Patient is a 66-year-old left hand dominant female who sustained a right displaced intra-articular comminuted distal radius fracture in a motor vehicle accident. (figures 1-3) She was brought to an outside hospital where she underwent closed reduction and splinting.  She presented to our clinic with a displaced and impacted distal radius fracture despite previous manipulation. She was offered open reduction and internal fixation (ORIF) and decided to proceed with this.

Distal Radius

Figures 1, 2 and 3: Pre-reduction PA, lateral and oblique radiographs of the distal radius fracture.

The surgical technique is performed under general anesthesia in the supine position. A tourniquet was placed on her upper arm, and the arm was placed on a radiolucent hand table.

A longitudinal volar incision was made over the flexor carpi radialis (FCR) tendon from the volar wrist crease, extending 10cm proximally. The FCR tendon was identified and sheath incised. The tendon was then retracted ulnarly, and the base of the FCR sheath was carefully incised, to avoid the palmar cutaneous branch of the median nerve as it pierces the ulnar base of the FCR sheath. The FCR was retracted ulnarly to expose the flexor pollicis longus (FPL), which was retracted, and pronator quadradus (PQ). The PQ was incised radially and retracted ulnarly to expose the fracture.

Ten pounds of traction was placed across the fracture using finger traps attached to rope hung off the hand table. This technique assists with fracture reduction. With traction and manipulation the fracture was reduced. Restoration of volar tilt, radial inclination and radial height was confirmed with fluoroscopic mini C-arm.

A distal radius locking plate was placed on the reduced radius so that the distal aspect of the plate lay just proximal to the watershed line and centered on the radius. A non-locking screw was placed centrally in the proximal slide hole. This allows small adjustment of plate placement either proximally or distally. The distal screw holes were then filled with locking and non-locking fully threaded screws.

Fluoroscopy confirmed restoration of volar tilt and radial inclination and reduction of the distal radioulnar joint. (figures 4 and 5) Two more non-locking screws were placed proximally. (figures 6 and 7)

Distal Radius

 

 

 

 

 

 

Figure 4: Lateral fluoroscopic image with plate placement distal to the watershed line.

Distal Radius

Figure 5: PA fluoroscopic image showing the plate shifted proximally in the proximal slide hole to maintain ideal distal plate placement.

 

Distal Radius

Figure 6: Final lateral fluoroscopic image with restoration of volar tilt. This image is taken at a 20 degree angle, parallel to the radial inclination with a clear view of the articular surface demonstrating that no screws have penetrated into the joint.

 

Distal Radius

Figure 7: Final PA fluoroscopic image with restoration of radial inclination and reduction of the articular surface.

The PQ was closed with 3.0 vicryl suture. The tourniquet was then released at 60 minutes. The subcutaneous tissue was closed with 2.0 vicryl and the skin was closed with a running subcuticular 4.0 monocryl. A well padded volar based short arm splint was placed.

The patient was seen in the office two weeks post-operatively. Her incision was healing well and radiographs showed well maintained fixation. She was transitioned into a short arm cast. She was seen again 5 weeks post-operatively. Repeat radiographs showed maintained reduction and callus formation. Her incision was well healed and she was neurovascually intact distally. She could tolerate a total of 60 degrees of passive range of motion with 30 degrees of flexion and 30 degrees of extension. Her cast was removed and she was referred to occupation therapy.

Tips:

  1. Incise bed of FCR sheath over entire length of plate to allow better visualization
  2. Use finger traps and traction to help with intraoperative reduction
  3. A thyroid retractor can be used to hook the ulnar aspect of the proximal fracture to translate the shaft radially to aid in reduction

 

Tracy Webber, MD
University of Connecticut Health Center
New England Musculoskeletal Institute

Jennifer Moriatis Wolf, MD
University of Connecticut Health Center
New England Musculoskeletal Institute