1. Surgical Approach

2. Incision

3. Dissection to FCR Tendon Sheath

4. Open and Release FCR Tendon Sheath

5. Access to Deep Volar Compartment

6. Radius Exposure

7. Elevation and Reflection of Pronator Quadratus to Expose Fracture Site

8. Brachioradialis Tendon Release

9. Assess Alignment Under Fluoroscopy

10. Fracture Mobilization

11. Provisional Reduction Under Fluoroscopy

12. Placement of Variable Angle Volar Plate and Confirmation of Fit and Position

a. Apply Proximal Plate

b. Reduce Fracture and Hold with K-Wires

c. Apply Distal Plate

d. Assessment Under Fluoroscopy

13. Proximal-First Reduction and Fixation

14. Closure

15. Dressings

Fractures of the distal radius are common injuries, with an annual incidence of 27 per 10,000 per year. As many as two-thirds of these fractures are displaced, necessitating reduction to restore wrist function and avoid neurovascular compromise. When adequate reduction cannot be achieved by closed reduction alone, closed reduction and percutaneous pinning versus open reduction and internal fixation is considered. Here we present the case of a middle aged female presenting with a dorsally displaced and angulated fracture of the distal radius after a fall on the outstretched hand. The fracture was treated by open reduction and internal fixation with a volar locking plate. We outline the natural history, preoperative care, intraoperative technique, and postoperative considerations of distal radial fractures. 


<h4>CHAPTER 1</h4>

<p>With the operative limb draped across the hand table, a tourniquet applied, and the limb prepped and draped, the incision is marked out directly over the FCR tendon sheath. The incision is then pre-injected with a local anesthetic. My preference is 0.5% Bupivacaine with epinephrine. After injection, the limb is exsanguinated, and the tourniquet is inflated to 250 mmHg.</p>

<h4>CHAPTER 2</h4>

<p>An incision is made with a 15 blade scalpel directly over the FCR tendon. Occasionally, branches of the palmar cutaneous nerve can be found crossing the FCR tendon sheath and must be identified and protected.</p>

<h4>CHAPTER 3</h4>

<p>Blunt dissection is then performed down to the FCR tendon sheath.</p>

<h4>CHAPTER 4</h4>

<p>With the FCR tendon exposed, the tendon sheath is then opened sharply with a blade and then extended proximally and distally with scissors. Retractors are then placed to expose the floor of the FCR tendon sheath. The release of the floor of the FCR tendon sheath is done with care and is a thin layer and should be done directly under the tendon. If you go too far radial, you can injure the radial artery. If you go too far ulnar, you can inadvertently injure the median nerve or the palmar cutaneous branch of the median nerve. It is helpful to take the release of the floor as far distal and proximal as possible in order to maximize exposure of the deep volar compartment. Here you'll see that the FCR tendon is retracted, and the floor is released as far as possible under direct visualization. Similarly, the floor is released proximal in a similar fashion.</p>

<h4>CHAPTER 5</h4>

<p>Once the floor is opened, the deep volar compartment is entered and can be readily accessed with blunt dissection. You'll notice that the radial artery is kept radial and in the field at all times, and blunt dissection only is used to mobilize the flexor tendons and they're all taken ulnarly. The radial-most flexor tendon should be the flexor pollicis longus tendon.</p>

<h4>CHAPTER 6</h4>

<p>Hohmann retractors are then placed next around the radial shaft both medially and laterally. Alternatively, a Weitlaner retractor can be utilized in order to expose the radius.</p>

<h4>CHAPTER 7</h4>

<p>With the pronator quadratus exposed overlying the radius, it is elevated sharply along the radial border and reflected medially. This is best performed sharply in order to maximize subperiosteal elevation for later closure if desired. Prior to releasing the transverse distal limb of the pronator quadratus, the radial part is released first, and a sharp elevator is then used to elevate the pronator quadratus. This elevator is off of the distal radius set, and the system being used is by Globus. The distal release is not performed yet as it is easy to inadvertently release the pronator quadratus over the joint line and inadvertently transect the volar radiocarpal ligaments. Once the fracture site and the joint line is identified and confirmed, the distal aspect of the pronator quadratus can be released. Notice it is being released with the knife being directed away from the flexor tendons and the median nerve. Once released, the elevator is brought back in, and the rest of the distal pronator quadratus is elevated, thereby exposing the fracture site.</p>

<h4>CHAPTER 8</h4>

<p>Next, in order to aid in fracture mobilization and increase exposure, the brachioradialis tendon can be released along the radial border. Here, the radial structure identified - this is a radial sensory nerve branch. This is the radial artery. Both these structures are identified and then retracted radially. Deep to that, the relationship between the first dorsal compartment tendons and the brachioradialis is appreciated. The first compartment tendons lie superficial to the brachioradialis tendon. There's a lot of motion and excursion of those first compartment tendons as identified here. They can be readily released and then retracted radially. The brachioradialis tendon will be deep to those tendons and have less motion and excursion as they're inserting along the radial border of the distal radius. They can then be sharply released at the level or slightly proximal to the fracture line and then elevated off the distal fragment.</p>

