Intraoperative traction with use of temporary intraoperative external
fixation or skeletal distraction is very helpful. We usually use external
fixation and then keep it in place for three to six weeks after the surgery to
provide additional support and to avoid the need for a tight circumferential
dressing (Fig. 2-A).
Such complex fractures usually require simultaneous dorsal and volar
exposure. The dorsal exposure provides direct access to the articular surface.
The volar exposure allows interdigitation of the stout volar cortex—the
strongest bone in the distal part of the radius and one of the few areas where
the surgeon is likely to be able to judge appropriate length and alignment and
to achieve bone-to-bone contact for additional
stability3.
Volar exposure is usually achieved with the approach described by
Henry4 in line with
the flexor carpi radialis, but a volarulnar exposure or an extended carpal
tunnel release5 can
be used when exposure to the volar lunate facet is more important than
exposure to the radial styloid. Many patients also have a carpal tunnel
syndrome, which is addressed with a volar-ulnar exposure but requires a second
incision in patients treated through a Henry exposure in order to avoid injury
to the palmar cutaneous branch of the median nerve
(Fig. 2-B).
Extending the skin incision across the transverse wrist flexion creases is
helpful when a more extensive exposure is needed. These flexion creases should
be crossed obliquely. The radial edge of the distal portion of the origin of
the flexor pollicis longus is elevated from the radius to increase exposure of
the pronator quadratus. The radial edge of the radius is exposed, and the
radial edge of the pronator quadratus is incised.
The pronator quadratus is then elevated subperiosteally. Leaving the
periosteum attached to the undersurface of the pronator may provide additional
stout tissue for repair as repair of muscle fibers alone is difficult and
often impossible. Release or z-lengthening of the brachioradialis can reduce
the radial deviation stress on the fragments
(Fig. 2-C).
All fragments of the volar metaphyseal cortex are saved and used as puzzle
pieces to judge restoration of length and alignment. They are wedged into
place and provisionally fixed with smooth Kirschner wires if necessary
(Fig. 2-D).
CRITICAL CONCEPTSINDICATIONS:The indication for combined dorsal and volar plate fixation is a fracture
of the distal part of the radius with complex comminution of the articular
surface and metaphysis for which a single dorsal or volar plate would not be
sufficient. Fortunately, these are very uncommon fractures.CONTRAINDICATIONS:There are no absolute contraindications to combined dorsal and volar plate
fixation of the distal part of the radius; however, the surgeon may need to
strongly consider alternatives such as a bridging plate or primary wrist
arthrodesis, depending on the complexity of the fracture. In general, we
usually attempt fixation initially, given that even a small amount of wrist
motion will enhance the function of the upper limb, and we reserve arthrodesis
as a salvage procedure. Open fractures are associated with a greater risk of
infection when there are devitalized central articular fragments, but an
attempt to salvage even devitalized joint fragments with débridement,
fixation, and parenteral antibiotics is reasonable.PITFALLS:The major pitfall in the treatment of this injury is underestimation of its
complexity. The surgeon should be prepared to find cortical bone in the joint,
joint fragments impacted deep into the metaphysis, and pieces of metaphyseal
bone distributed throughout the area as if the distal part of the radius had
exploded. If a physician is not prepared to deal with this degree of
complexity, the patient should be referred to a surgeon who has greater
experience with the injury. If the complexity is discovered in the operating
room, an external fixator should be applied for comfort and stability, the
surgeon should consider releasing the carpal tunnel, and the patient should be
referred for definitive treatment.AUTHOR UPDATE:Combined dorsal and volar plate fixation has evolved to some degree to
so-called fragment-specific
fixation6, but the
only substantive difference is the use of a separate plate for the radial
styloid. Given the relative infrequency of fractures that are sufficiently
complex to require this treatment method, we have limited experience with the
procedure beyond the data presented in our paper. Our recent results are
similar to those in the original paper: combined dorsal and volar plate
fixation does not appear to result in devascularization of the bone fragments,
major complications are uncommon, and patients gain more motion than one might
expect, given the complexity of the fracture and the limitations of surgical
reconstruction (Figs. 3-A,
3-B,
4-A,
4-B,
4-C,
4-D,
4-E,
4-F).
CRITICAL CONCEPTS
INDICATIONS:
The indication for combined dorsal and volar plate fixation is a fracture
of the distal part of the radius with complex comminution of the articular
surface and metaphysis for which a single dorsal or volar plate would not be
sufficient. Fortunately, these are very uncommon fractures.
CONTRAINDICATIONS:
There are no absolute contraindications to combined dorsal and volar plate
fixation of the distal part of the radius; however, the surgeon may need to
strongly consider alternatives such as a bridging plate or primary wrist
arthrodesis, depending on the complexity of the fracture. In general, we
usually attempt fixation initially, given that even a small amount of wrist
motion will enhance the function of the upper limb, and we reserve arthrodesis
as a salvage procedure. Open fractures are associated with a greater risk of
infection when there are devitalized central articular fragments, but an
attempt to salvage even devitalized joint fragments with débridement,
fixation, and parenteral antibiotics is reasonable.
