Distal Radius Open Reduction and Internal Fixation

Abstract

Fractures of the distal radius are common injuries, with an annual incidence of 27 per 10,000 per year. As many as two-thirds of these fractures are displaced, necessitating reduction to restore wrist function and avoid neurovascular compromise. When adequate reduction cannot be achieved by closed reduction alone, closed reduction and percutaneous pinning versus open reduction and internal fixation are considered. Here we present the case of a middle-aged female presenting with a dorsally displaced and angulated fracture of the distal radius after a fall on the outstretched hand. The fracture was treated by open reduction and internal fixation with a volar locking plate. We outline the natural history, preoperative care, intraoperative technique, and postoperative considerations of distal radial fractures. 

Case Overview

Background

Fractures of the distal radius represent 17% of all orthopedic complaints seen in the emergency department.¹ As two-thirds of these fractures are displaced on presentation, reduction of the fracture will be necessary in the majority of cases.² 

Surgical options for treating fractures in which satisfactory alignment cannot be achieved by closed manipulation include closed reduction and percutaneous pinning, closed reduction and external fixation, as well as open reduction and internal fixation (ORIF). In comparing these two methods, ORIF has been shown to carry a decreased risk of infection, complications, and malunion vs. external fixation, though ORIF may carry an increased risk of tendon rupture.^3, 4, 5 

Focused History of the Patient

Obtain a history including mechanism of trauma, timeline and progression of the present injury, and any previous injury to the affected area. 

• Was it a low- or high-energy injury?
• Is it an isolated injury or not?
• Is the patient an independent ambulator or one who requires assistive devices?
• Is the patient experiencing signs of neuropathy (pain, tingling, loss of sensation, etc.)?
  

Physical Exam

• Inspection: Assess for deformity, swelling, ecchymosis, bleeding, and open wounds.
• Palpation: Assess for pain, crepitans, and range of motion.
• Neuro: Perform a targeted neurological exam focusing on the median nerve, including sensation to the radial three and a half digits and thenar strength by way of thumb abduction strength.
• Vascular: Assess radial and ulnar pulses at the wrist, and assess capillary refill to screen for vascular compromise.
  

Imaging

Standard assessment of suspected fractures of the distal radius includes at least two radiographs: a posteroanterior (PA) view and a lateral view.⁶ A CT is also reasonable for preoperative planning purposes to determine greater fracture characterization. 

Natural History

The natural history of distal radius fracture depends on the degree of displacement. Potential complications of displaced distal radius fracture include malunion, stiffness, weakness, tendon rupture (most commonly of the flexor pollicis longus), carpal tunnel syndrome or median neuropathy, complex regional pain syndrome, compartment syndrome, and post-traumatic arthritis.⁷ However, fractures of the distal radius that go on to heal within acceptable alignment, either with operative or non-operative treatment, can be expected to have a full recovery.

Options for Treatment

Non-displaced or minimally-displaced fractures can readily be treated non-surgically with cast or brace treatment. Displaced or unstable fractures are often treated operatively with either closed reduction and percutaneous fixation, external fixation, and ORIF. 

Rationale for Treatment

The primary goal of ORIF for distal radius fractures is the restoration of anatomical position and function of the wrist. Internal fixation of displaced or non-reducible fracture decreases the likelihood of long-term fracture complications including post-traumatic osteoarthritis, diminished range of motion, malunion, and persistent functional impairment.⁸ Moreover, the distal radius acts as a fulcrum for extensor tendon function so dorsally angulated fractures as seen in this case can decrease tendon mechanical advantage and lead to long-term tendinopathy and hand extensor weakness.⁹ 

Special Considerations

There are few absolute contraindications for ORIF of radius fractures. Relative contraindications include severe osteoporosis, elderly individuals with low functional status, general anesthesia intolerance, and patient preference.

