ORIF - Bridge plate

Comminuted fractures of the distal ulna usually occur in combination with distal radial fractures.

In multifragmentary ulnar fractures, there is instability and shortening, and bridge plating is the chosen means of stable internal fixation.

Attention should be paid to restoring correct rotation and correct length in relation to the radius.

Complete dislocation of the radiocarpal joint is often associated with disruption of the distal radioulnar joint (DRUJ).

This procedure is normally performed with the patient in a supine position for distal ulnar fractures.

For this procedure an ulnar approach is normally used.

Choose a plate which will be of sufficient length to obtain adequate fixation in the proximal and distal fragments after the fracture has been reduced.

If available, a low profile plate should be used, as soft tissue irritation is a common postoperative problem.

The plate is inserted using one screw distally, then alignment of the distal fragment with the proximal shaft is achieved, before the second screw is inserted.

If the distal fragment is small, fixation may be more secure if a condylar or a T-plate is used.

Reduction is then achieved by manipulation of the distal fragment, using the plate, possibly with the help of a hook, to restore anatomical length and rotation in relation to the distal radius.

Check this reduction, using intraoperative image intensification, before proximal fixation of the plate.

The fracture zone is bridged, with no attempt to reduce the individual fragments of the multifragmentary zone, and the plate then secured to the proximal shaft using screws inserted in a neutral fashion.

Pearl

An x-ray image of the uninjured side allows comparison of the configuration of the DRUJs.

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.