PITFALLS:
The major pitfall in the treatment of this injury is underestimation of its
complexity. The surgeon should be prepared to find cortical bone in the joint,
joint fragments impacted deep into the metaphysis, and pieces of metaphyseal
bone distributed throughout the area as if the distal part of the radius had
exploded. If a physician is not prepared to deal with this degree of
complexity, the patient should be referred to a surgeon who has greater
experience with the injury. If the complexity is discovered in the operating
room, an external fixator should be applied for comfort and stability, the
surgeon should consider releasing the carpal tunnel, and the patient should be
referred for definitive treatment.
AUTHOR UPDATE:
Combined dorsal and volar plate fixation has evolved to some degree to
so-called fragment-specific
fixation6, but the
only substantive difference is the use of a separate plate for the radial
styloid. Given the relative infrequency of fractures that are sufficiently
complex to require this treatment method, we have limited experience with the
procedure beyond the data presented in our paper. Our recent results are
similar to those in the original paper: combined dorsal and volar plate
fixation does not appear to result in devascularization of the bone fragments,
major complications are uncommon, and patients gain more motion than one might
expect, given the complexity of the fracture and the limitations of surgical
reconstruction (Figs. 3-A,
3-B,
4-A,
4-B,
4-C,
4-D,
4-E,
4-F).
Dorsally, a longitudinal incision is centered over the Lister tubercle, or
in line with the third metacarpal and radial shaft given that the Lister
tubercle is deformed or cannot be palpated in the majority of these complex
fractures. The incision extends distal to the radiocarpal joint to allow for a
generous capsulotomy to provide good visualization of the joint
(Fig. 2-E). Broad skin flaps
are developed to protect the radial sensory and dorsal ulnar cutaneous nerve
branches while allowing broad access to the dorsal aspect of the radius
(Fig. 2-F).
The extensor pollicis longus is identified and mobilized
(Fig. 2-G). It is transposed
dorsally and radially into the subcutaneous tissues and left there at the end
of the operation. The radial wrist extensors are retracted radially. An
attempt should be made to keep the fourth dorsal compartment intact by
elevating it subperiosteally in the ulnar direction
(Fig. 2-H).
The wrist capsule can be divided in a myriad of ways, but in most cases it
makes sense to incise it longitudinally, leaving it attached to the dorsal
fracture fragments. The fragments and capsule can then be retracted to expose
the joint (Fig. 2-I). Exposure
of the joint is more difficult through the volar wound, primarily because a
volar capsulotomy is not advisable. The volar capsule is stouter and
structurally more important than the dorsal capsule. Some joint exposure can
be obtained volarly by mobilizing the fracture fragments or by mobilizing the
radial shaft and rotating it out of the way, but this is not necessary when a
combined dorsal and volar exposure is used.
Joint exposure allows identification and treatment of a scapholunate
ligament injury when one is present (Fig.
2-J), allows the surgeon to be sure that the volar articular
fragments are properly rotated (Fig.
2-K), and permits identification and realignment of impacted
central articular fragments (Fig.
2-L).
It is sometimes useful to place the distal screws first so that bringing
the plate down to the bone proximally will improve alignment of the volar
fragments (Figs. 2-M and
2-N). Screws that lock to the
plate (angular stable screws) are very useful for complex injuries,
particularly when there is poor-quality bone.
A large radial styloid fragment can be repaired with a plate applied to the
dorsal-radial surface of the distal part of the radius between the first and
second dorsal compartments (Fig.
2-O). With the volar and radial fragments realigned and
stabilized, the extent of the central dorsal and metaphyseal comminution is
apparent (Fig. 2-P). While
angular stable screws provide a great deal of support to the articular
surface, the surgeon should also be prepared to apply an autogenous bone graft
or a bone-graft substitute to support the articular surface, particularly the
central fragments. In young patients, it is sometimes possible to fill the
defect with all of the loose and displaced bone fragments collected during the
operation (Fig. 2-Q).
Carpal injuries are repaired prior to repair of the dorsal fragments
(Fig. 2-R). The dorsal-ulnar
fragments are then replaced along with the dorsal capsule, are stabilized with
provisional smooth Kirschner wires, and then are fixed with a plate and screws
(Fig. 2-S). This completes a
cage, or matrix, of angular stable screws that support the articular
fragments. The dorsal capsule is not repaired. The wounds are closed
(Fig. 2-T), and a bulky,
nonconstrictive dressing is applied.
Active and active-assisted finger and forearm exercises are initiated
immediately after the surgery. Patients treated without external fixation wear
a volar thermoplastic wrist splint for three to six weeks. Functional use of
the limb for light daily tasks is encouraged. Use of external fixation and
wrist splints is discontinued between three and six weeks after the surgery,
and wrist motion exercises are begun. Resistive exercises are not allowed
until radiographic signs of healing have been established.