ORIF - Palmar plate

In these fractures, the palmar rim of the distal radius is sheared off, resulting in a partial articular fracture. There may be additional comminution. This is best demonstrated by CT scans.

The result of the injury is joint incongruity and palmar subluxation of the carpus. The treatment of choice is palmar buttress plating.

There are various plates available. The size of the palmar rim fragments will influence the choice of plate.

Plates with variable angle screw options may be useful in this situation.

Reduction is achieved by applying longitudinal traction either manually or using Chinese finger traps.

The reduction is maintained by a temporary splint.

If definitive surgery is planned, but cannot be performed within a reasonable time scale, a temporary external fixator may be helpful.

AO teaching video: Radius, distal—reverse Barton’s fracture (23-B3). Fixation using the 2.4 mm VA-LCP Two-Column Distal Radius Plate

If there is dense sensory loss, or other signs of median nerve compression, the median nerve should be decompressed.

These injuries may be associated with shearing injuries of the articular cartilage, scaphoid fracture and rupture of the scapholunate ligament (SL). Every patient should be assessed for this injury. If present, see carpal bones of the Hand module.

These injuries may be accompanied by avulsion of the ulnar styloid and/or disruption of the DRUJ. If there is gross instability after the fixation of the radial fracture, it is recommended that the styloid and/or the triangular fibrocartilaginous disc (TFC) is reattached. This is not common in simple fractures, but may occur with some high energy injuries.

The uninjured side should be tested as a reference for the injured side.

It may not be possible to assess DRUJ stability until the fracture has been stabilized (as described below).

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 by hyperextension of the wrist over a pad.

Perfect anatomical reduction can be achieved by direct manipulation of the distal fragment using a dental pick or a fine hook.

Ensure that the plate is contoured so that its distal limb exerts even pressure over the fragment or fragments of the palmar rim of the radius. The distal end of the plate should end at the anatomic watershed zone of the distal radius.

Attach the plate to the distal radial shaft, using an appropriate screw through the oblong plate hole. Before fully tightening it, check the plate position using intraoperative imaging, adjusting the position of the plate as necessary to provide an optimal buttress effect.

Now tighten the first screw and insert a second screw. Check adequate buttress pressure on the palmar rim fragment(s).

Confirm reduction using image intensification.
Secure the distal fragment(s) with at least two screws through the appropriate distal holes, as dictated by the fracture pattern. The screws must not penetrate the dorsal radial cortex.

If a plate is selected with threaded holes in the distal limb, then locking head screws are used.

For a multifragmentary fracture comprised of a small distal articular rim fracture, a palmar plate which directs the very distal screws proximally may be applicable.

As the screws are placed in a very subchondral manner, there is a high risk that there may be some inadvertent penetration of the joint. Special care must be taken to exclude this with imaging.

As the plate is so distal, flexor tendon irritation is common and so this plate usually must be removed.

For very small fragments, it may be easier to obtain strong hold by suturing the palmar ligaments and capsule to the plate.

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.

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.

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

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

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

...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.

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.