Discussion

There are two classic approaches to distal radius fractures in order to perform an ORIF with locking plate fixation; palmar and dorsal. Depending on the fracture characteristics, surgeons may prefer one approach to another. The patient in this case had a minimally-displaced dorsally angulated fracture, which was approached palmar using the modified Henry approach.^10, 11In this technique, an incision is made sharply over the flexor carpi radialis (FCR) tendon, ulnar to the radial artery but radial to the median nerve. The plane between the FCR tendon and the radial artery is developed and the flexor tendons are mobilized ulnarly with the radial-most flexor tendon being that of the flexor pollicis longus. The floor of the FCR tendon sheath is incised to provide access to the deep volar compartment and the pronator quadratus is sharply elevated using an L-shaped incision, first along the radial surface, then distally just proximal to the joint line. This provides adequate access to the fracture site.

The patient in this case received a volar locking plate for internal fixation. Options for plating include both dorsal, radial, bridge, and volar plates. Classically, volar plating was used primarily for palmar angulated fractures. However, reports of high rates of complications with dorsal plating, including extensor tendon rupture and joint stiffness caused many surgeons to prefer volar plating as the preferred form of management of most distal radius fractures.¹² With that being said, the superiority of volar plating to dorsal plating is still being investigated.

Volar plating was thought historically to have a lower risk of tendon complications, as the plate is placed farther from the flexor tendons and may be covered by the pronator quadratus intraoperatively. However, there are reports that volar plating may still be susceptible to extensor tendon rupture.¹³ Additionally, volar plating has also been associated with other common complications, such as carpal tunnel syndrome, median nerve injury, neuropraxia, and complex regional pain syndrome.¹³ Which plating method, then, should be used in the majority of patients? To answer this question, Wei et al. conducted a meta-analysis examining complication rates between dorsal and volar plating in 2013.¹⁴ Interestingly, this group found no difference overall in complication rates between dorsal and volar plating. However, on sub-group analysis, volar plating was found to have a significantly increased risk of neuropathy and carpal tunnel syndrome, whereas dorsal plating was found to carry an increased risk of tendonitis. This group also found that overall, the risk of complex regional pain syndrome and tendon rupture did not differ significantly between the two groups. Subsequently, Disseldorp et al. found, in comparing volar plating with next-generation lower profile dorsal plates, that again there was no difference in complication rates between each method, though volar plating demonstrated slightly increased range of motion when compared with the patient’s uninjured wrist.¹³ The authors advocated, therefore, that the surgical approach should be guided by surgeon preference and experience, rather than by consideration of various complication rates.

Following surgery, wounds are cleaned and dressed until the postoperative visit 10 to 14 days postoperatively. During that time, patients are advised to use their hand for activities of daily living but to avoid strenuous activity. After office assessment, a splint is typically applied and rehabilitation is begun. Rehabilitation for distal radius fractures can be divided into three phases: early splinting, mobilization, and strengthening. The ultimate goals of surgical treatment of most intra- and peri-articular fractures are the restoration of articular surfaces, stable internal fixation of the fracture, and early joint mobility.¹⁵ However, at this point, no consensus has been reached on the optimal postoperative treatment regimen for fractures of the distal radius. A 2017 paper by Quadlbauer et al. compared early mobilization of the injured wrist with casted immobilization in patients treated with a volar locking plate for distal radius fractures. They found that patients rehabilitated with early mobilization showed significantly improved range of motion in the sagittal and frontal planes, improved 6-week forearm rotation, increased grip strength at 6-month follow-up, and improved functional scores when compared with patients with immobilized wrists.¹⁵ Early mobilization also resulted in no change in pain, duration of physical therapy, and loss of reduction, providing evidence that early mobilization programs may be superior to prolonged casting in some patients.¹⁵ So while the optimal rehabilitation protocol is still being explored, early referral to physiotherapy will likely play a key role moving forward.

Equipment

The implant used in this procedure was the Globus Medical ANTHEM™ 7 Volar Plate (Audubon, Pennsylvania, USA).

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.