Techniques in Hand and Upper Extremity Surgery 9(1):2–6, 2005
Ó 2005 Lippincott Williams & Wilkins, Philadelphia
T E C H N I Q U E
Internal Distraction Plating of Distal
Radius Fractures
Anastasios Papadonikolakis, MD and David S. Ruch, MD
Department of Orthopaedic Surgery
Wake Forest University
Bowman Gray School of Medicine
Winston-Salem, NC
n ABSTRACT
Internal distraction plating can be used for the treatment
of highly comminuted distal radius fractures especially in
elderly patients. The technique involves the use of 3.5,
2.7, or 2.5 dynamic compression plates. The instrumentation is applied in distraction dorsally from the radial diaphysis, bypassing the comminuted segment, and fixed
distally to the long metacarpal. The advantages of this
technique are: a) it can be used as an alternative for managing difficult fractures in the elderly population; b) it is
indicated in patients with osteoporotic bone; c) complications associated with external pins are avoided; and d)
the stability of the plate allows patients to use the extremity for transfer and activities of daily living. On the other
hand, possible disadvantages to be considered are: a) the
need of a second operation to remove the plate; and b) the
prolonged duration of immobilization. Elderly patients
with osteoporotic bone who undergo treatment of comminuted distal radius fractures may result in poor outcomes
with high rates of complications if external fixation or
standard internal fixation is used. The current approach
represents an alternative that provides union of the fracture with excellent alignment, functional range of motion,
and minimal functional disability.
Keywords: distal radius, fractures, bridge plates, internal
distraction
n HISTORICAL PERSPECTIVE
From a functional and surgical perspective, the ideal
management of highly comminuted osteoporotic fractures
of the distal radius in the elderly remains controversial.
Pragmatically, the difficulties in managing intra-articular
Address correspondence and reprint requests to David S. Ruch, MD,
Professor, Department of Orthopaedic Surgery, Wake Forest University,
Bowman Gray School of Medicine, Winston-Salem, NC. E-mail:
[email protected].
2
fractures in this patient population are significant. It is
the thesis of many authors that internal fixation may be
compromised if the distal fragments are small and
osteopenic.1–3 Additionally, external fixation cannot be
considered an ideal treatment option because it is associated with prolonged immobilization to maintain alignment and healing. The increased period of immobilization
can lead to digital stiffness and poor functional outcome,
which may be compromised by pin tract infection or
loosening.4 Weber and Szabo reported a complication
rate of 62% using external fixation for treatment of highly
comminuted distal radius fractures.5 Ironically, it seems
that despite the achievement of acceptable anatomic results, the patients’ functional outcome can be disappointing.6 Hove et al reported that the reduction failed in 3 of
29 patients after too early removal of the fixator.7
Although it has been suggested that closed reduction
can be a reasonable treatment option in elderly patients,
it is estimated that over 50% of the patients may have
an obvious clinical deformity.8 On the contrary, Madhok
and Green reported that 26% of elderly patients report
residual difficulty in performing activities of daily
living at a mean follow-up of 1 and 1.5 years following
fracture.9
Alternatively, highly comminuted distal radius fractures can be treated with open reduction and internal
fixation using low-profile plates. Metaphyseal bending
fractures using locking plates and screws have shown
to be successful at preventing collapse.10 Screw perforation of the articular surface, plate bending and breakage,
tendon irritation and rupture from prominent plate screws,
deep infection, and skin breakdown are complications associated with open reduction and internal fixation.1,2,11
Based on the principle of wrist distraction and ligamentotaxis, the internal distraction of the distal radius
with the use of a 2.7-mm or 3.5-mm dynamic compression plate (DCP) can be a valuable treatment option.12,13
In slender individuals, when device prominence is a
Techniques in Hand and Upper Extremity Surgery
Internal Distraction Plating of Distal Radius
concern, the 2.4-mm or 2.7-mm plate may be preferred.
In addition, locking plates are more preferable and useful
because of the advantages of the locking plate technology.
Using this technique, pin loosening or pin tract infections
are avoided while maintaining a long-term fracture immobilization that may be required for the osteopenic
bones to heal. The current technique provides excellent
screw purchase in osteopenic bone because the device
is secured to the cortical bone of the long metacarpal
and the radius. The biomechanical stability allows
patients to bear weight with a platform walker and maintain independence, which is of particular interest in polytrauma patients. They are permitted to use a platform
walker with the affected limb if an assistive walking
device is needed. Furthermore, the limit of maximum
lifting can be set at 5 pounds.
