and 3 months postoperatively 4
• Supination and pronation return faster than flexion/extension (92% of uninjured side by 3 months) 4

Long-term Recovery (3-12 Months)

• Continue range of motion exercises - improvement continues until 12 months 4
• Grip strength returns to 94% of uninjured wrist by 12 months 4
• Radiographic follow-up at time of immobilization removal to confirm healing 1

Critical Pitfalls and Complications to Avoid

Technical Errors

• Avoid intra-articular screw penetration - check multiple fluoroscopic views intraoperatively
• Do not overdistract the fracture - this increases finger stiffness risk without improving outcomes 1
• Ensure plate positioned at watershed line to prevent flexor tendon irritation 2

Postoperative Complications

• Finger stiffness (most disabling): Prevented by immediate active finger motion exercises 1
• Tendon irritation/tenosynovitis: Occurs in approximately 9% requiring plate removal 3
• Reflex sympathetic dystrophy: Occurs in approximately 6% of cases 3
• Consider vitamin C supplementation for prevention of disproportionate pain (moderate evidence) 1

Management of Delayed Presentation

• Key consideration: At 1 month post-injury, fracture may have early healing requiring osteotomy rather than simple manipulation
• Higher risk of stiffness due to prolonged immobility before surgery - emphasize aggressive finger motion exercises 1
• May require more extensive soft tissue dissection if early callus present

Expected Outcomes

Radiological Results

• Volar plating provides superior maintenance of radial length, volar tilt, and ulnar variance compared to external fixation or conservative treatment 3, 5
• Anatomic reduction maintained in majority of cases with stable internal fixation 2, 3

Functional Recovery Timeline

• 3 months: Supination/pronation at 92% of uninjured side 4
• 6 months: Continued improvement in flexion (only motion showing significant improvement between 3-6 months) 4
• 12 months: Grip strength at 94% of uninjured side, with continued improvement in all motions 4
• Function and pain improve but may not return completely to normal by 12 months 4