Authors of section

Authors

Renato Fricker, Jesse Jupiter, Matej Kastelec

Executive Editors

Steve Krikler, Chris Colton

Open all credits

ORIF - Dorsal plate

1. Preliminary Remarks

Fracture assessment

These are partial articular injuries involving the ulnar column of the distal radius, so affect both the radiocarpal and distal radioulnar joints. The fixation needs to resist the shearing forces to which the fragment is subjected.

An isolated fracture of the lunate facet of the distal radius results from a direct axial impaction by the carpal lunate.

CT scans are strongly recommended to define this unusual articular injury better.

orif dorsal plate

Provisional reduction in displaced fractures

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.

orif palmar plate

2. Associated injuries

Median nerve compression

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

orif dorsal plate

Associated carpal injuries

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.

orif dorsal plate

DRUJ/ulnar injuries

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).

closed reduction k wires and cast external fixator

3. Patient preparation and approach

Patient preparation

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

joint spanning external fixation temporary or definitive

Approach

For this procedure a dorsal approach is normally used.

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

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4. Reduction

Periosteal elevator

If necessary, use a periosteal elevator to disimpact and elevate the dorsoulnar fragment.

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Provisional K-wire fixation

Insert a K-wire to hold the fragment provisionally.
Confirm reduction using image intensification.

If in doubt about congruity of the articular surface under image intensification it is mandatory to open the joint (dorsal capsulotomy).

orif dorsal plate

5. Plate positioning and contouring

Plate contouring

Many plates are available for this fracture, some with locking screws. The most recently designed plates have variable angle locking screws.

Because of the shape of the dorsal distal metaphysis, the plate may need to be adapted to fit the bone surface and the proximal limb may require some torsional adaptation.

orif dorsal plate

An appropriately sized L-plate is chosen, preferably one with locking holes distally.

If the plate being used has fixed angle locking screws, there is a risk that the screws may penetrate the joint. To prevent this, the distal limb of the plate must be bent to ensure the screws are parallel to the joint surface.

To avoid this problem, the use of variable angle plate is recommended.

orif dorsal plate

Pitfall: Screw hole distortion

Avoid contouring the plate through the locking holes, otherwise the locking head screw might not fit any more.

orif dorsoradial double plate

Plate position

The plate should be applied as distal and as ulnarward as possible onto the dorsoulnar column of the distal radius.

orif dorsal plate

6. Plate fixation

Insert a screw through the oblong plate hole, using a screw long enough to engage the opposite cortex. Do not fully tighten the screw yet.

Confirm the reduction and plate position using image intensification. If necessary, adjust the plate position until it is as distal and as ulnar as possible. Now tighten the screw.

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Insert proximal screw

A screw is inserted through the most proximal plate hole.

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Insert distal screw

Insert a distal screw.

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Confirm screw position

Confirm using image intensification that the distal screw has not penetrated the articular surface. To have a view in line with the articular surface, the beam should be angled 20º from the true lateral.

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Depending on the fragment size, an additional distal variable angle locking screw may be inserted.

partial articular sagittal fracture of the radius involving the lunate fossa

7. 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

8. 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.