Dealing successfully with difficult fractures

Radius fractures are among the most common and most commonly treated fractures. Although Abraham Colles stated that after a radius fracture, full freedom of movement and function are restored—and that statement may be true for fractures in the very young or very old—fractures in the younger adult population can certainly be problematic.

Distal radius fractures are often the result of high-energy impacts and falls and can be difficult to treat. This article outlines a way for orthopaedic surgeons to deal successfully with difficult fractures of the distal radius (Fig. 1A, 1B).

High-energy impact to the distal radius creates injuries potentially fraught with peril for both the patient and the surgeon. Complications can include, but are not limited to, the following: neurologic compromise, stiffness, infection, arthrosis, malunion, nonunion, and pain. With careful attention to the initial presentation, the pattern of injury, and a few details during treatment, the orthopaedic surgeon can create a healing environment that gives the patient the best chance for a successful outcome and avoid many potential complications.

The goals of treatment have always been to restore the anatomy of the radius—length, tilt, inclination, and joint surface. Newer techniques and devices make that goal more attainable than ever before. Nevertheless,no one technique is always best, and a return to normal may not be possible, regardless of treatment.

Look beyond the wrist
Comprehensive initial evaluation of the patient who has sustained a radius fracture is vital to successful treatment. Not only is the mechanism of injury important, but the patient’s medical and social history also can affect treatment decisions. A careful physical examination is important as well; the initial evaluator should not be so focused on the radius that he or she underestimates concomitant conditions such as injuries about the elbow or acute neurologic compromise.

Careful radiologic evaluation of the injury itself is needed. The surgeon must consider the degree of injury to the radius—including displacement, comminution, and articular involvement—along with other injuries to the wrist as treatment commences.

Choosing fixation
Closed reduction should not be used for high-impact distal radial fractures; cast treatment alone is inadequate to treat the significant instability and deformity in these fractures. External fixation, external fixation with pinning, pins alone, and volar plating are the most popular treatment options, with volar locking plates recently gaining a great deal of popularity.

The choice of fixation should depend on how well it addresses the problem and on how familiar and facile the surgeon is with that method. Volar plating is a useful treatment for distal radius fractures; this article will give useful information on the optimal use of volar locking plates, with attention to details designed to help the patient avoid complications.

Indications for volar locking plate fixation

Most comminuted fractures of the distal radius can be managed with volar locking plates. Due to the architecture of the plates, even severely comminuted, intra-

articular fractures can be managed using this method (Fig. 2). The locked distal screws can be used to support and stabilize distal comminuted fragments. The locked proximal portion creates a stable three-dimensional construct. These devices can also be used with less comminuted fractures that demonstrate instability.

Surgical approach and technique
Once the surgeon determines that volar fixation will be used and assesses other issues surrounding the injury, he or she can begin surgical treatment. The following seven steps will help ensure successful treatment:

• Determine whether carpal tunnel release (CTR) is indicated. The decision can be based on the patient’s history and physical exam. If the radial three-and-a-half digits have numbness or significant paresthesias, CTR should be considered. If CTR is necessary, a second incision in the palm, essentially in line with the ring ray, can be made. Avoid injury to the palmar cutaneous branch of the median nerve that courses radial to the palmaris longus. (Connecting the incisions without isolating this tiny nerve can often result in injury to the nerve.)
• Prepare and drape the patient appropriately. Many patients with distal radial fractures have been in splints for extended periods. Be certain that the skin is appropriately cleansed prior to the formal prep and that preoperative antibiotics are administered. Some of these fractures will be open, if only minimally. Check for allergies before giving antibiotics. Usually a first-generation cephalosporin is appropriate. Use a radiolucent hand table and tourniquet on the arm.
• Use image intensification to assess reduction and fixation. Small fluoroscopy units are an extremely useful adjunct in radius fixation and can be used to assist in fracture reduction, fixation placement, graft placement or fill, and assessing stability. An inclined lateral view (20º to 25º) can assess both articular congruency and periarticular screw placement to ensure no fixation is intra-articular. Although arthroscopy is occasionally useful for treating the intra-articular fracture, swelling may result and complicate the procedure if it is not done at the appropriate time or with great skill.
• Know your approach. A standard anterior approach to the distal radius traverses the radial aspect of the flexor carpi radialis tendon sheath and proceeds bluntly. The radial artery must be protected and retracted on the radial side, as must the flexor palmaris longus and finger flexors on the ulnar side. The pronator quadratus is swept ulnarly, exposing the distal radius and enabling the surgeon to view the distal radius and fracture.
• Put the plate in the best place. Generally, the best place for the plate is centered on the radius, hugging the volar surface. Occasionally the plate will not sit easily on the bone, but many plate designs come with nonlocking distal screws that can be used to lag the distal fragments back to the plate and then be exchanged for locking screws after additional fixation is applied.
• Optimize the reduction. Traction, fragment manipulation, and proper help from an experienced assistant can all be helpful in obtaining a maximal reduction. Temporary use of Kirschner wires (K-wires) can be helpful as well. Many modern plates have jigs that screw into the plate and distal fenestrations that can be used as K-wire guides to help temporarily stabilize the fracture. This, along with the lag screw technique described above, can give you the means necessary to obtain an optimum reduction, with far greater stability than earlier methods.
• Maintain the reduction. Proper screw placement, appropriate screw length, and sufficient screw numbers are all key in maintaining reduction of the fragment (Fig. 3). Screws into the wrist joint will cause harm. Using screws that are too long can result in tendon and nerve complications, while using screws that are too short risks loss of fixation and stability. Using too few screws can compromise stability and increase the possibility of metal fatigue. Use fluoroscopy to determine whether the overall reduction and stabilization is satisfactory. If there is bone loss, adjunctive use of graft materials may be necessary; take the time needed to make a repair if such a void is present.

Postoperative Care
Postoperative immobilization of up to 6 weeks is often indicated; if the repair is very stable, however, earlier movement can help avoid stiffness. Therapy is also often indicated. Maximum recovery can take a year or longer. Obtain postoperative radiographs at each of the first three follow-up visits to ensure maintenance of reduction and to confirm healing at the 6-week mark.

Edward H. Holliger IV, MD, specializes in the hand and upper extremity at Resurgens Orthopaedics in Atlanta.