In the past, wedge fractures have usually been fixed rigidly. The underlying principle focused on mechanical issues, not on biology. Today, biology takes precedence and for this reason not all wedge fragments are incorporated rigidly into the fixation. Small wedge fragments that do not have a significant effect on stability should not be addressed (they will become incorporated into the fracture by indirect bone healing). Larger wedge fragments that contribute to the stability of the fixation, are fixed to one main fragment. Sometimes, fixation of the wedge to one main fragment helps reduction of the residual fracture. If a lag screw is inserted separate from the plate, a 2.7 mm screw is often used, depending on the size of the bone, for biological reasons, and to reduce the risk of splitting the wedge. If a lag screw is inserted through a 3.5 mm plate, a 3.5 mm screw should be used.
Note on approaches
When both bones need to be reduced and fixed, a separate approach to each bone should be performed to reduce the risk of heterotopic bone formation.
For proximal radial shaft fractures, the anterior approach (Henry) is most often used to minimize the risk of damage to the posterior interosseous nerve, which crosses the proximal radius within the supinator muscle.
Check the completed osteosynthesis by image intensification. Make sure that the plate(s) are at proper locations, the screws are of appropriate length and a proper reduction was achieved.
The elbow should be stabilized at the epicondyles and the forearm rotation should be checked between the radial and ulnar styloids.
6. 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.
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.
In order 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...
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.
7. Postoperative treatment of a fracture treated with plating
Following stable fixation, postoperative treatment is usually functional.
Immobilization in a circular cast may compromise the range of motion later. Temporary immobilization with a well-padded, bulky splint for 10-14 days is advised to allow adequate soft-tissue healing. During this period, elevation, gentle finger motion, active and passive, together with elbow flexion/extension and shoulder motion, can be started. The splint is then removed and active assisted range of motion exercises, including gentle forearm rotation, begin.
Lifting and resisted exercises are restricted until radiographic signs of healing appear. More intensive exercises, such as progressive resisted exercises can start thereafter. Timing of return to sport will depend on the individual patient and the nature of the sport.
Close postoperative follow-up is required in fractures that have been treated by means of absolute stability. Direct bone healing without callus formation is anticipated and early signs of instability with the presence of irritation callus should alert the surgeon to consider secondary interventions, such as restabilization and bone grafting.
Follow-up x-rays should be obtained according to local protocol. X-rays to assess fracture position are usually taken at 1, 2, and 4 weeks after operation. Subsequent x-rays are usually taken to assess bony healing at appropriate intervals from 6-8 weeks, depending on the fracture configuration and potential for healing.
In forearm shaft fractures, the issue of implant removal is controversial. As the radius and ulna are not weightbearing bones, and as removal of plates can be a demanding procedure, implant removal is not indicated as a routine. There is a high risk of nerve damage associated with procedures to remove forearm plates.
Furthermore, as there is significant risk of refracture, most surgeons prefer not to remove plates from the forearm.
The general guidelines today are:
removal only in symptomatic patients, possibly only on the ulna where the implants are subcutaneous
removal no earlier than 2 years after osteosynthesis
If both bones have been plated, sequential removal of implants with a least 6 months in between is recommended (risk of refracture).