The application of instrumentation on the dorsal side
of the distal radius combines the advantages of both
unloading the wrist and supporting the fragments on
the dorsum of the wrist. The combination of distraction
and buttressing on the dorsal side is of particular importance given that Bartosh and Saldana14 reported that ligamentotaxis without any other mean of stabilization is
unreliable in re-establishing radiopalmar tilt. This is partially related to the axis of load application after external
fixation of the wrist. Conventional external fixation relies
upon maintaining the length of the intermediate column
of the radius from a radially based axis. The application
of the implant to the long metacarpal centralizes the distraction force and makes the device more efficient and
rigid for stabilizing the lunate facet. The authors prefer
to use the third metacarpal for distal fixation because in
this position, the distraction force is transmitted through
the intermediate column. Thus, reduction of the lunate
facet and restoration of normal palmar tilt can be achieved
without overdistraction. In a study by Garcia et al,15 the
internal distraction of the distal radius fractures resulted
in a mean palmar tilt of 6.6°.
Although it is reported that prolonged immobilization of the wrist after external fixation may lead to poor
functional outcomes,4 Garcia et al15 pointed out that despite the prolonged immobilization, the range of motion
can be satisfactory after internal distraction. The average
duration of bridge plating in the study of Garcia et al15
was 134.3 days compared to the 49 to 56 days reported
by Kaempffe et al4 for external fixation. This may be attributed to the fact that early range of motion of the wrist
does not necessarily result in improved functional of
range of motion.16 Pragmatically, the functional outcome
as evaluated with the Disabilities of the Arm, Shoulder
and Hand (DASH) score was very good. In the series
of Garcia et al,15 the average DASH score was 9.4 at
a mean follow-up of 20.3 months. Only 1 patient had
a score of 55, and this patient was initially treated with
closed reduction unsuccessfully. However, the poor result was attributed to the comorbidities of end-stage renal
disease and chronic obstructive pulmonary disease.8
n INDICATIONS
a. Comminuted osteoporotic fractures (intra- and extraarticular and/or open fractures) in which traditional
treatment methods may lead to loss of reduction due
to poor bone quality. The technique is usually indicated
in patients aged 60 years or more (Figs. 1 and 2).
b. The use of the 3.5-mm plate in distal radius fractures,
which is associated with significant diaphyseal or shaft
involvement, can be considered treatment of choice.
c. To maximize functional independence by avoiding
bulky external fixators in osteoporotic bones and in
polytrauma patients.
d. Patients who are unwilling to undergo external fixation for cosmetic or psychologic concerns.
n CONTRAINDICATIONS
A relative contraindication can be considered the presence of a palmar lunate facet that does not reduce with
distraction alone and may require adjunctive treatment
through a palmar approach. For these cases, an alternative
technique may be indicated. The issue of metal allergy remains controversial; however, an alternative treatment
option may be indicated in patients with documented metal
allergy. In case of concomitant third metacarpal shaft
fracture, the second metacarpal can be used for fixation
distally. Furthermore, the loss of soft-tissue coverage
can be considered a contraindication to the technique.
n TECHNIQUE
The patient is positioned supine on a radiolucent table,
and a tourniquet is used for the affected upper extremity.
The surgical approach involves 3 incisions. The first is
performed over the midshaft of the third metacarpal. A
second incision measuring approximately 4 cm is required at the dorsal aspect of the radius at least 4 cm from
the most proximal portion of the comminuted fracture.
The extensor mechanism is retracted after the first incision (Fig. 3A). A 2.7-mm or 3.5-mm DCP is then passed
along the surface of the bone from the distal to the proximal incision (Fig. 3A). A 12-, 14-, 16-, or 20-hole plate
can be selected. However, plate selection should
permit the insertion of a minimum of 3 cortical screws
proximally. The third incision, approximately 2 cm in
length, is made over the Lister’s tubercle to facilitate
mobilization of the extensor pollicis longus (EPL) tendon.
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Papadonikolakis and Ruch
FIGURE 1. These radiographs demonstrate a case of a 28-year-old polytrauma patient with fractures of the midshaft of the
ulna, ulnar styloid, and a highly comminuted intra-articular (C3-3) distal radius fracture. Notice the dorsal displacement of the
metaphyseal fragments and the palmar displacement of the lunate facet in the posteroanterior (A), oblique (B), and lateral
views (C).
This helps with the passage of the plate under the extensor tendons. Complete release of the EPL is performed to
verify that the plate lies underneath the tendons, and to
facilitate placement of grafts, because this incision can
also be used as a portal for placement of allograft bone
in the metaphyseal area if a defect is present (Fig. 3B).