<h4>CHAPTER 9</h4>

<p>Now with the fracture exposed, the fracture is examined on fluoroscopy to assess the alignment. As discussed previously, this fracture is primarily dorsally angulated with minimal displacement.</p>

<h4>CHAPTER 10</h4>

<p>Now with the fracture fully exposed and released, the fracture is now being mobilized. This fracture is nearly 2 weeks old so it's getting a bit sticky so a freer is being used to mobilize the fracture and the distal fragment. If further mobilization and visualization of the distal fragment is necessary, the volar extensile approach can be utilized by mobilizing the proximal fragment and placing a tenaculum retractor around that proximal fragment and then carefully pronating it out of the wound, thereby fully exposing the distal fragment as shown here. Once pronated out of the wound, the distal fragment can be better mobilized and also visualized. Intra-articular fragments can be reduced, dorsal hematoma can be decompressed, dorsal periosteum can be released, and dorsal comminution can also be mobilized and decompressed and/or better reduced. In this case, to better mobilize the distal fragment as it is nearly 2 weeks old, the dorsal periosteum is being released. First it was released with a knife and now being spread with tenotomy scissors.</p>

<h4>CHAPTER 11</h4>

<p>Now with the fracture fully released and mobilized, it can be more readily reduced. Here a standard traction, ulnar deviation, and volar flexion is being applied with the thumb being placed on the volar cortex as counter-traction, and a nice reduction is achieved.</p>

<h4>CHAPTER 12</h4>

<p>With provisional reduction confirmed, a variable angle volar plate is selected. This implant is made by Globus Medical. Fluoroscopy confirms good fit and position of the plate.</p>

<h4>CHAPTER 13</h4>

<p>Broadly speaking, there are 3 standard reduction techniques for distal radius fractures. One is proximal-first. The second is distal-first. And third is the neutralization technique. Proximal-first is what is being done here. Once satisfied, then a reduction can be readily achieved. The plate is applied to the proximal fragment first and then the distal fragment will be brought to that plate. In contrast, the distal-first construct is when the plate is applied to the distal fragment and then the plate and the distal fragment is then applied to the bone. Lastly, the neutralization construct is when the fracture is fully reduced and pinned in place, and then the plate is applied to neutralize the reduction.</p>

<p>Following the proximal-first strategy, here the plate is confirmed reduced on the proximal shaft. The distal fragment is now brought to the plate. A K-wire placed in the distal fragment dorsally is used as a joystick to help manipulate the fracture and to aid in reduction. Once satisfied with the reduction, K-wires are then placed through the plate into the distal fragment to hold it in position as shown here.</p>

<p>With the fracture reduced and held with K-wires, the distal screws are placed. I always drill in oscillation in order to avoid binding up any soft tissue. The first screw that I placed is a cortical screw placed bicortically in order to compress the distal fragment to the plate. This also dials in some additional volar tilt. Then the other, unicortical, subchondral locking screws are placed. Either locking screws or pegs can be placed. Once they're placed, that first bicortical non-locking screw is replaced with a unicortical locking screw. As discussed, once the distal fragment is fixed with additional locking screws, that first bicortical screw is removed and replaced with a unicortical locking screw or peg. In this case, I'm using a peg as shown here.</p>

<p>Final radiographs were taken to assess fracture reduction and hardware position. Typically, 2 or 3 shaft screws is sufficient. Locking screws in the shaft are typically not needed unless very osteopenic or bridging a bony defect. The subchondral distal screw should not be too proud and should not exit past the dorsal limit of the lunate. Radiographs are scrutinized to make sure that the screws are not in the radiocarpal joint or the distal radial ulnar joint. The final construct, shown intraoperatively.</p>

<h4>CHAPTER 14</h4>

<p>Once satisfied, the wound is washed and closed in layers. The pronator quadratus can be closed over the plate if desired. I typically close with a few subcutaneous sutures with a 3-0 Vicryl and then a running 4-0 Monocryl as shown here.</p>

<h4>CHAPTER 15</h4>

<p>After the wound is closed, a soft dressing is applied. The patient is asked to leave that soft dressing on and dry until the first postoperative visit in the office. That visit is typically 10 to 14 days after surgery. The patient is allowed to use their hand during that time for activities of daily living, but nothing strenuous or heavy. At that visit, a removable splint is given to be worn for protection and comfort, and formal therapy is prescribed. Thank you for watching.</p>

Watch this narrated surgical video of a distal radius open reduction and internal fixation performed by Dr. Asif Ilyas at the Rothman Institute.

DOI
Publication Date	2022/02/18
Article ID	301
Production ID	0301
Volume	2022
Issue	301
https://doi.org/10.24296/jomi/301

Distal Radius Open Reduction and Internal Fixation

Procedure Outline

Table of Contents