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A General Review

Generally, all distal radius fractures or injuries do not require operative treatment. Only about 35–40% of all distal radius fractures need operative treatment.  The goal of operative treatment is to achieve anatomical reduction and stable fixation. Hand Plating System proves very helpful to achieve this goal of treatment. Nowadays bone plate manufactures are providing a good range of plates for the treatment of fractures.  Disruption of supporting ligaments should be minimal and maintenance of the vascularity of the fragments should be maintained.  In the case of operative treatment, exposure must be extensile and soft tissues should be treated with extra care. Surgery can be performed under the regional axillary block. General anesthesia is performed in case of high-energy injuries or combined injuries for which a longer operative time is anticipated. Local anesthesia or brief general anesthesia can be performed if an iliac bone graft is needed, while the graft is harvested and the wound is closed.

Surgical approaches to the Distal Radius

Dorsal Approaches

The indications for dorsal approaches are extra-articular and intra-articular fractures with dorsal metaphyseal comminution, dorsal displacement, and the fractures of the radial styloid and fractures that involve the dorsoulnar aspect of the lunate facet. Straight longitudinal incisions centered between various extensor compartments are done for dorsal surgical approaches.

This approach is centered between the first and second extensor compartments for radial and styloid fractures. For the identification and protection of the multiple branches of the superficial radial nerve, one must be very careful. And the undue tension during the procedure needs to be avoided. The radial artery may also be jeopardized because it courses around the styloid into the anatomical snuffbox particularly in the case of the distally extended incision. A partial arthrotomy of the wrist between the second and third compartments can be helpful for the assessment of articular reduction. It also helps in viewing the disruption of scapholunate ligament particularly in severely proximally displaced radial styloid fracture.

Through the tip of the radial styloid dorsal K-wires or cannulated cancellous screws are inserted to the tendons of abductor pollicis longus and extensor pollicis Brevis. The plant is placed underneath the fourth compartment and the rest under the third and second compartments. To cover the plate radially the retinaculum flap is used during the closure. And the extensor pollicis longus is left in a subcutaneous position.

A longitudinal dorsomedial incision centered over the Lister's tubercle is needed for the exposure of the dorsal metaphysis and central articular fractures. The approach crosses the third dorsal compartment with radial transposition of the extensor pollicis longus tendon. Then the second and fourth compartments are elevated sub-periosteally from the dorsal rim fragments. In case of plate fixation, dissection of ulnarly based flap of retinaculum is performed precisely radial to the second compartment which is elevated exposing the radial half of the fourth compartment extensor and pollicis longus. After the application of the plate, a part of the implant comes to lie underneath the fourth compartment and the rest part underneath the third and second compartments. In order to cover the plate radially, the retinaculum flap is used during closure and the extensor pollicis longus is left in a subcutaneous position.

In the end, a dorsal ulnar incision between the fifth and sixth extensor compartments is used for internal fixation of the ulnar styloid process, repair of the triangular fibro-cartilage, or reconstruction of fractures of the ulnar head. When the incision goes distal to the level of the ulnocarpal joint on the dorsum of the hand, the dorsal cutaneous branch of the ulnar nerve is jeopardized.

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