ORIF - Palmar plate

In these fractures, the distal fragment is displaced in a palmar direction. These are often referred to as Goyrand or Smith fractures. Due to the pull of the flexor tendons, the fragment tends to redisplace after closed reduction.
The treatment of choice, therefore, is palmar buttress plating.

Advances in plate design have provided angular stable fixation. This allows enhanced stability and ease of application, even in the presence of osteoporotic bone. Plates with variable angle locking screw options may be useful.

This procedure is normally performed with the patient in a supine position for palmar approaches.

There are two palmar surgical approaches to the distal radius – a modified Henry approach to the radius and a more ulnar approach, designed to expose the median nerve as well as the distal radius.

A thorough knowledge of the anatomy around the wrist is essential. Read more about the anatomy of the distal forearm.

Reduce the fracture using the following steps:

1. Increase palmar angulation to disimpact
2. With traction applied, in association with distal pressure on the metaphyseal fragment, extend the hand and wrist
3. Final anatomical reduction can be achieved by direct manipulation, using a dental pick or similar hook.

A smooth K-wire is placed through the radial styloid across the fracture site into the opposite radial cortex to secure the reduction.

Pitfall: Over reduction

Care must be taken not to over reduce the distal fragment and create a dorsal displacement of the distal fragment. After confirmation of reduction under image intensification, the distal fragment should always be secured with plate and screws.

Apply the plate to the bone. The distal end of the plate should end at the anatomic watershed zone of the distal radius.

Insert a screw into the oblong plate hole in the proximal radial fragment. Select a screw which is long enough to engage both cortices.

Before fully tightening it, check the plate position using intraoperative imaging, adjusting the position of the plate as necessary.

The initial distal screw should be placed through the ulnar sided screw holes.

The reason for this is that if the initial screw is placed on the radial side it will block accurate imaging of the ulnar screw placement.

A sagittal image is obtained with the angle of the X-ray beam directed 20° obliquely to the radius to control that the screw is not penetrating the radial carpal joint.

Insert at least 3 distal locking head screws.

Then insert at least two more proximal screws.

Remove the K-wire.

Immediately postoperatively, the patient should be encouraged to elevate the limb and mobilize the digits, elbow and shoulder.

Some surgeons may prefer to immobilize the wrist for 7-10 days before starting active wrist and forearm motion. In those patients, the wrist will remain in the dressing applied at the time of surgery.

Wrist and forearm motion can be initiated when the patient is comfortable and there is no need for immobilization of the wrist after suture removal.

Resisted exercises can be started about 6 weeks after surgery depending on the radiographic appearance.

If necessary, functional exercises can be under the supervision of a hand therapist.

See patient 7-10 days after surgery for a wound check and suture removal. X-rays are taken to check the reduction.

Implant removal is purely elective but may be needed in cases of soft-tissue irritation, especially tendon irritation to prevent late rupture. This is particularly a problem with dorsal or radial plates. These plates should be removed between nine and twelve months.