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Treatment

Lag screw and medial bridging plate fixation

This technique is used to achieve interfragmentary compression for anatomically reducible long oblique or butterfly fractures.

With this technique, absolute stability is achieved. The lag screw provides primary fixation of the radius and applies interfragmentary compression to the fracture. The bridging plate protects the primary fixation and offers additional stability.

$Lag screw and medial bridging plate fixation of 23-C2 fractures$

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.

Reduction of the fracture line

In an oblique fracture pattern, the bones are slid along the fracture line into anatomical reduction with the help of one or two pointed reduction forceps placed across the fracture line.

$Sliding the bone fragments along the fracture line into anatomical reduction using pointed reduction forceps$

Fixation of the fracture

The oblique fracture is secured with a lag screw.

Alternative: Lag screw through bridging plate

If the plate is applied on the medial side, as an alternative to fixation with independent lag screws, the fracture can also be fixed with lag screws inserted through the bridging plate.

$Fixation of the fracture with lag screws inserted through the bridging plate if the plate is applied on the medial side$

Plate selection

According to the size of the distal fragment, a straight nonlocking or locking plate should be used in order to have a minimum of two screws in the distal fragment and three screws in the proximal fragment.

Lag screw and medial bridging plate fixation

Plate contouring

If a nonlocking plate is selected, it must be meticulously contoured to the bone to avoid fragment displacement and loss of reduction.

Pearl: The plate can be precontoured to x-rays of the normal contralateral limb. It reduces the operating time and ensures that the radial bow-shaped curve is reproduced, thus avoiding procurvatum or recurvatum deformities. Precountouring is especially helpful for medial plating.

Plate application

The contoured plate is applied to the medial 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.

If required, the alignment is corrected and the plate-holding forceps are repositioned.

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

Screw insertion close or at the level of the fracture line should be avoided. Screws are placed in neutral mode. Screw insertion order is not critical.

$Insertion of the screw in neutral mode and not close to or at the level of the fracture line$

Fixation with a locking compression plate

A push-pull device can be inserted instead of plate-holding forceps in the proximal and distal fragment to temporarily stabilize the plate if a locking compression plate (LCP) is used.

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

Insertion of a push-pull device instead of plate-holding forceps in the proximal and distal fragment

Locking plates lend themselves well to bridge plating and do not require perfect contouring. Additionally, locking screws provide superior fixation to the bone. If an LCP is used, two to three locking screws per main fragment are needed.

Note: When used in bridging mode, an LCP is not used to achieve compression.

Note: If a combination of nonlocking and locking screws is used, the plate must be anatomically contoured at the sites where nonlocking screws are inserted. All nonlocking screws must be inserted and tightened before any locking screws are placed.

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-C2 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.