Supplemental bone grafting is delayed in cases of open
injuries to avoid the risk of infection. In general, the combination of cancellous allograft and demineralized bone
matrix is the authors’ preference. The EPL is then exposed, and the position of the plate is re-evaluated to ensure that the plate does not impinge on either the EPL or
the digital extensors.
Afterward, the plate is fixed to the long finger metacarpal (Fig. 4). The hole must be drilled at the midline of
the metacarpal to avoid any rotatory displacement. Traction is then applied manually under fluoroscopic visualization to obtain radial length. The plate is then fixed
FIGURE 2. These radiographs demonstrate the open reduction and internal fixation of the distal radius fracture illustrated in
Figure 1, with the use of an internal distraction plate (A and B). In the final radiographs, a smooth articular (C) can be noticed
along with acceptable restoration of the palmar tilt (D).
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Techniques in Hand and Upper Extremity Surgery
Internal Distraction Plating of Distal Radius
FIGURE 3. A 4-cm incision is made over the midshaft of the third metacarpal. The extensor mechanism is then retracted (A).
A second incision measuring approximately 4 cm is made at the dorsal aspect of the radius at least 4 cm from most proximal
portion of the comminuted fracture (B). A 12-, 14-, 16-, or 20-hole 2.7-mm or 3.5-mm dynamic compression plate is then
passed along the surface of the bone from distal to the proximal incision. A third incision approximately 2 cm in length is made
over the Lister tubercle to facilitate mobilization of the extensor pollicis longus (B). The plate is fixed to the long finger metacarpal, taking care to drill the hole at the midline of the metacarpal to avoid any rotatory displacement.
proximally in neutral rotation. The wrist must be in neutral position. The diaphyseal fragments are then reduced
and fixed to the shaft. Interfragmentary screws can be
valuable where necessary (Fig. 4).
The restoration of the articular surface of the radius is
achieved percutaneously. In case of difficulties, a small
dorsal incision may be helpful to ensure adequate length
of the radial column. Anatomic reduction may require
the placement of a cancellous screw through the plate
into the reduced articular segments. Sometimes, the distal fragments are too small for screws. In this case,
Kirschner wires can be used under fluoroscopy to reduce
the articular surface. In case pins were used, they have to
be removed at 6 weeks.
n COMPLICATIONS
The complications are minimal. However, potential complications include:
a. Extensor lag especially in the long finger
b. Superficial or deep infections
c. Bone nonunion. The mean time to union is approximately 124 days (range 54–226 days)
d. Device failure
e. Rarely, extensor tendon irritation or rupture
According to the authors’ experience, the most frequent complication is the extensor lag of the long finger,
with a rate of approximately 10%.
n REHABILITATION
To avoid the development of extensor tendon adhesions
and finger stiffness, active and passive range of motion is
initiated immediately postoperatively and is maintained
throughout the duration of the internal fixation. Protective immobilization in forearm splints is required only
for the first week after the operation. It is important to
allow the patients to perform activities of daily living;
however, they should be careful not to lift weights of
more than 5 lb. If the fixation construct is deemed stable
enough, a platform walker may be used in the polytrauma
patient. Forearm rotation is not restricted. After radiographic verification of bone union, the plate can be
removed under local anesthesia. Range of motion exercises of the wrist and digits are initiated immediately,
whereas at this point, no splitting is required.
n REFERENCES
1. Axelrod TS, McMurtry RY. Open reduction and internal fixation of comminuted, intraarticular fractures of the distal
radius. J Hand Surg [Am]. 1990;15:1–11.
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2. Bradway JK, Amadio PC, Cooney WP. Open reduction and
internal fixation of displaced, comminuted intraarticular
fractures of the distal end of the radius. J Bone Joint Surg
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3. Seitz WH Jr. Complications and problems in the management of distal radius fractures. Hand Clin. 1994;10:117–
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4. Kaempffe FA, Wheeler DR, Peimer CA, et al. Severe fractures of the distal radius: effect of amount and duration of
external fixator distraction on outcome. J Hand Surg [Am].
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external fixation and pins and plaster techniques. J Hand
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6. McQueen MM, Michie M, Court-brown C. Hand and wrist
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patients. J Orthop Trauma. 2005. In press.
FIGURE 4. Traction is applied manually under fluoroscopic visualization to obtain radial length. The plate is then
fixed proximally in neutral rotation. The wrist must be in
the neutral position. The diaphyseal fragments are then reduced and fixed to the shaft. Interfragmentary screws can
be valuable where necessary.
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16. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic external fixation of unstable fractures of the distal part of the
radius. A prospective, randomized comparison with static
external fixation. J Bone Joint Surg Am. 1994;76A:1149–
1161.
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