Authors of section

Authors

Renato Fricker, Jesse Jupiter, Matej Kastelec

Executive Editors

Steve Krikler, Chris Colton

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ORIF - Palmar bridge plate

1. Preliminary remarks

Fracture assessment and decision making

These fractures are extraarticular but multifragmentary. They may often be associated with an ulnar styloid fracture.

Because of extensive comminution, fixation should aim to restore length, axis and rotation. The function of the plate is bridging the comminution and promoting secondary healing with callus formation.

As these injuries are often associated with disruption of the DRUJ, before starting the operation, the uninjured side should be tested as a reference for the injured side.

orif palmar bridge plate

Bridge plating of the distal radius - plate choice

In the presence of extensive metaphyseal comminution, conventional plates do not allow for enough purchase particularly in the proximal fragment. Specially designed, longer, angular stable plates have been developed to allow stable fixation of the distal fragment and metaphyseal bridging of the comminution.

orif palmar bridge plate

2. Patient preparation and approach

Patient preparation

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

orif palmar plate

Approach

The radial shaft is approached using a classical Henry’s palmar (anterior) approach.

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

palmar approach  modified henry approach

3. Radial plate fixation

The plate is pre-contoured distally, so it is already adapted to the palmar curvature of the distal radius.

orif palmar bridge plate

Plate insertion

The plate is first positioned distally on the flat intact palmar surface of the distal radius and fixed with distal locking screws parallel to the articular surface. The distal end of the plate should end at the anatomic watershed zone of the distal radius.

The first screw inserted is in the hole on the ulnar side of the plate and its position should be checked under image intensification with the hand elevated 20-30° off the table – in lunate facet view.

orif palmar bridge plate

The other distal screws should be inserted in a way that the radial inclination of approximately 20° is restored.

orif palmar bridge plate

Restoring radial length

The correct length of the radius in relation to the ulna should be established preoperatively by taking radiograph of the opposite wrist. The length of the radius in relation to the ulna is then achieved by inserting a unicortical screw just proximal to the proximal end of the plate, and then using a spreader, as illustrated, to move the plate gently distally.

orif palmar bridge plate

Once the correct length is achieved, the plate is provisionally fixed proximally with standard screws.

orif palmar bridge plate

The relationship of the radius to the distal ulna is checked under image intensification before the plate is fixed with additional proximal screws

extraarticular wedge or multifragmentary fracture of the radius

4. Assessment of Distal Radioulnar Joint (DRUJ)

Before starting the operation, the uninjured side should be tested as a reference for the injured side.

After fixation, the distal radioulnar joint should be assessed for forearm rotation, as well as for stability. The forearm should be rotated completely to make certain there is no anatomical block.

Method 1

The elbow is flexed 90° on the arm table and displacement in dorsal palmar direction is tested in a neutral rotation of the forearm with the wrist in neutral position.

This is repeated with the wrist in radial deviation, which stabilizes the DRUJ, if the ulnar collateral complex (TFCC) is not disrupted.

external fixation

This is repeated with the wrist in full supination and full pronation.

external fixation

Method 2

To test the stability of the distal radioulnar joint, the ulna is compressed against the radius...

external fixation

...while the forearm is passively put through full supination...

external fixation

...and pronation.

If there is a palpable “clunk”, then instability of the distal radioulnar joint should be considered. This would be an indication for internal fixation of an ulnar styloid fracture at its base. If the fracture is at the tip of the ulnar styloid consider TFCC stabilization.

Pronation

5. Aftercare

Functional exercises

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

joint spanning external fixation temporary or definitive

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.

orif palmar plate

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.

orif palmar plate

Follow up

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

Implant removal

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.