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T-plate fixation

The goal of 23-A2 fracture treatment is anatomical reduction.

Bone plate fixation is the treatment of choice in all patients.

A contoured T-plate is applied on the cranial side of the distal radius and fixed first on the distal fragment and then on the proximal side. With the insertion of a push-pull device (for larger plates) or a drill guide and pin (for smaller plates), plate position and anatomical reduction are checked and adjusted if necessary.

There is a potential for compression with some T-plate designs.

$T-plate fixation of 23-A2 fractures$

The patient can be in dorsal or lateral recumbency.

In lateral recumbency, the affected leg should be in contact with the table.

A craniomedial approach to the distal radius is performed.

The goal is to achieve anatomical reduction.

$T-plate fixation of 23-A2 fractures$

The extensor carpi radialis tendon should be elevated and retracted laterally to create room for bone manipulation and plate fixation.

Elevation and lateral retraction of the extensor carpi radialis tendon

Bone-holding forceps are applied to the proximal and distal fragments for distraction. This is necessary to counteract the strong muscles surrounding the bone, particularly in large breed dogs.

The fracture ends are elevated, toggled, and placed back into reduction.

$Elevation, toggling, and placing of the fracture ends back into reduction$

Alternatively, a Hohmann retractor or similar instrument can be used as a lever to align the fragments.

Use of a Hohmann retractor as a lever to align fragments

Option

Alternatively, the plate can be fixed in the distal fragment first and then used to achieve reduction on the proximal fragment. In this case, the plate should be contoured before application.

Plate fixation in the distal fragment to achieve reduction on the proximal fragment

Plate selection

There are different formats of long and short T-plates, including locking, nonlocking, and hybrid locking plates.

The T-plate should have a minimum of two screws in the distal fragment and three screws in the proximal fragment.

Note: If three screws cannot be inserted on the distal fragment, use of a locking system would be preferable.

Different formats of long and short T-plates, including locking, nonlocking, and hybrid locking plates

Plate contouring

A plate of appropriate size is contoured to fit the shape of the distal radius, taking into consideration the procurvatum. The degree of procurvatum can vary according to the breed and should be checked in the unaffected leg, if possible.

Appropriately sized plate is contoured to fit the distal radius

T-plate application – nonlocking plate

The contoured plate is applied on the cranial surface of the distal radius and secured with plate-holding forceps.

Note: It is essential to use bone-holding forceps or another temporary fixation when drilling and placing the screws, as slight movement of the plate can cause loss of fracture reduction.

The anatomical reduction is carefully checked. If required, the alignment is corrected, and the plate-holding forceps are repositioned.

Application of the contoured plate on the cranial surface of the distal radius and securing with plate-holding forceps

Screw insertion

Usually, the plate is secured to the distal fragment first.

The first cortical screw is inserted after drilling with a neutral guide through the plate. The screw is fully tightened.

Pearl: The screw length can be determined based on preoperative x-rays and should be measured with a depth gauge in surgery to ensure the screw is not engaging the ulna. Fluoroscopy can also be used to ensure proper screw length.

Insertion of first cortical screw in the distal fragment

The second cortical screw is inserted in the proximal fragment using the drill guide in load position.

Note: It is possible to use a load guide for up to two screws on either side of the fracture line to achieve compression. This is, however, rarely necessary, and there is a risk of overcompressing the bone.

Note: It is essential to obtain load-bearing contact between the trans-cortices as the screws are tightened. This is achieved by overbending the plate before application.

Insertion of second cortical screw in the proximal fragment

The remaining cortical screws are applied in neutral mode.

The plate is secured with at least two bicortical screws in the distal fragment and three in the proximal one. It is not necessary to fill all the available plate holes.

Note: Care must be taken to ensure that the screws do not engage the ulna, as this could limit the pronation and supination of the forearm.

Insertion of the remaining cortical screws in neutral mode

T-plate application – locking/hybrid plate

The contoured plate is applied on the cranial surface of the distal radius and secured with plate-holding forceps.

Note: It is essential to use bone-holding forceps or another temporary fixation when drilling and placing the screws, as slight movement of the plate can cause loss of fracture reduction.

The anatomical reduction is carefully checked. If required, the alignment is corrected, and the plate-holding forceps are repositioned.

A push-pull device (for larger plates) or a drill guide and pin (for smaller plates) can be used instead of plate-holding forceps in the proximal and distal fragment to temporarily stabilize the plate if a locking compression plate is used.

With the temporary fixation in place, plate position and anatomical reduction are checked thoroughly and adjusted.

Alternatively, in smaller plates, a pin placed through the locking guide may be used to hold the plates in place.

Use of a push-pull device or a drill guide and pin instead of plate-holding forceps in the proximal and distal fragment if a locking compression plate is used

Management of concurrent ulnar fractures

Fracture of the distal radius is usually associated with fracture of the distal ulna. Fixation of the radial fracture is sufficient in the majority of cases.

Fixation of ulnar fractures is required only in case of lateral collateral ligament instability or in giant breed dogs.

$Fracture fixation of the radius with T-plate and, only if necessary, fracture fixation of the ulna$

Phase 1: 1–3 days after surgery

The aim is to reduce edema, inflammation, and pain.

Following appropriate internal fixation, there should be no absolute need for external coaptation for a 23-A2 fracture. If bandaging is used to decrease edema and protect the surgical wound, it should be removed after 24–48 hours to reduce the risk of complications.

Integrative medical therapies, anti-inflammatory medications, and analgesics are recommended.

10–20 minutes of ice therapy is recommended every 8 hours in most cases.

The patient can immediately bear weight, but with strict control of activities.

Phase 2: 4–10 days after surgery

The aim is to resolve hematoma and edema, control pain, and prevent muscle contracture. Anti-inflammatory and analgesic medications may still be needed.

Rehabilitation and integrative medical therapies can be used.

A careful evaluation is recommended if the patient is not starting to use the limb within a few days after surgery.

Phase 3: > 10 days after surgery

The sutures are removed 10–14 days after surgery. Immature patients should be radiographed every 4 weeks.

A radiographic assessment is performed every 4–6 weeks until bone healing is confirmed, more frequent assessment may be necessary for skeletally immature patients.