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. Volume 9, Issue 1 3 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). 4 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. Volume 9, Issue 1 5 Papadonikolakis and Ruch 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 Am. 1989;71:839–847. 3. Seitz WH Jr. Complications and problems in the management of distal radius fractures. Hand Clin. 1994;10:117– 123. 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]. 1993;18:33–41. 5. Weber S, Szabo R. Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques. J Hand Surg [Am]. 1986;11:157–165. 6. McQueen MM, Michie M, Court-brown C. Hand and wrist function after external fixation of unstable distal radial fractures. Clin Orthop. 1992;285:200–204. 7. Hove LM, Furnes O, Nilsen PT, et al. Closed reduction and external fixation of unstable fractures of the distal radius. Scand J Plast Reconstr Surg Hand Surg. 1997;31:159– 164. 8. Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg [Am]. 2000;25: 19–28. 9. Madhok R, Green S. Longer term functional outcome and societal implications of upper limb fractures in the elderly. J R Soc Health. 1993;113:179–180. 10. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am]. 2002;27:205–215. 11. Seitz WH Jr, Froimson AI, Leb RB. Reduction of treatment-related complications in the external fixation of complex distal radius fractures. Orthop Rev. 1991;20:169– 177. 12. Becton JL, Colborn GL, Goodrich JA. Use of an internal fixator device to treat comminuted fractures of the distal radius: report of a technique. Am J Orthop. 1998;27:619–623. 13. Burke E, Singer R. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Upper Extrem Surg. 1998;2:248–252. 14. Bartosh RA, Saldana MJ. Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. J Hand Surg [Am]. 1990;15:18–21. 15. Garcia I, Ginn T, Ruch DS, et al. Distraction plating for treatment of comminuted distal radius fractures in elderly 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. 6 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. Techniques in Hand and Upper Extremity Surgery
